State Policies Bolster Investment in Community Health Workers

July 20, 2023 | Brianna Gorman

As public health emergencies ebb and flow, community health workers (CHWs) are often hired for specific, short-term response efforts rather than being hired in long-term, routine positions to develop and deepen a long-standing community presence. Paralleled with ongoing efforts to advance health equity, CHWs, who have a close understanding of the community and who serve as liaisons between health services and community members' needs are trusted public health workers. More than 97 million Americans live in a Health Professional Shortage Area—one of many determinants of limited access to healthcare. Integrating CHWs into the public health and healthcare delivery systems increases access to care by supplying appropriate workforce resources to historically underserved and underinsured communities.

Policymakers and CHW allies increasingly recognize CHWs’ unique ability to holistically tackle population health challenges, with expertise and adaptability across health and social issues. In the current legislative cycle, there are several policy strategies that support the development and integration of CHWs into the public health workforce, including dedicated federal funding and state laws supporting workforce development programs, certification standards, and Medicaid coverage appropriated to CHWs.

Federal and State Funding

Recent promising federal allocations have contributed to the sustainability of the CHW workforce during the pandemic.

• The COVID-19 Health Disparities grant provided a total of $2.245 billion over a two-year period to grantees who are currently using this funding to directly hire CHWs.
• The 2022 American Rescue Plan enabled HRSA to award $225.5 million to states, counties, higher education institutions, and other entities to deliver a CHW Training Program. The investment supports training for 13,000 CHWs and is the largest ever one-time federal investment in the CHW workforce.
• The Consolidated Appropriations Act of 2023 includes $50 million annually to build CHW workforce capacity through 2027.

Similarly, states are appropriating funds to support CHW coalitions and expand programs that employ CHWs:

Connecticut enacted HB 6671 in February 2023, which appropriates funding to the CHW Association of Connecticut ($100,000) and increases operating funds supporting Community Action Agencies’ CHWs, from $3 million to $4 million, which supports the employment of approximately 60 CHWs who reach people that are not well connected to the state’s healthcare systems.

Washington enacted its two-year operating budget in May 2023 appropriating general funds to a two-year grant program that will reimburse for CHW services delivered to pediatric patients in primary care clinics.

CHW-Led Workforce

States are establishing advisory boards and workgroups to lead CHW-informed approaches to public health policies and programs:

Louisiana enacted HB 587 on June 8, 2023, creating the Louisiana Community Health Worker Workforce Board housed in the Louisiana Department of Health. The 11-person board, more than half of whom will be current CHWs from community-based organizations, will develop recommendations on training, competencies, financing streams, tracking employment, and enhancing employer readiness to hire. With this Act, Louisiana provides an example for other states of ways to include and effectively collaborate with CHWs to develop policies that affect their occupational well-being.

Virginia enacted HB 1567 in March 2023, directing the Department of Health to recommend enhancements to maternal health and public health support systems and expansion of a perinatal healthcare hub model. The Department must convene a workgroup to support these recommendations, which must include licensed and unlicensed maternal health service providers and CHWs.

CHW Certification

Currently, 13 states have CHW certification programs and others are considering adopting state standards, demonstrating continued momentum around CHW certification as a means to further define and formalize the CHW workforce. For example, Ohio’s State Board of Nursing has maintained oversight of CHW certifications and associated costs since 2003. Hence, new law SB 131 allows the board to recognize CHW certifications from other states.

North Dakota enacted HB 1028, directing its Department of Health and Human Services to establish and implement CHW certification methods including requirements, fees, required education and experience, and the parameters of CHWs’ contract work with third parties.

New Hampshire’s legislature is considering SB 86, which would direct the state Office of Professional Licensure and Certification–in collaboration with the New Hampshire Department of Health and Human Services–to issue recommendations to the governor regarding CHW certification and scope of practice by July 1, 2024.

Medicaid Coverage Changes for CHW Services

As of July 2022, 29 states established Medicaid payment for CHW services. States continue to expand service areas, solidifying CHWs as critical providers.

In Colorado, under SB 23-002, stakeholder meetings with CHWs will be held to establish the fee for service and Value Based Payment models that are equitable and acceptable among CHWs.

New York’s S 4007, enacted May 3, 2023, allows Medicaid reimbursement for CHW services for certain high-risk populations. These include culturally appropriate patient education, healthcare navigation, care coordination, patient advocacy, and support services for care management of children under age 21 and adults with health-related social needs. Notably, healthcare navigation services include screening for social needs and referrals to community-based organizations.

Nevada’s SB 117, enacted May 29, 2023, allows Medicaid coverage of services provided by CHWs under the supervision of providers including physicians, physician assistants/associates, or advanced practice registered nurses. The bill directs the state Medicaid agency to submit a state plan amendment (SPA) to CMS.

Texas enacted HB 113 on June 13, 2023. It allows Medicaid managed care organizations participating in the STAR Medicaid program to recognize CHW services as a quality improvement cost instead of administrative expense. Medicaid administration costs are limited by federal requirements to adhere to a medical loss ratio, requiring 85% of plans costs to be on clinical care or quality improvement and limiting administrative costs to 15%. This allows managed care organizations (MCOs) to invest more in CHW services through the QI portion.

Michigan’s SB 190, currently under consideration, would direct the Medicaid agency to formally recognize CHWs as enrolled providers and to utilize the state’s Medicaid matching funds for CHW services, which could include submitting an SPA or waiver to CMS. Michigan’s Medicaid program currently requires MCOs to maintain a ratio of one CHW per 5,000 participants. Michigan’s CHW reimbursable services can include health education, health navigation, assessment of nonclinical and social needs, health advocacy, and preventive services in general.

Sustaining Investments for CHWs

As states work towards addressing health disparities and systematic inequities, CHWs continue to be a vital asset in defining, advocating for, and brainstorming solutions for needs of underserved and historically marginalized populations. State health officials and policymakers can continue to support CHWs by maintaining a strong CHW presence in all advisory bodies, directing state funds and other investments to support CHW alliances, developing training and certification opportunities, and pursuing sustainable financing options for CHW-delivered services.

ASTHO will continue to inform state, territorial, and freely associated state health officials of CHW policy and legislation updates as they arise.