Community Health Workers in the United States: Time to Expand a Critical Workforce

Community health workers (CHWs) have a long, rich global history of extending essential health services and helping address social determinants of health for underserved populations.1 The 1978 Declaration of Alma-Ata, which called for the achievement of "health for all," explicitly defined a role for CHWs as an integral member of primary health care teams.2 In the United States, CHWs have historically been patient health educators and advocates, particularly for patients who have limited health knowledge or whose first language is not English. The 2010 Affordable Care Act called for the integration of CHWs into primary care settings to help improve the provision of care to culturally diverse patients. Despite these efforts, the CHW workforce in the United States has been underrecognized and underutilized, and many have called for policy change to better integrate CHWs into the US health system.3,4 CHWs have been largely neglected in health workforce planning, with existing programs often led by multiple actors without coordination, with fragmented or disease-specific foci, unclear links to the health system, and unclear identities because of wide-ranging job titles. Small programs and demonstration projects have shown the efficacy and promise of CHWs to improve population health outcomes,5,6 but monitoring and evaluation systems for large-scale CHW programs have been weak, and evidence of their real-world effectiveness and cost-effectiveness has been limited.In this issue of AJPH, Heisler et al. (p. 766) describe an innovative multisector partnership between Medicaid health plans, a local health department, community-based organizations, and academia that implemented and evaluated a health plan-led CHW program in a low-income neighborhood in Detroit, Michigan. One year in, the study found that emergency department visits and costs were lower in the intervention group of Medicaid beneficiaries randomized to the CHW program compared to beneficiaries who received usual care. Outpatient ambulatory care costs were higher in the intervention group. Although total costs did not differ between the two groups, increases in ambulatory care use among low-income, medically underserved populations are a clear marker of success, and future longitudinal studies may demonstrate important implications for long-term savings and health outcomes.