I am very excited that the Journal has once again committed itself, in the last 2 issues, to bringing attention to a critical part of the health care team—community health workers (CHWs). In their preface to this issue, the editors Noelle Wiggins and Elizabeth Lee Rosenthal ask many of the critical questions that constitute barriers to widespread dissemination of CHWs.
As several authors implicitly state and now quoting Kieffer et al, the main challenge confronting the integration of CHWs into our rapidly evolving health care system is “lack of understanding of the unique expertise of CHWs, together with a critical need for ... sustainable financing mechanisms.”
After reading the articles in these 2 issues devoted to CHWs, my sense is that we are still far from understanding financing mechanisms. The seeds are there. The seeds are sprinkled throughout these 2 issues of the Journal.
At the same time, we can look to two recent supreme court decisions for some of the necessary ingredients for success. Community Catalyst, the key consumer organization fighting on health reform in the United States, recently published (http://www.communitycatalyst.org/blog/reflecting-on-last-weeks-victories#.VZkNkCfD_IU) a reflection that for me highlights the necessary path to CHW recognition:
Last Thursday the Supreme Court ruled that millions of people can have tax credits to help them purchase health coverage. The next day the Court made marriage equality the law of the land. Both decisions are the culmination of years of policy and legal strategies, organizing, and advocacy. Both are about fundamental human rights. Both had strong connections to organizing efforts in Massachusetts. The two cases are also connected in their future impact. LGBT people face deep disparities in accessing comprehensive health care and marriage equality can help remove those barriers. The ACA ruling ensures that a married LGBT couple who meet the eligibility guidelines will be able to access tax credits to make health insurance more affordable.
The lessons from the Supreme Court decision are necessary for CHW success but not nearly sufficient. To achieve what the authors of the articles in these 2 issues of the Journal want to achieve, more steps (not necessarily more time) are necessary. For me, the following are key parts to the long-term successful strategy for recognition of CHWs:
- There need to be strong organizing and advocacy leadership at a local and then at the state level. State CHW associations need to be formed that, in turn, can lead to legislation advocating for all aspects of CHW professionalization (expertise, training, financing). There are articles in these 2 issues that address this critical/local or statewide part of the strategy.
- The statewide associations do not appear at this time strong enough to implement necessary elements of a national strategy. That said, CHWs, representatives of the statewide groups that do exist, together with academics, should start to map out a national strategy. The part that they could implement today is to meet with sympathetic federal bureaucracy policy makers such as at the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and other agencies. These same people should meet with legislative aides to make them aware of the presence and importance of CHWs. Part of this national strategy should include meetings with sympathetic foundations that have a stake ideally in both the success of current payment reform efforts and appreciate the importance of community engagement.
- Academics, in particular, but working together with the aforementioned groups should carefully operationalize a research agenda that prioritizes initiatives that are most likely to document the positive impact of CHWs. This will be challenging. One look at the important table in Rishi Manchanda's article in the first issue(p219) devoted to CHWs highlights the formidable challenge of a CHW research agenda that crosses health, social, and political realms. Researchers, advocates, and policymakers need to document the positive financial and health impact of CHWs on specific aspects of this table that connects, in this example, the type of prevention with patient, health care in the community, and broader societal-level influences for improved diabetes outcomes. On the basis of this documentation, allies need to map out CHW training, which, in turn, will result in greater recognition and ... better understanding of how and where CHWs can improve financial and health outcomes. A recent article in The Washington Post on navigators points to the opportunities while again highlighting the challenges (http://www.washingtonpost.com/national/health-science/navigators-for-cancer-patients-a-nice-perk-or-something-more/2015/07/03/28c44930-1a9d-11e5-93b7-5eddc056ad8a_story.html).
While this will be a long road, I remain convinced that CHWs will become a routinized part of our health care landscape. Today, in my health center, people are medical assistants one day and then get promoted in 24 hours to CHW status at a higher salary. Tomorrow, to become a CHW, there will need to be significant training and recognition before one can become a CHW. Just like the recent Supreme Court decisions, this will happen as society (both policymakers and individual patients) demands it. It will also happen as the American health care system slowly but inexorably moves to paying for better outcomes. I am convinced that CHWs are a critical ingredient to this push for better outcomes, especially for those suffering from socioeconomic disparities. These 2 issues of the Journal will hopefully play a small part in that road.
—Norbert Goldfield, MD