To Advance Health Equity During COVID-19 and Beyond, Elevate and Support Community Health Workers

Health equity interventions undertake the challenging work of mitigating the effects of racism, classism, ageism, homophobia, and ableism, which produce and sustain health disparities.¹ These structural factors are the root causes of negative social determinants of health, fundamentally influencing the extent to which members of systematically excluded communities are able to achieve and maintain health.² Community health worker (CHW) programs—long heralded as a best practice for reducing health disparities³—reflect the core tenets of health equity interventions.

As a community-based public health workforce, CHWs are cost-effective,^4,5 patient-centered,⁶ and reduce chronic disease disparities in low-income, ethnic minority communities.⁷ As an Institute of Medicine discussion paper noted in 2015, studies have demonstrated that CHWs are so effective that “if these were the results of a clinical trial for a drug, we would likely see pressure for fast tracking through the FDA.” As members of the communities where they work, CHWs possess an intrinsic understanding of the needs of those they serve, which is central to who CHWs are and what they do. They engage in advocacy, resource linkage, emotional and social support, and health outreach. They are, indeed, deserving of their designation as essential workers.

Community health workers have emerged as heroes during the COVID-19 pandemic and are gaining broader recognition for their invaluable work.⁸ The American Rescue Plan Act of 2021 allocates $250 million to aid community-based organizations and public health departments in hiring CHWs for COVID-19 vaccination efforts, as well as $3 billion to shore up municipal health departments through hiring and retaining CHWs. This financial commitment reflects mainstream acknowledgment that incorporating CHWs into the fabric of social, medical, and public health systems is essential for strengthening national public health infrastructure.

As we continue to navigate the sociopolitical and economic upheaval catalyzed by the COVID-19 pandemic, we must ask what we can do to marshal long-needed attention and resources to this workforce. The long-standing history of overlooking CHWs’ centrality in supporting the nation’s public health is all the more concerning given that the CHW workforce is predominantly composed of members of the same marginalized, minoritized communities they support, and that the crux of their effectiveness is rooted in their continual confrontation and navigation of the very structural factors they are tasked with aiding others to overcome.

We must continue to advance health equity by implementing, evaluating, and adopting community-based interventions that are acceptable to the intended recipients, consistent with the settings and circumstances, and developed in partnership with a broad swath of stakeholders. However, advancing health equity through the use of CHWs must also be envisioned as inextricably linked to supporting their personal and professional growth. Bolstering the CHW workforce will require a health equity lens that is multipronged and centered on CHWs. This commitment includes, but is not limited to, strengthening employers’ institutional capacity to be responsive to CHWs’ personal and professional needs, as well as advocating for and generating sustainable funding mechanisms to support CHWs working within diverse settings.

A study of CHWs’ perceptions of their role in care teams indicates that connectedness to peer CHWs, access to electronic medical records, and participation in team meetings and organizational trainings foster a sense of having received organizational support.⁹ These findings are congruent with our work with CHWs in Baltimore, Maryland, and underscores the wide variability of CHW experiences within health care teams, ranging from full inclusion to feelings of alienation. The latter occurs when those employing or working with CHWs do not understand who CHWs are or their scope of practice and also fail to appreciate their unique expertise. This has implications for the type of supervision CHWs receive, their satisfaction with their roles, their opportunities for professional advancement within the field, and, ultimately, their delivery of services and supports for the intended beneficiaries of their work.

Although substantial efforts have been made to establish certification and credentialing procedures for CHWs within states, the organizations that employ them must also be held accountable for cultivating an environment that allows CHWs to thrive professionally. These organizational responsibilities include disseminating information about who CHWs are, including the type and nature of the tasks they perform, and hiring supervisors who are familiar with the broader CHW model, being sensitive to the intersection of CHWs’ personal lives and their work, and grasp the tension that CHWs commonly face in their efforts to remain connected to their communities while serving as a bridge to social, public health, and medical systems. A supportive institutional culture also values the lived experiences of CHWs as one might value formal education in other roles.

Our experience designing, implementing, and evaluating CHW-delivered interventions has shown that many CHWs qualify to receive the same financial resources to which they connect their patients or clients. The characteristically unstable patchwork nature of funding for CHW programs is concerning because it perpetuates social and health inequities. Providing sustainable funding mechanisms for CHWs is both critical to ensuring their full participation in the nation’s public health infrastructure and a health equity intervention in its own right.

Although the number of states enacting legislation to promote Medicaid reimbursement of CHWs’ services is growing and offers some form of sustainable financing, 2 issues persist. The first is that the current processes for obtaining Medicaid reimbursement of CHW-delivered interventions (typically achieved through state plan amendments, Medicaid §1115 waivers, and managed care contracts) constrain the types of services deemed eligible for reimbursement and do not include the full scope of activities central to CHW roles. The second issue is that a sizable portion of the CHW workforce operates outside health care settings and is supported by time-limited grant funding. Because a combination of approaches is necessary to support the broader CHW workforce, irrespective of the organizational contexts in which they work, sustainable federal funding is essential. To promote program maturity, foster sustainability, and maximize the effect on participants’ psychosocial and health outcomes and CHWs’ professional advancement, we suggest that federal, state, and local governments, as well as private funders, extend grant terms for CHW initiatives. Legislation that adds CHWs as an optional benefit in Medicaid should deem tasks related to addressing individuals’ health-related social needs as eligible for Medicaid coverage.

The COVID-19 pandemic has reified, in devastatingly stark terms, the fissures in US society that undergird health disparities at large, and COVID-19 disparities in particular. The racially patterned social, financial, and psychological mayhem caused by the pandemic underscores the need to use strategies that support the health and well-being of systematically disenfranchised populations. All of us—from those working within the federal government, to those employed by local municipal public health departments as well as community-based and health care organizations—must commit to constructing health and social systems of support that endure beyond the immediate crises of the moment by elevating CHWs’ work and lived experiences.¹⁰

The aforementioned groups would do well to adopt the national CHW policy platform proposed by the National Association of Community Health Workers. Instituting policies and practices that promote CHWs’ personal and professional development and advancement is a matter of social justice—and for many communities, a matter of life or death.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Ibe CA et al. JAMA Health Forum.

Corresponding Author: Lisa A. Cooper, MD, MPH, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205 (lisa.cooper@jhmi.edu).

Conflict of Interest Disclosures: None reported.