Lawmakers Discuss the Future of Community Health Workers in California

Alex Fajardo, executive director of a San Bernardino-based center that trains CHW/P/Rs, testified to lawmakers about the importance of community health workers: “This is a movement to carry the hopes of marginalized communities.” Photo: El Sol Neighborhood Educational Center

How can California integrate community health workers, promotores, and representatives — also known as CHW/P/Rs — into the health care system while embracing the social justice focus that is central to delivering their services to community members?

The Assembly Health Committee and Assembly Budget Subcommittee No. 1 convened on March 12 for a joint informational hearing to learn about the bright spots and barriers to realizing the potential of California’s CHW/P/R workforce. Assemblymembers heard how CHW/P/Rs have a long history of promoting culturally responsive health care (PDF), providing linguistic services, and centering social well-being across California communities, particularly for immigrants, people of color, and people with low incomes.

Defining the CHW/P/R Workforce

A community health worker (CHW) is a frontline public health worker who is a trusted member of and has an unusually close understanding of the community served. A promotor/a (P) is a trusted person who empowers their peers through education and connections to health and social resources. They largely work in Latino/x and Spanish-speaking communities. The R stands for community health representatives (CHRs), who do similar work in American Indian and Alaska Native communities.

CHCF’s use of this abbreviation and inclusion of CHRs is shifting. As of early 2023, we added CHRs to honor the important role and long history of CHRs in the US and California.

Demand for the CHW/P/R workforce is growing. California has set a goal of training 25,000 new CHW/P/Rs by 2025 to work in health care and social services in California. This would help address the demographic mismatch between California’s health workforce and the state’s diverse population. CHW/P/Rs can also bring new skills, capabilities, and capacity to California’s health care systems — exceedingly important benefits considering the state’s health workforce shortages.

CHCF Senior Program Officer Carlina Hansen testified that there are about 6,700 community health workers in California today. A survey by UCSF found hospital representatives say it would be ideal if they hire more than 10 times as many CHW/P/Rs (PDF) as currently planned. Community health center staff would hire almost three times more than planned.

However, staff from both hospitals and health centers reported that they plan to hire far fewer due to constraints associated with the financing and sustainability of these roles. Though important progress has been made to fund the CHW/P/R workforce through Medi-Cal, panelists at the hearing said a variety of barriers still exist and sustainability has not yet been achieved.

“Research shows the demand outweighs supply for this workforce,” Hansen testified. “To advance, CHW/P/Rs need additional support, including thriving wages, good training, opportunities for advancement and recognition, supportive supervision, and good workplace integration.”

CHCF Senior Program Officer Carlina Hansen gives testimony on the future of community health workers in California.
CHCF Senior Program Officer Carlina Hansen testified that demand for the CHW/P/R workforce is growing.

CHW/P/Rs and state officials were direct in telling assemblymembers that integration into state programs and a pathway to sustainable financing have hit bureaucratic obstacles since the state established CHW/P/R services as a benefit in Medi-Cal, the state’s Medicaid program, in 2022.

CHW/P/Rs worked for nearly a decade to achieve that benefit and hoped it would bring financial stability to the workforce. Instead, challenges cited at the hearing include:

  • Lack of familiarity among providers and community-based organizations about the CHW/P/R services covered by Medi-Cal and how to use the benefit.
  • Federally Qualified Health Center (FQHC) payment systems do not enable them to leverage the Medi-Cal benefit to scale and support their CHW/P/R workforce.
  • Inadequate engagement between health plans and community-based organizations that have not contracted with managed care plans.
  • Low reimbursement rates for the CHW/P/R benefit.

More Than a Set of Roles

CHW/P/Rs told lawmakers about the importance of being able to maintain their expertise and role in the health care ecosystem. Health workers expressed concern that they might be subsumed into existing health infrastructures and roles that do not align with the way they now work in their communities.

“CHWs’ work is more than a set of roles, titles, or even a delivery service,” said Alex Fajardo, executive director of San Bernardino-based El Sol Neighborhood Educational Center, a leader in training CHW/P/Rs. “This is a movement to carry the hopes of marginalized communities — this movement is health equity.”

Fajardo testified about the work of a CHW/P/R regional capacity collaborative in San Bernardino, Riverside, and Orange Counties that brings a social justice lens to implementing the CHW/P/R Medi-Cal benefit and addresses workers’ concerns about assimilating into pre-existing health professions. The regional collaborative has consistently been driven by CHW/P/Rs who are cocreators of all the work that they do in the region. That is a principle that needs to be better incorporated into state policies and practices around CHW/P/Rs, he said.

Mayra Alvarez, president of The Children’s Partnership, encouraged state leaders to be consistent in centering community voices and seeking CHW/P/Rs’ input as California develops processes to implement and improve the benefit and certification of the workforce. There have been many challenges with the certification of CHW/P/Rs and an unclear and inconsistent stakeholder process, she said. This has created worker frustration just as state leaders are turning to communities for solutions.

“What we know is that communities found a way,” Alvarez said. “Communities recognize the power that exists in knowing you have a support network and families and neighbors who will do anything to help. Communities create a culture that nurtures you. Not one of us made it to where we are alone, and CHW/P/Rs embody this belief. For centuries, communities themselves implemented solutions.”

Recommended Policy Priorities for CHW/P/Rs

Assembly Health Committee Chair Mia Bonta (D-Oakland) asked witnesses what priorities state leaders should focus on to balance integration of a workforce into health and state systems that have historically excluded people of color, women, and Californians with low incomes from providing care and labor in their communities. The panelists’ recommendations included:

  • Increasing support for more training programs and addressing “training deserts” for CHW/P/Rs in California. There are only 25 training programs statewide, and they are predominantly clustered around Los Angeles and the San Francisco Bay Area.
  • Addressing education, immigration status, and other structural barriers that block CHW/P/Rs from jobs. Panelists emphasized the importance of removing language, education, and immigration requirements to enable the health care system to take full advantage of CHW/P/Rs’ expertise.
  • Providing fair compensation and greater inclusivity. Discussions at the hearing underscored the need for fair wages and expanded opportunities for these community health experts to contribute to policy and state health strategies.
  • Addressing Medi-Cal benefits and reimbursement rates. Witnesses and members of the public pointed out a general lack of familiarity among health plans, providers, and organizations with the new Medi-Cal CHW benefits and the challenges posed by low reimbursement rates. They also named the unique challenges faced by FQHC providers who have long worked with CHW/P/Rs.
  • Improving engagement and technical assistance between health plans and community-based organizations. Contracting with managed care plans is new for many community-based organizations. State resources and support are needed for the successful implementation of CHW benefits and services.

Andrea Mackey, a senior policy manager with the California Pan-Ethnic Health Network , said that as an advocate and a third-generation CHW, it is a powerful experience to see people transformed from being “passengers to drivers of their health.” She described watching how Filipino community members felt shame for using money on diabetes medication instead of supporting their family members in the Philippines and then shifted to feeling joy because education and intervention from CHWs like herself cause their health to improve.

“That’s the energy of this workforce — the transformation of community,” Mackey said. “If we want to see true success of the CHW Medi-Cal benefit, we need to remember the mantra that there is nothing about us without us, and there is a need to expand our services further where current health care systems have either ignored or harmed our communities, whether it be Black, Native Indigenous, Asian American, LGBTQ+, Trans, Latino/x, and rural communities.”