Editor’s Note: Shreya Kangovi, MD MS is the founding Executive Director of the Penn Center for Community Health Workers, and an Associate Professor at the University of Pennsylvania Perelman School of Medicine. Rebekah E. Gee, MD, MPH is CEO of Healthcare Services for Louisiana State University and formerly served as Louisiana’s Secretary of Health where she led the state’s Medicaid expansion. Rear Admiral Susan Blumenthal, MD, MPA (ret), the Senior Medical Adviser at amfAR, The Foundation for AIDS Research, served as US Assistant Surgeon General, Deputy Assistant Secretary for Health, and a White House Health Adviser. The views expressed in this commentary belong to the authors. Read more opinion articles on CNN.
In order to emerge stronger from the Covid-19 pandemic and a year of social and economic tumult, we need to focus on bolstering public health, re-building the economy and achieving racial justice. There is one often-overlooked workforce that will be critical on all three of these fronts: Community Health Workers (CHWs).
CHWs are trustworthy individuals who come from the communities they serve. They are part of a Department of Labor classified workforce and unlike many other professions – such as social workers and nurses – they are not defined by training or licensure, but rather by who they are and what they do. Throughout the pandemic, CHW have served on the front lines, engaged in public health messaging and contact tracing, addressed broader social and health needs within their communities and could inform policy and system changes. Many are now working on the ground to ensure that marginalized people have reliable Covid-19 vaccine information and access. However, the impact of CHWs could be much greater.
There are approximately 60,000 CHWs in the country, employed by grassroots organizations, hospitals, clinics or public health departments with funding from a patchwork of grants and pilot funding. Increasingly, policymakers have voiced support for investing in and mobilizing this workforce.
A bipartisan group of congressional leaders urged the US Department of Health and Human Services (HHS) to direct Covid-19 and Medicaid dollars to CHWs. In his campaign platform, President Joe Biden promised to create jobs for 150,000 CHWs from within some of America’s hardest-hit urban and rural communities; Biden’s recent pandemic response plan renews his commitment to including CHWs as part of a US Public Health Jobs Corps.
Despite growing policy momentum, many Americans have never heard of CHWs. This oversight may in part be due to the fact that the CHW workforce is commonly black, brown, or rural white and may not have graduate degree letters behind their name. Yet, it is a mistake to overlook this important workforce. Here is what Americans need to know about CHWs, and how they can guide us through public health, economic and moral recovery.
Public health
With the severe delays in delivering Covid-19 immunizations across the country, lower income, Black and Brown people continue to bear a disproportionate impact of the disease. And Americans are sick and dying at startling rates, not only of Covid-19, but its effects: unemployment, food insecurity, deferred preventive care, social isolation, alcohol and opiate use and suicidal ideation.
CHWs have a flexible, holistic approach that is well-suited to this range of challenges. Imagine Maggie, a 43-year-old who has lost hours at her retail job due to the pandemic and can’t make rent. Her son has autism and is having a difficult time being out of school. She has concerns about the safety of a Covid-19 vaccine and her ability to even access one. A CHW would get to know Maggie as a whole person. She would ask Maggie what she thinks would improve her life and health. And then she would work with Maggie to do those things: battle an eviction notice, introduce her to an autism support group and connect her with a good primary care provider who can talk her through the risks and benefits of a Covid-19 vaccine, as well as help ensure that she gets immunized when eligible.
In the United States, we typically take a piecemeal approach to health that does little to connect the silos of public health, community-based organizations and health care. By investing in CHWs we can do more than build lamp posts; we can build a power grid that can shed light where needed for a given individual. Many developing nations have incorporated CHWs as integral players in their health systems with lifesaving dividends including reductions in childhood and maternal mortality, enhanced uptake of vaccinations as well as increased HIV testing and delivery of treatment services.
A large body of scientific evidence suggests that in the US CHWs may help improve chronic disease control and mental health outcomes, promote healthy behavior, and reduce hospitalization and health spending. And they could play a critical role in ensuring that people get vaccinated where they live. The National Committee for Quality Assurance is translating science-based best practices into national standards for CHW hiring, training and infrastructure on a national scale.
Economic recovery
America spends far more on sick care than every other developed country in the world. We tend to wait for people to get sick and then pay a fortune to treat them in hospitals and clinics with expensive drugs and high-tech medical devices. CHWs address the root causes of poor health such as racial discrimination, unstable housing, intimate partner violence, loneliness, or food insecurity. Their effect on health translates into cost savings: randomized controlled trials have shown that CHWs can prevent costly hospitalizations and save $4,246 per Medicaid beneficiary. We estimate that if scaled up to serve to even 15% of the Medicaid population, CHWs have the potential to save American taxpayers $46 billion annually.
As the Covid-19 pandemic was emerging as a threat to the US, the Centers for Medicare & Medicaid Services (CMS) predicted healthcare costs would soar past $4 trillion by the end of 2020, consuming over 20% of GDP. A large part of this spending comes from Medicaid which has surpassed Medicare for the number of enrollees as the largest public payer of healthcare in this country.
Since the pandemic began, 12 million newly jobless Americans lost their employer sponsored insurance; many of these individuals will enroll in Medicaid and strain an already overburdened system. Investing in CHWs is one of the only proven ways to improve efficiency in Medicaid: CHWs can improve health while also reducing health spending. Additionally, expanding the CHW profession can help create economic opportunities, particularly in hard-hit disadvantaged communities.
Moral recovery
While many other health-care professionals are defined by their training, CHWs are defined by their identity. They come from within the communities they serve and thus are a diverse reflection of disadvantaged Americans: Based on 2014 data, 65% are black or Latinx, 23% are white and 10% are Native American. They may not have extensive formal schooling, but many have lived expertise of racism and financial hardship. CHWs are typically selected on the basis of attributes such as altruism, empathy, and listening skills. They are trusted because they are trustworthy.
At a time when trust seems to be in short supply in America, CHWs are uniquely positioned to be weavers that repair our social fabric. They can earn trust using innate empathy and hyper-local grassroots connectivity. And they can use their expertise to lead anti-racism and social justice efforts. For example, in St. Louis, CHWs are working to train police officers on how to build community engagement after Ferguson. In Philadelphia, CHWs are mentoring doctors on anti-racism.
A path forward
Mobilizing this critical workforce to benefit public health has bipartisan, bicameral support from Congress. By supporting CHWs, we can bolster job creation, local self-determination, fairness and economic recovery, and a swift public health response in our hardest hit communities.
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The rollout of Biden’s recent Covid response plan and proposed US Public Health Jobs Corps must focus on hiring CHWs and deploying them in evidence-based ways to respond rapidly to Covid-19 and form the basis of a long-term health workforce. CMS and Congress must ensure that Medicaid covers the full range of evidence-based supports that CHWs provide.
There are few policy opportunities to stem a public health crisis, generate a return on investment for public dollars, put people back to work and restore trust. This is one we cannot afford to miss.