As pandemic ebbs, community health worker funding drying up
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* Mark Barna

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/53/9/1.1/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/53/9/1.1/F1)

Veronica Ramirez, a Los Angeles community health worker, registers Robert Bunnett at a 2020 flu shot clinic. The ranks of U.S. CHWs swelled during the pandemic, but funding is drying up.

Photo by Mayra Beltran Vasquez, courtesy Los Angeles County

> “States saw during the pandemic where CHWs fit, and they would like to keep it going.”
> 
> — Elinor Higgins

Benny Gates was concerned. The elderly man he bought groceries for each week had not called him that day as usual. So late morning, he rang up the Henrico County, Virginia, resident, who answered but spoke in garbled sentences. The man was having a stroke.

Gates, a community health worker, called 911, and responders later told him he saved the older adult’s life.

“That’s the type of thing that as a community health worker you do, and these experiences, they happen all the time,” Gates told *The Nation’s Health.* “I’m sure all of the community helpers can tell you stories like this.”

For years, Gates has worked for community organizations that help vulnerable people in the Richmond, Virginia, area be healthier. His days might include finding people transportation to medical appointments, delivering groceries to people who are food insecure and helping patients with chronic illnesses navigate the health care system.

The work by Gates and others like him serves an important need in the public health system and has been shown to improve health. A recent study in West Baltimore City, Maryland, found a 40% reduction in emergency visits in areas where community-based health workers were assigned, for example. Their connections to communities can often make in roads where government officials cannot.

Recognizing those connections, federal officials allotted more than $500 million in emergency funding during the height of the COVID-19 pandemic to hire, train and deploy CHWs in communities nationwide. The workers educated residents on risks, answered questions and supported thousands of COVID-19 vaccination events, boosting uptake and helping to save lives in vulnerable communities. As the pandemic ebbs, many have been assigned to other public health needs.

But this year, many programs are losing that emergency funding, causing concern over sustainable pay for the expanded CHW workforce. Other federal health funding has arrived — notably a $3.2 billion infusion in May from the Centers for Disease Control and Prevention to strengthen the public health workforce and infrastructure — but how much will make it to community programs employing CHWs remains unknown.

Shanteny Jackson, MA, CCHW, CSAC, executive director of the Virginia Community Health Workers Association, said many local community health programs that employed CHWs in Virginia have not been renewed. A national survey this year found that 26% of CHWs said their employers were running out of funding and contemplating layoffs.

CHWs need new, sustainable funding sources to be able to continue their work and remain effective in public health, according to Denise Smith, MBA, CHW, PN, executive director of National Association of Community Health Workers.

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[Figure2](http://www.thenationshealth.org/content/53/9/1.1/F2)

Community health workers in Multnomah County, Oregon, celebrate their three years of work battling COVID-19 in May. The gathering was described as bittersweet, as federal funding for their “wraparound” work was coming to an end.

Photo courtesy Multnomah County Communications, via Flickr Creative Commons

## Continued funding for CHWs sought

In Virginia, community health workers were integral to increasing COVID-19 vaccine uptake for people of color. By summer 2021, 40% of the commonwealth’s Hispanic population was vaccinated for COVID-19, second only to white people in the state.

Ana Zuñiga, a health educator at Blue Ridge Health District in Charlottesville, Virginia, took part by knocking on doors, working in a call center and offering bilingual assistance. Despite her hours being cut as the pandemic has waned, she has continued educating on health, helping people with appointments and facilitating transportation for care.

“Sometimes we don’t have the money to serve others,” Zuñiga told *The Nation’s Health.* “That gives us a lot of stress.”

![Figure3](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/53/9/1.1/F3.medium.gif)

[Figure3](http://www.thenationshealth.org/content/53/9/1.1/F3)

Members and staff of the Virginia Community Health Workers Association pose in January in front of the Richmond City Health District offices.

Photo courtesy Virginia Community Health Workers Association

Community-based organizations, individual and family services, and local governments are the primary CHW employers, though in recent years hospitals and health care clinics have hired them, too. While some CHWs are paid through an organization’s operation budget, most are paid through grants, which are not a sustainable funding stream.

Smith was a community-based health educator for 22 years, primarily for the Central Area Health Education Center in Hartford, Connecticut. Funding came from grants, such as for HIV testing outreach, nutrition education, and maternal and child health support.

“I learned to write grants the first year I started working there,” Smith told *The Nation’s Health.* “And every year or two I had to write a grant to keep my job.”

CHW is an umbrella term for a host of public health positions, such as promotores de salud, community health aide, health educator and patient navigator. The U.S. Bureau of Labor Statistics estimates there are about 61,300 CHWs in the nation.

But employers do not follow the Department of Labor’s CHW definition, meaning the department’s estimate fails to capture the actual CHW workforce, according to Smith. Data on CHWs is lacking at every level of government, making it difficult to estimate exact numbers.

## Using Medicaid to support CHWs

These days, many states are looking to Medicaid funding as a sustainable way to keep community health workers on their staff. The pathway opened in 2014, when the Centers for Medicaid and Medicare Services broadened the preventive services rule to allow unlicensed health workers to be eligible for Medicaid reimbursement for their work. To qualify, CHWs must meet a state’s requirements for education, training and credentials.

About half of states allow CHW Medicaid reimbursement, according to the National Academy of State Health Policy, and efforts to reimburse CHWs beyond chronic care are growing. Washington state is piloting CHW reimbursement in pediatric primary care, and New York announced this summer that next year CHWs will be reimbursed for services for pregnant and postpartum people.

But progress is hampered by lack of data on the workforce. To convince state lawmakers in holdout states to greenlight Medicaid reimbursement for CHWs, data on what they do, who they serve and their successes can be a game-changer, Smith said. And with the data, states can more effectively translate CHW services into Medicaid reimbursement codes, getting more employers on board.

Workplace data also helps match workers’ skill sets with residents in need, she said. A CHW who has experienced pregnancy and postpartum recovery, for example, could be matched with residents needing services in those areas.

But lack of data is not the only problem. Community-based organizations struggle with navigating the Medicaid reimbursement process, Smith said. One barrier is that community organizations usually do not have billing departments, a physician or other eligible practitioners on staff who supervise CHW employees for billing purposes. The National Association of Community Health Workers has asked CMS to issue guidance.

“It is currently impossible for most CBOs to bill Medicaid for CHW services,” Smith said.

Despite the issues, progress has continued among states, said Elinor Higgins, a policy associate on population and public health at the National Academy for State Health Policy. Over the last year, several states have committed to Medicaid reimbursement for CHWs. Maine is exploring a multi-pay model that includes Medicaid, and Vermont, which already uses the multi-pay model, is exploring additional sustainable funding.

“States saw during the pandemic where CHWs fit, and they would like to keep it going,” Higgins told *The Nation’s Health.*

APHA’s Community Health Workers Section will have a full lineup of sessions dedicated to the workforce during the Association’s upcoming Annual Meeting and Expo in Atlanta. An afternoon session on Sunday, Nov. 12, will examine federal, state and local support for CHWs and opportunities for expansion.

For more information, visit [www.apha.org/annualmeeting](https://www.apha.org/annualmeeting) and [www.nachw.org](https://nachw.org/).

*   Copyright The Nation’s Health, American Public Health Association