How Community Health Workers Can Help Rebuild Trust in Public Health

Public health in America faces a paradox: its mandate encompasses the population as a whole, yet the infrastructure of public health—the teams of epidemiologists, interconnected data systems, layered prevention programs—is often invisible to the people it serves. Public health has also faced workforce woes that were amplified by the stress of the COVID-19 pandemic. Nearly half of all employees in local and state health departments left their positions between 2017 and 2021. And we will see further impacts to the public health workforce as a result of the more than $11 billion in funding cuts recently announced by the federal government.

This creates a vicious cycle. How do we recruit professionals into a field that blends its brushstrokes on the canvas such that the public can hardly tell where and how they’ve made their mark? Capacity gaps hinder the ability of public health to deliver on its essential services, further obscuring the work of public health from the public’s eye.

Meanwhile, with trust in the health system at record lows, it is understandable that many Americans find appeal in the “Make America Healthy Again” agenda. It is undeniable that too many in this country suffer from chronic diseases, addiction, and mental illness—and that existing health strategies and messengers have too often fallen short. People who reject the health establishment and its evidence often do so because they do not see themselves represented or heard by those institutions, and thus do not trust them. In seeking to win them over, we cannot confuse a battle seemingly over facts for what is actually a battle over trust.

Fundamentally changing this requires introspection by health leaders about becoming more trustworthy. “Hyperlocal” approaches, or those that work with community members on a neighborhood level, are most effective at combating misinformation and building trust. Community health workers (CHWs), particularly those who come from the neighborhoods they serve, become bridges to communities where there is often a justified and historically-rooted distrust of medical authorities. Last year, Chicago rapidly contained a measles outbreak, administering 30,000 vaccinations in less than 3 months, by taking a hyperlocal approach that incorporated CHWs partnered with local doctors.

CHWs have long been integral to local public health, delivering health education and services, linking individuals to vital health and social programs, and connecting health departments to the health care system. The benefits of integrating CHWs into these systems—particularly for chronic disease management—are not just anecdotal; they have been validated in randomized trials, and interventions have been demonstrated to generate positive return on investment for sponsors. Dr. Shreya Kangovi encapsulated the manifold benefits in a recent webinar when she said, “What if I told you there was a treatment for loneliness, discrimination, [and] intergenerational poverty that had been tested in multiple randomized controlled trials? … It’s empathy delivered in a structured way by community health workers.”

CHWs served on the frontlines during the COVID-19 response as a force amplifier for public health, with the Centers for Disease Control and Prevention (CDC) estimating that CHWs helped public health reach over 20 million Americans with health-related education and messaging. As a local example, consider New York City, where the city launched a new CHW program known as the Public Health Corps that connected over a million individuals to vaccination sites.

The nimble deployment of CHWs during a crisis demonstrates the need for sustained investment in CHW programs for everyday public health activities beyond emergency response. Interest in CHWs has only grown since the pandemic, with the CDC launching over 700 new CHW partnerships since 2021, though some are threatened by the recent federal cuts. More can and should be done to extend the reach and impact of these expert practitioners.

How can we bring the seeds of CHW programs planted during the pandemic to bloom? A common rate-limiting step is reimbursement. An analysis of the use of CHW services in 9 states from 2016 to 2020 found that only 731 CHWs billed state Medicaid programs during this time period – a fraction of the over 18,000 CHWs registered in those regions and the nearly 60,000 CHWs registered nationally during the study’s timeframe. Efforts are underway to realign financial incentives for CHWs; for instance, Medicare updated the Physician Fee Schedule in 2024 to include the first-ever billing code for CHW services. Nearly half of state Medicaid programs today now cover CHW services, although the mechanisms of coverage remain a policy patchwork ranging from State Plan Amendments to Section 1115 demonstration waivers. While legislation that would operationalize national coverage of CHW services was introduced last year, it has not been reintroduced for consideration by the 119th Congress.

Effective scaling also requires positioning CHWs as a linchpin for collaboration across health care and public health. Take Washington State, which in the wake of COVID-19, leveraged its Medicaid Section 1115 waiver and Accountable Communities of Health structure for health system partnerships to introduce a new statewide network of “Community Care Hubs.” These hubs position CHWs to serve as intermediaries between public health agencies, health care providers, hospitals, and social service and housing providers, steering clients from one node to the next. In this way, CHWs are a bridge not only to communities, but between our health care and public health institutions as well.

This is the concept at the center of a national call to action by the Common Health Coalition, a not-for-profit organization dedicated to strengthening partnerships between health care and public health. The inaugural Common Health Challenge will award grants to 10 exemplary CHW initiatives actively implementing this partnership model, and it will create a Community of Practice to advance strategies for formalizing cross-sector partnerships and supporting sustainability planning.

The exigency for American public health has prompted a national conversation about purpose, funding, and outcomes. In this moment of national turbulence, the truism—“all health is local”—may help provide a compass for navigating the challenges facing public health. CHWs help public health with its invisibility problem—and, in a virtuous cycle—its trust problem as well. By bringing care directly to communities, CHWs do the work of building trust in each other, demystifying health concepts, and helping people connect with services to live their healthiest lives.

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