Shocking Changes to Medicaid: Are Community Health Workers About to Lose Their Funding? Find Out Now!

As the United States grapples with rising healthcare costs projected to reach $8.6 trillion by 2033—accounting for roughly 20% of the nation’s gross domestic product (GDP)—the health status of many Americans, especially those on Medicaid, continues to decline. Amidst this troubling backdrop, community health workers (CHWs), including promotores and community health representatives (CHR), are emerging as vital players in the healthcare landscape, addressing not only medical needs but also the underlying social determinants of health.

CHWs have long provided essential services such as resource navigation, peer support, health coaching, and advocacy, and a growing body of research underscores their effectiveness. Well-designed CHW programs have shown significant promise in improving chronic disease control, enhancing mental health, promoting healthy behaviors, reducing hospitalizations, and increasing engagement in primary care. Notably, randomized controlled trials indicate that CHWs working with Medicaid beneficiaries experiencing chronic conditions can save approximately $2,500 per enrollee annually by preventing expensive hospitalizations.

For decades, funding for CHW programs has relied on a fragmented system of grants, but recent developments signal a shift. As of January 2024, more than half of state Medicaid programs have initiated some form of coverage and payment policy for CHW services. This evolution is critical, as it acknowledges the potential of CHWs to enhance health outcomes while simultaneously curbing costs. Indeed, Medicare has taken a significant step forward by introducing the first billing code for CHW services in its 2024 Physician Fee Schedule, setting a precedent for states to follow.

The National Academy for State Health Policy has published a comprehensive review on developing State Plan Amendments (SPAs) for CHW services, highlighting best practices for involving CHWs in the process. The toolkit, which includes model language for Medicaid leaders and CHW advocates, aims to facilitate the establishment of coverage and payment for CHW services nationwide. Key principles guiding this effort include:

• Inclusion: Emphasizing a “nothing about us without us” philosophy, where CHWs, who understand the challenges of their communities firsthand, play a crucial role in policy development.
• Empowerment: Recognizing the power of lived experiences, which can inform and uplift policy decisions impacting the CHW workforce.
• Evidence: Utilizing data-driven approaches to ensure CHW programs effectively address the needs of underserved populations.

As Medicaid and Medicare make strides toward integrating CHWs into their payment structures, the implications for the healthcare system are profound. Not only can these programs improve health outcomes for vulnerable populations, but they also present a strategic opportunity to address the growing costs associated with chronic diseases and inadequate healthcare access.

The toolkit for Medicaid leaders and CHW advocates features model text for SPAs, which can be tailored to meet the specific needs of different states. This includes recommendations for eligible populations, services covered, and guiding principles for setting reimbursement rates for CHW services. By leveraging the expertise and perspectives of CHWs in policymaking, states can ensure that these programs are not only effective but also sustainable.

As we move forward, the integration of CHWs into healthcare systems represents a significant shift toward a more holistic approach to health. Their ability to connect with individuals on a personal level, understand their unique challenges, and advocate for their needs ensures that healthcare becomes more inclusive and responsive. This transition is not merely a trend but a necessary evolution in the fight for equitable healthcare access in the United States.

The outcomes of these initiatives could pave the way for a healthier future, illustrating that investing in community health workers is not only a moral imperative but also a financially sound decision for our healthcare system.