Although they do not provide clinical care, community health workers (CHWs) can play a critical role in healthcare delivery, particularly in rural and frontier communities. Also known as promotores or community health representatives, CHWs serve as liaisons between patients and providers, leveraging cultural awareness and community ties to improve access to care.

CHWs’ efforts vary based on community needs. They may coordinate medical appointments, assist with insurance enrollment, address transportation barriers, or connect families with essential resources. Their outreach can range from leading grocery store tours for patients with diabetes to conducting home visits for chronic disease management or maternal health support.

While formal education requirements vary by state and employer, CHWs typically complete specialized training programs covering health education, patient advocacy, and care coordination. Many states have established certification programs to standardize competencies, and some employers require prior experience in community outreach or public health.

Background

The American Public Health Association (APHA) defines CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served.” CHWs originated as outreach “health aides” in underserved communities in the mid-20th century. During the 1960s War on Poverty, several programs deployed neighborhood health aides to support migrant farmworkers, urban poor, Native Americans, and other marginalized groups. In 1968, Congress established the Indian Health Service’s Community Health Representative (CHR) program, the first federally funded CHW initiative, to engage American Indian and Alaska Native communities in their healthcare.

Interest in community-based health workers grew in the 1970s and 1980s, but CHW programs remained small and primarily grant-funded, often targeting specific health issues in disadvantaged communities. CHWs focused on reaching patients who might be overlooked or hesitant to engage with the formal healthcare system. By providing culturally appropriate health education, offering basic health services, and assisting with care navigation, CHWs demonstrated their effectiveness as liaisons between healthcare systems and marginalized populations.

Rise of CHWs in the Late 20th Century and Expanded Access

Building on their success in reaching underserved populations, CHW programs expanded and professionalized throughout the 1980s and 1990s. One notable initiative was the Camp Health Aide program, launched in the mid-1980s by a coalition of religious and community leaders to train farmworkers as health workers. This effort eventually grew into MHP Salud, an organization that spurred multiple CHW-led interventions across the Midwest, Texas, and Florida.

In 1998, the landmark National Community Health Advisor Study systematically identified CHWs’ roles in their communities and the core competencies needed to be most effective. The study gave practitioners and policymakers a framework for understanding how CHWs improve health outcomes and how CHW programs could be strengthened.

By 2000, an estimated 86,000 CHWs  were active in the United States, with approximately two-thirds in paid roles and one-third serving as volunteers. These late-20th-century developments solidified CHWs’ role as a bridge between healthcare systems and the communities they serve, helping to expand access to care and improve patient engagement for populations facing cultural, linguistic, and economic barriers to health services.

Policy Developments and State-Level Initiatives

Formal policy support for CHWs accelerated in the early 2000s. By 2010, the Affordable Care Act (ACA) explicitly recognized CHWs as part of the healthcare workforce, including them in prevention and care coordination initiatives. This validation opened new funding streams.

In 2013, the Centers for Medicare & Medicaid Services (CMS) issued a rule allowing state Medicaid programs to reimburse for preventive services delivered by non-licensed providers—including CHWs—if ordered by a licensed practitioner. Effective January 2014, this policy gave states a mechanism to fund CHWs through Medicaid for the first time, paving the way for their broader integration into care teams. Around the same time, the Centers for Disease Control and Prevention (CDC) and state health agencies began developing guidance to strengthen CHW programs.

The CDC released several key resources to support states in CHW workforce development:

• 2014: A Policy Evidence Assessment Report identifying key components of successful state CHW policies, including standardized training and financing strategies.
• 2015: A technical assistance guide to help states engage CHWs in diabetes self-management education programs, further strengthening the role of CHWs in chronic disease prevention.

State Leadership in CHW Workforce Development

State governments have played a central role in advancing CHW training, credentialing, and workforce integration. Texas enacted the nation’s first CHW training and credentialing standards in 2001, setting a precedent for other states. By 2016, 16 states had established CHW standard operating procedures or certification programs to define training requirements and scope of practice.

Momentum has continued in recent years:

• By 2023, 13 states operated formal CHW certification programs, with others actively developing training standards.
• Ohio and New Mexico have long-standing certification processes, while states like North Dakota and New Hampshire have recently passed laws establishing CHW training and credentialing frameworks.
• States are increasingly creating CHW advisory boards or councils to guide workforce development. For example, in 2023, Louisiana enacted a law establishing a CHW Workforce Board to oversee training, financing, and workforce integration—with significant representation from CHWs.

These initiatives reflect a broader trend toward legitimizing and standardizing the CHW workforce, ensuring their continued role in improving care coordination, prevention efforts, and health outcomes across diverse communities.

Financing CHW Services and Medicaid Integration

Policy support for CHWs has increasingly focused on financing their services, mainly through Medicaid reimbursement. As of July 2022, 29 states authorized Medicaid payment for certain CHW services through state plan amendments, managed care requirements, or demonstration waivers.

• Targeted Medicaid Coverage: Some states limit CHW reimbursement to high-need populations. For example, in 2023, New York approved Medicaid coverage of CHWs for high-risk children and adults with social needs, while Nevada authorized CHW services under provider supervision in its Medicaid plan.
• Billing Flexibility: In 2024, New Mexico became the first state to allow CHWs to bill Medicaid without a physician’s order, following approval from the Centers for Medicare & Medicaid Services (CMS).
• Medicaid Managed Care Innovation: States are also incorporating CHWs into Medicaid managed care models. In Texas, Medicaid managed care organizations can now count CHW expenditures as quality improvement costs, incentivizing plans to invest in CHW programs.

Expanding CHW Infrastructure and Federal Investments

Over the past 15 years, a combination of Affordable Care Act provisions, Medicaid reforms, and state certification laws has expanded the infrastructure supporting CHW programs. The COVID-19 pandemic further accelerated CHW workforce investment through federal initiatives to bolster public health capacity.

• The Coronavirus Preparedness and Response Supplemental Appropriations Act (2020) provided funding to strengthen frontline public health efforts, including support for community health workers through health center grants, worker training programs, and state and local public health initiatives.
• In 2021, the American Rescue Plan allocated $225 million to launch a national CHW training program—the largest one-time federal investment in CHWs to date—with a goal of training at least 13,000 new CHWs.

These policies reflected the previous administration’s focus on addressing social determinants of health and underscored a belief in the value of CHWs in care coordination. Anticipated reductions in federal healthcare spending may reduce funding for CHW programs and slow their growth. In particular, proposed changes to Medicaid funding are likely to impact CHW reimbursement.