At CHAP we’re working towards a day when all members of the community-based workforce–including community health workers (CHWs), promotores de salud, doulas, and peer support specialists—are supported through sustainable financing. This will require braided public and private funding streams to support long-term employment with a livable wage. Until the COVID-19 pandemic, the United States had not seen dramatic reinvestment in the public health system. The CARES Act set aside $153.3 billion for public health, and the American Rescue Plan Act allocated $86.24 billion for health, most notably $7.66 billion for a public health workforce (1,2). In the March 2022 Omnibus deal, $61 million was appropriated for public health workforce initiatives through the CDC, a $5 million increase above the FY 2021 enacted level (3). Additionally, in the State of the Union address on March 1st 2022, President Biden announced CHWs as a key part of a national mental health strategy, with Health and Human Services expected to award $225 million in discretionary funding for training programs (4). New bipartisan legislation introduced in the Senate in 2022 has further appropriations for 3 years of CDC and HRSA funding for CHWs (5). What will happen with this funding, which totals nearly $240 billion combined?
Many states have chosen to use this increased funding to invest in CHWs. The American Public Health Association’s definition of CHWs, endorsed by the National Association of Community Health Workers, is a “frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served” (6). CHWs are members of a larger community-based workforce (CBW) which can bridge the clinical and community centers of healthcare in the United States. CHWs are hired from and for their communities, and their unique place-based knowledge makes them especially impactful in rural and low-income, ethnic minority communities (7,8). In New Jersey, the Colette Lamothe-Galette Community Health Worker Institute is set to hire hundreds of CHWs in the coming years. This is a promising start for rebuilding the capacity of health departments to engage with communities, but a thoughtful approach–informed by community-based workforce members themselves– will create more potential for long-term sustainability, ensuring that the workforce can outlast the current investment boom and become a permanent component of the national health system.
Ongoing support from state budgets, federal appropriations, and government health agencies is needed to quickly follow-up on the short-term investments made in public health during the COVID-19 crisis. If we neglect to do this, the well-established and debilitating “boom and bust” cycle of public health funding will continue to deplete capacity and erode trust in the public health system, especially in racial and ethnic communities (9). Previous booms of public health funding occurred after the 9/11 anthrax attacks in 2001 and H1N1 epidemic in 2009. But it’s the in-between—the bust—that is especially worrisome for the future of the public health workforce. At the state level, spending on public health has dropped as much as 16% in some states since 2004 (10). Most states spend less than $100 per person on public health, with just 3% of state and local government budgets dedicated to public health (11). On the local level, health departments lost more than 55,000 jobs (about 20% of the workforce) between 2008-2017 (10). Large funding cuts have resulted in the termination of community-based workforce positions, debilitating organizational capacity for authentic community engagement. CHWs positions are crucial to sustain, as they bring value to health systems as change agents that promote health, equality, and wellbeing through wraparound services, relationship building, and an intrinsic understanding of needs (7). Rushing to hire, only to subsequently fire members of the most impacted communities will further erode the trust in public health systems that is already so elusive.
At CHAP, we believe the philanthropic community has an obligation to ensure that short-term investments have a pathway towards long-term financial sustainability. This means supporting state and local government policy and infrastructure development to braid funding–taking private grants, government grants, and annual appropriation funding–to strengthen community health systems. With our focus on a community-based workforce, it also means providing the capacity governments need to implement and evaluate evidence-based programs, centered in communities–for CHWs, doulas, and peer support specialists. Finally, it means working now to avoid the funding cliff in three years. States need technical advice and more specialized expertise to navigate the regulatory intricacies of Medicaid and Medicare programs and policies to create sustainable funding for these important members of the health workforce. Philanthropy should consider capacity building grants to help states navigate Section 1115 waivers, State Plan Amendments, and other mechanisms that will take CHW programs from a patchwork of year-to-year grants to a foundational workforce, covered by insurance.
And most important of all–foundations must honor and support the credo– “Nothing about us, without us.” The workforce must be at the heart of all aspects of designing, implementing and evaluating any programs they are a part of and foundation funding should go first and foremost to ensuring the centrality of these voices.
A robust community based workforce can address the primary drivers of poor health— social determinants. CHWs, promotoras, doulas, and peer specialists can improve America’s health outcomes and address the country’s atrocious health disparities. By acting now, and collaboratively, philanthropy can help to institutionalize the recent influx of federal funding, build a more equitable and community engaged public health system, and improve community health outcomes. We know this temporary funding will go away. Let’s make sure the workforce doesn’t go along with it.
- NPR 2020
- NACo American Rescue Plan Act Funding Breakdown
- Labor, Health and Human Services, Education, and Related Agencies. (n.d.).
- FACT SHEET: President Biden to Announce Strategy to Address Our National Mental Health Crisis, As Part of Unity Agenda in his First State of the Union | The White House. (n.d.). Retrieved March 10, 2022, from https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/
- Casey, Tillis, Smith, Murkowski Introduce Bipartisan Bill to Strengthen Community Health Workforce | Senator Bob Casey. (n.d.). Retrieved February 15, 2022, from https://www.casey.senate.gov/news/releases/casey-tillis-smith-murkowski-introduce-bipartisan-bill-to-strengthen-community-health-workforce
- Community Health Workers. (n.d.). Retrieved March 6, 2022, from https://www.apha.org/apha-communities/member-sections/community-health-workers
- Ibe, C. A., Hickman, D., & Cooper, L. A. (2021). To Advance Health Equity During COVID-19 and Beyond, Elevate and Support Community Health Workers. JAMA Health Forum, 2(7), e212724. https://doi.org/10.1001/jamahealthforum.2021.2724
- Glenn, L. E., Nichols, M., Enriquez, M., & Jenkins, C. (2020). Impact of a community-based approach to patient engagement in rural, low-income adults with type 2 diabetes. Public Health Nursing, 37(2), 178–187. https://doi.org/10.1111/phn.12693
- Center for Health Security, 2021
- Associated Press, 2020
- Kaiser Health Network, 2020