State Plan Amendment for community health workers is too limited, stakeholders say


Soraya Marashi


In a webinar hosted by the California Health Care Foundation (CHCF) last week, stakeholders sought to understand how the proposed preventive services Medicaid State Plan Amendment (SPA) can support a sustainable community health worker and promotore workforce. They also identified opportunities and challenges of the SPA and discussed how it can support community health workers and promotores (CHW/Ps) in California.


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Panelists agreed that the SPA was not flexible enough in its proposed payment models, scope of services covered, and requirements for certifications and training.

James Lloyd, research specialist at the Rutgers Center for Health Services Research, said the SPA would provide a pathway for the state to support CHW/Ps, develop additional funding relationships between Medi-Cal and CHW/P service providers, and create opportunities to establish combined funding structures from state, federal, and private sources.

“The Medicaid payment, perhaps for certain services, perhaps for certain people, [could be] used alongside other sources, and that can help create a more sustainable financing system for this really valuable workforce.”

However, he emphasized that the SPA could not be the sole source of support for all CHW/Ps due to Medicaid’s regulatory restrictions.

“It really is a valuable part of the state’s effort to support the workforce more broadly, it can be a starting block on which to build to help support this, but it’s never going to capture all the services and it’s never going to capture all the CHWs and promotores … we all know that the CHW and promotore workforce is so vast, and the things it does are so expansive, it’s difficult to … fit it all into the Medicaid regulations.”

Lloyd said the holistic and community-focused work of a community health worker or promotore would be challenging to capture in the Medicaid system. 

“Medicaid envisions a payment structure of reimbursement for discrete services rendered. A provider delivers a service, [treating] a broken bone or prescribing some antibiotics, and then is paid for it. The record of the service and payment are then part of what the state submits to CMS and gets matching funds according to a formula established in the regulations. 

Compare … the way Medicaid is conceptualized … to the more holistic or community focused work of a CHW or promotore. It doesn’t quite look like the provision of discrete medical services. And so, capturing CHWs and promotores efforts and then supporting that effort through Medicaid requires a little bit of finesse.”

Seciah Aquino, deputy director at the Latino Coalition for a Healthy California (LCHC), emphasized how important CHW/Ps are to advancing health equity in California.

“Employing promotores is a surefire strategy to achieving health equity, all while transforming our existing workforce, driving employment opportunities back into communities of color, breaking systemic-led poverty cycles through increased access to wealth distribution pipelines, and ultimately strengthening individual, local, and state economies.”

She believes, however, that the SPA’s requirements for formal certification or education could present numerous barriers to entry for a variety of reasons. These include a lack of access to financial resources needed to enroll in a CHW/P certification program, and the fact that the majority of formal certification programs are provided in English, thereby excluding monolingual Spanish or indigenous language speakers.

“Unfortunately, certification efforts may inadvertently decenter the value of experience, community knowledge, [and] connection [for CHWs and promotores] … while excluding the very people who need to be prioritized for this workforce … Thereafter, during the actual hiring process, promotores without formal education will face high competition when applying against a pool of applicants that hold both a high school diploma and a formal certificate.”

Aquino said LCHC recommends leaving certification and high school requirements out of the SPA, or make them fully optional, and instead prioritize lived promotore experience.

Cindy Keltner, director of care transformation at the California Primary Care Association, agreed.

“The SPA requiring CHW certification and training programs presents sort of immediate concerns for us and for our members as this could continue or further strain their limited financial resources … It could also create delays in CHWs in the workforce and really further strain staff in the clinics now with administrative burdens and the workforce challenges brought on by the pandemic.”

Keltner also said covered services for CHW/Ps in the SPA needed to be expanded.

“The draft listing is narrow, it’s medically focused, [and] it does not acknowledge the preventative and low cost interventions that CHWs and promotores currently offer, which … are pretty much embedded within [the] health promotion and coaching category. Specifically, we think the benefit needs to cover case or care management servicesservices within a clinic like translation services so that culturally competent and linguistically competent services can be provided to patients. We think outreach enrollment … should be included in that list, and also coordinating medical equipment and supply delivery.”

Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network, said much more flexibility was available to the state than is reflected in the draft SPA, especially concerning the current payment model she believes is being considered by the DHCS. 

“What was seen in terms of the draft pretty rigidly and clinically defines the roles of CHWs and it even excludes some things that we think are really important, like case management, like helping people enroll in government programs. And while the draft that DHCS has circulated doesn’t explicitly discuss payment, I think that leads us to believe that the department is looking at a fee-for-service payment model, and the concern with that is that you’re going to have CHWs and their employer organizations reporting exactly what [they] did, for whom, and how long it took. And that’s not how a CHW operates. That really limits the possibilities.

Savage-Sangwan said alternative payment models that allow for a broad scope should be prioritized, as well as those that allow community based organizations to employ CHW/Ps and do quality improvement over time.

DHCS is currently in the process of drafting the SPA and will be incorporating stakeholder input through March 2022. The SPA is scheduled to go live in the summer of 2022.