The saying “not all heroes wear capes” is certainly true to healthcare workers in the community. Community Health Workers (CHWs) are frontline public health workers with living experience and local knowledge, and are particularly effective at supporting individuals through health education, care navigation, personal advocacy and resource links. Often they work in a neighborhood clinic, community-based organization, churches, residential facilities, schools, and engage in telephone and video calls. Above all, they help build trust, understand the needs and interests of their clients, and overcome social determinants of health (SDOH) challenges (housing, food access, transportation, etc.). Their approach is most importantly guided by a culturally sensitive, person-centered strategy, based on local contexts.
Recognition and refund challenges: Systematic barrier navigation
CHW goes by many names, including care navigators, health advocates, promotions, community health officials, and many others, but often do not have advanced degrees or clinical licenses. Additionally, other providers such as doctors, nurses, and social workers are regulated at the state level, or sometimes optional, with CHW certification or other qualification procurement standards. Despite its invaluable contributions to health and well-being, CHW has historically not been recognized by the medical ecosystem and has been significantly uncompensated.
As a result, organizations employing CHW had to rely on public health contracts, charities and donations to maintain their programs to navigate the unstable fundraising flow. This reliance on “soft funding” not only undermines the stability of the CHW initiative, but also hinders its ability to bring about lasting change within the community.
The momentum of CHW recognition
In recent years, CHWS support atriums have been spotted, partially catalyzed by their essential role during the Covid-19 pandemic. In September 2022, the Biden administration awarded $225 million to train more than 13,000 CHWS, and $50 million per year was allocated as part of the 2023 Consolidated Budget Act to enhance the capacity of the CHW workforce. Many community colleges and other workforce development organizations currently offer CHW certificate training programs, and the state CHW associations created to organize this workforce locally have grown in scale and have influenced the development of policies and practices that prioritize the sustainability and quality care of providers.
In April 2019, the National Association of Community Health Workers (NACHW) was established by a majority of CHW and cross-sector allies. NACHW continues to increase membership in all 50 states and dozens of U.S. tribes, territories, and freedom-related states, in order to support the organization's vision of supporting communities in achieving health, equity and social justice through geography, language, race, ethnicity, sector and living experiences, to help more individuals integrate.
Driven by the strong leadership of the first executive director and CHW himself, Dennis Octavia Smith, Nacher will continue to capitalize on the increased membership of CHW and allies. Increased evidence of the effectiveness of CHW. Highly popular celebrations such as the National CHW Awareness Week to boost this dynamic workforce.
Medicaid Refund Reform: paving the way for sustainable funding
Increased interest in CHWS has spurred several states to enact changes to their Medicaid program policies. This made a different decision for each state. Some states have chosen to grant 1115 exemptions to help fund CHWS, while others have created new routes to utilize billing codes tailored to CHW. These codes allow organizations employing CHWS to bill services ranging from health and social screening to health education, individual advocacy and resource links. In particular, “non-traditional” organizations, including community-based and non-profit organizations, are eligible to receive payments for these services. This is a major change in healthcare reimbursement practices.
According to the 2022 KFF report of the Annual Medicaid Budget Survey, more than half of the states have approved CHW's Medicaid refunds, with 29 of the 48 responding countries already allowing the payment. Fifteen states have allowed Medicaid refunds for CHW services through state planning amendments, with more states quickly joining this list, but positive policy changes are not comparable to adoption. In most cases (11 states), health plans play an important role in the CHW provider certification process, review of submitted claims, and payment. However, unless they are motivated to engage in these programs and support this developing workforce, CHWS may not be able to earn compensation for the work they are already doing.
Implementation Challenges: Navigate complexity at the state level
Despite these advancements, the current landscape of the state's CHW program is fragmented and inconsistent. This lack of uniformity poses challenges for community-based organizations and contributes to minimal participation from those engaged in this important work. A 2024 report by Family USA highlights these challenges.
In many cases, community-based organizations using CHWs cite additional hurdles. These include strict provider approval requirements, boring eligibility verification, lack of appropriate technical systems, and difficulties in working with health plans and providers with extensive process of credentials and additional reporting requirements. This complexity extends to medical coding and tracking work for claims purposes. This often varies from health planning partner to health planning partner. Representatives from various community-based organizations have expressed their frustration, highlighting the need for greater support and resources to effectively navigate these obstacles, as well as the increased billing rate for completed services.
It is clear that a proactive policy alone does not guarantee fair access to CHW services. A more comprehensive effort is needed to provide CHW and community-based organizations with the necessary expertise, skills, technical resources and funding to strengthen capabilities and effectively strengthen underserved communities.
Transformational Impact: CHWS in Medicare and the National Health Environment
On November 2, 2023, the Centers for Medicare and Medicaid Services announced a doctor's fee schedule in 2024 that healthcare workers in the community supporting Medicare members can bill their services. This recent policy change represents an important milestone in recognizing CHW's contributions at the national level, while justifying the important work of CHW within a broader healthcare environment.
Building Capacity and Infrastructure: The Role of Technology in CHW Empowerment
By integrating CHWS into the healthcare system, organizations can improve access to health and social resources, reduce the burden on other healthcare providers, promote culturally sensitive care approaches, and ultimately reduce overall healthcare costs in a scalable way. However, many CHWs work with non-profit, community-based organizations that operate on short-term programmatic grants, smaller team sizes, and outdated documentation tools such as paper and Excel spreadsheets. These financial, labor and infrastructure factors lead to programmatic decline and flow, creating major barriers for organizations interested in new refund mechanisms. Additional challenges include potential competency gaps by nonprofit leaders, extensive management and compliance requirements for claim submissions, and variable technical skills for workers.
Here, the power of care navigation platforms, mobile applications, telehealth and remote surveillance systems, and virtual assistants and document tools with AI holds the greatest potential to help community-based organizations overcome these challenges. When successfully developed, technology can meet broad compliance and billing requirements, improve work efficiency and increase clinical and financial outcomes. This has led to the technology company expanding significantly across the country and partnering with a health plan to recharge the CHW organization.
Future outlook: Unlocking the possibilities of CHW in a changing healthcare paradigm
Despite the uncertainty surrounding known challenges for CHWS and community-based organizations, and federal and state funding priorities, there is undeniable momentum from leaders across the political spectrum to strengthen this transformative workforce. Extensive training initiatives, advocacy and technology innovations can help uncover equitable social care now and ensure CHW receives the recognition, support and sustainable funding they deserve. At the same time, the emerging focus on community-based care models in the healthcare industry highlights the pivotal role of CHW in bridging care gaps, with research and claims data further examining economic and social impacts. Most importantly, policy makers, health providers, health plans, and the CHW itself need to be at the table to deploy impactful programs and develop scalable strategies to ensure long-term sustainability.
Photo: IRINA_STRELNIKOVA, Getty Images
Colby Takeda is co-founder and CEO of Pear Suite, a digital health company that empowers healthcare workers in the community and addresses the social determinants of health. Through Pear Suite's social care navigation platform, health plans, providers and community-based organizations can increase member engagement, improve health outcomes, and reduce the costs of care in person-centered, cultural and linguistically central ways. Colby is a former senior living executive and has dedicated much of his professional career to improving community well-being through population health management programs, policy changes and technical solutions, particularly focusing on social determinants of health. After completing her undergraduate course in health sciences, Colby completed her Masters in Business Administration (MBA) from the University of Hawaii Manoa University and Sidler University of Business, and earned her Masters in Public Health from the University of California, Berkeley School of Public Health.
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