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Promoting Sustainable Financing of Community Health Worker Programs Advancing Sustainable Financing of Community Health Workers Logan Kelly Learn how health agencies can shape policy development and implementation to support sustainable financing of community health worker services. Community health workers (CHWs) develop trusted relationships with individuals based on community knowledge and shared life experiences, and provide services such as coaching, navigation of health and social services, and social support. Federal and state COVID-19 funding streams spurred the growth of the CHW workforce, as it supported hiring, training, and deploying CHWs across the country. As these funding streams come to an end, many CHW programs now face funding gaps—however, Medicaid and Medicare present new, promising funding opportunities. In a growing number of states, there are mechanisms for Medicaid to cover CHW services, and in January 2024, Medicare began reimbursing for a new set of services called Community Health Integration (CHI), marking the first time that Medicare services were designed to include specific roles for CHWs. In this shifting funding landscape, state and territorial health agencies (S/THAs) can shape policy development and implementation to support sustainable financing of CHW services. They are critical in elevating CHW and community perspectives, and ensuring that the community organizations hiring CHWs can access relevant financing systems. Further, public health leadership can raise awareness of new funding streams, track their utilization, and see that these new policy options “stick.” With CDC support, ASTHO partnered with the Center for Health Care Strategies (CHCS) to convene a series of calls for state public health agency staff around emerging CHW financing options. Drawing on the experience and insights of participating states, outlined are key strategies for S/THAs to support the CHW workforce. Policy Development and Implementation Support effective design and implementation of Medicaid and Medicare funding opportunities, including by engaging CHWs and community partners. Throughout the establishment of new funding opportunities, S/THAs can be key partners in supporting policy development and implementation by: Incorporating perspectives of CHW stakeholders, community organizations, and multiple agencies in program design decisions. Some states have established CHW advisory bodies to support policy design and implementation. Encouraging adequate Medicaid reimbursement rates. Medicaid rates for CHW services and overall CHW average wages vary widely across states. States such as South Dakota and Kansas have engaged CHW partners in developing rates that will support greater access to these services. Providing education and supporting infrastructure development for CHW employers to integrate with health care entities and receive new forms of reimbursement. Analyzing Medicaid claims data periodically to understand uptake of CHW services and support effective implementation in states with Medicaid reimbursement for CHW services. Capacity-Building Support capacity-building for braided and blended funding models. As new health care financing opportunities for CHW services become available, S/THAs can work with CHW employers to create funding models that braid or blend funding from different sources (e.g., public health, health care, and social services) to avoid overreliance on a single funding source. This involves: Supporting the development of community care hub infrastructure. Community-based organizations (CBOs) often lack the infrastructure to contract with health care entities. Community care hubs coordinate administrative functions and manage funding streams for a network of CBOs and are especially important for supporting the CBO-health care partnerships to contract for Medicare CHI services. Considering opportunities to align public health, Medicaid, and/or Medicare funding, including through initiatives that incorporate CHWs into broader strategies to address social determinants of health (SDOH). Some states are exploring how to align Medicaid coverage with CHI services in Medicare. Identifying non-traditional funding sources to support CHW activities. There is a range of HHS grants that have directly addressed CHW training and hiring, but other federal agencies such as the U.S. Department of Labor or Housing and Urban Development may have funding opportunities that can incorporate CHW services. CHW Training and Certification Design and refine CHW training and certification programs to align with financing opportunities. States vary in how they structure and administer CHW training and certification programs, though S/THAs serve as program administrators in many states. Although there is no federal requirement for CHWs to be certified for Medicaid reimbursement, it is common for states and CHWs to pursue certification and/or training requirements as part of authorizing new Medicaid coverage. The Medicare rule authorizing CHI services defers to relevant state rules on training and certification. S/THAs can align CHW training and certification with these new funding streams, while also addressing the importance of accessible certification for practicing CHWs, by: Aligning CHW training program requirements with the knowledge, skills, and abilities that CHWs will need to deliver services reimbursable by health care payers. S/THAs can develop a crosswalk of existing training curriculum requirements against CHI and Medicaid competencies to identify any gaps. Offering dual certification or specialized certification/training pathways to maximize opportunities for CHW employment and reimbursement. For example, the New Mexico Office of CHWs offers both a state generalist CHW certification and three levels of specialist certifications, which have helped to support more CHWs to bill to Medicaid. Allowing certification reciprocity between states, which could ease the pathway to certification especially among CHWs who work near/across state borders or serve tribal populations. Looking Ahead The growing momentum for CHW services and new financing opportunities enable S/THAs to enhance the sustainability of CHW programs. S/THAs can support policy development that meaningfully engages CHWs, and affirms the full range of the CHW workforce’s strengths and capabilities. Learn more about how S/THAs can serve as CHW program funders, administrators, and policy design champions in ASTHO-CHCS report, “Opportunities for Public Health Agencies to Advance Sustainable Financing of Community Health Worker Programs.” website yes

Learn how developing effective partnerships can help health agencies and tuberculosis programs address drug shortages.

Economic security and well-being, job stability, access to safe and affordable housing, access to healthy and nutritious foods, and access to resources to manage mental and physical health—all of these things impact individual, family, and community health. The COVID-19 pandemic has fundamentally impacted each of these social determinants of health for many Americans. Furthermore, some communities and industries have faced harder economic impacts than others, including households with low incomes, non-white households, and households with children. Human services and public health leaders can collaborate to make sure we are rebuilding systems and programs in a way that creates healthier, more resilient families and communities.

On Oct. 4, 2023, ASTHO, CDC, the Center for Law and Social Policy, and Mental Health America released a framework for public health leaders with effective strategies to improve mental health and prevent suicide for all people, in every community in the settings where they live, learn, work, and play.

As COVID spread through the country and infection rates rose in every state, many of the the U.S. Affiliated Pacific Islands (USAPI) received media attention for remaining relatively COVID-free. The USAPI’s unified response in the face of a global pandemic is a history-making tale of collaboration, communication, and partnership. The successes of public health leaders provide important lessons for preventing, preparing for, and responding to future public health emergencies.

The opioid crisis continues to claim the lives of thousands across the United States and has cost the economy billions in health care, mortality, and criminal justice costs. In 2018, it’s estimated that 67,367 people died of overdose, with opioids (prescription opioids, heroin, and other synthetic opioids other than methadone) made up almost 70% of overdose deaths. Provisional data for the twelve-month period ending December 2019 shows that there were 71,130 overdose deaths, with 50,178 overdose deaths attributed to opioids. The COVID-19 pandemic has also exacerbated the drug overdose crisis. Data shows that in the time of continued lockdowns and social distancing that overdose rates have increased, indicating a sustained need to support people with substance use disorder.

ASTHO CEO Michael Fraser, PhD, and Tracey Wareing Evans, President and CEO of APHSA, sit down to discuss building a foundational family well-being roadmap amidst the COVID-19 pandemic.

State and local jurisdictions are developing Ending the HOV Epidemic plans. The EHE initiative has largely focused on four key strategies: Diagnose, Treat, Prevent, and Respond to potential outbreaks. The EHE initiative set a goal to increase the estimated percentage of individuals with indications for PrEP who have been prescribed PrEP to 50 percent by 2025, as the national average as of 2018 is 18.2 percent. Several states have proposed and/or passed legislation to ensure insurance coverage of PrEP and/or to allow pharmacists to prescribe and dispense it. In addition to efforts addressing cost-related challenges, states can also employ innovative approaches—such as telehealth—to expand access to PrEP services to those in need.

In anticipation of the upcoming presidential election in November, the Republican and Democratic National Committees released their platforms. These platforms provide an overview of values, policies, positions, and principles on various domestic and foreign issues deemed most important to the two political parties. For the upcoming 2020 elections, delegates of the Republican National Committee approved a resolution that renewed support for the platform adopted in 2016 and the Democratic National Committee approved a 2020 platform. Although both platforms touch on a diverse list of issues, there are several that are of interest to health and public health.

The adage “what gets measured, gets done” has had staying power for a reason. When we can accurately describe conditions, quantify impact, and elucidate connections, we have a better chance at taking collective (and effective) action to tackle even the most challenging problems facing our communities. The National Survey of Children’s Health is a powerful tool to provide this critical information to researchers, policymakers, and state-level decision makers.

State and Local Health Officials at the Capitol to Urge Congress to Prioritize Funding for Public Health ARLINGTON, VA—Over 80 state, local, and territorial health officials from across the country will meet with members of congress on Capitol Hill together on March 13, 2019. The aim of their visits is to share the critical need to sustain investments in public health agencies that protect and promote the health of all Americans and prevent sequester cuts in the FY20 budget. This is the first-time members of the Association of State and Territorial Health Officials (ASTHO) and the National Association of County & City Health Officials (NACCHO) will combine their annual Hill Days to show a collective voice for governmental public health at the Capitol. Public health leaders are concerned about the impact of the potential $55 billion cut to non-defense discretionary spending that will happen in FY2020 if Congress does not act to prevent it. ASTHO and NACCHO strongly urge Congress to work in a bipartisan manner to raise FY2020 budget caps and provide needed funding for non-defense discretionary programs, and support increasing CDC’s budget 22 percent by FY22. “Our entire governmental public health system is strained. My colleagues are on the ground dealing with several measles outbreaks, the opioid epidemic, and natural disaster recovery, all while continuing the core work of disease prevention—especially at the community level. Unfortunately, we are consistently underfunded and must do more with less. As a nation, we must do better and prioritize investing in public health,” says Nicole Alexander-Scott, MD, MPH, ASTHO president and director of the Rhode Island Department of Health. “Every person and every community should have the opportunity to be as healthy as possible. As part of ASTHO’s President’s Challenge, additional federal resources will help equip health officials to mobilize community-led, place-based collectives to improve the way we live, work, and play.” “In the decade since the Great Recession, public health departments have lost about a fifth of their workforce due to funding issues and recovery has been slow at best. We see the impact of these resource losses on the health and well-being of our communities every day. In so many areas of public health, we know what works, but we don’t have the resources to ensure that all Americans, no matter where they live, have access to the same basic public health infrastructure, services, and protections,” says Kevin Sumner, NACCHO president and health officer/director for the Middle-Brook Regional Health Commission. “So much of our public health system operates silently in the background. By joining together on Capitol Hill, we will amplify our voice and spread the message of the importance of governmental public health in all sectors.” For more information on ASTHO’s advocacy priorities, visit http://www.astho.org/Advocacy-Materials. For more information about the President’s Challenge, visit http://www.astho.org/ASTHO-Presidents-Challenge/2019. For more information on NACCHO’s advocacy priorities, visit https://www.naccho.org/uploads/downloadable-resources/flyer_legislativeagenda_2019.pdf. ASTHO Press Release Boilerplate NACCHO Boilerplate website yes

The ASTHO-Mason Collaborative for Applied Public Health Practice will increase access to public health education and training through student fellowships, innovative curriculum, applied practice and policy research, and academic and continuing education programs for public health students and professionals.

ASTHO and PIHOA Praise Approval of Medicaid Funding Fix for U.S. Territories ARLINGTON, VA—This week, Congress approved legislation to extend Medicaid funding for two years for the U.S. territories in their fiscal year 2020 appropriations bills and extenders package. Esther Muña, the chief executive officer of the Commonwealth Healthcare Corporation, Association of State and Territorial Health Officials (ASTHO) board member, and Emi Chutaro, executive director of the Pacific Island Health Officer’s Association (PIHOA), issued the following statements applauding the bipartisan and bicameral extenders package. The legislation avoided devastating cuts to the territories’ health care services for their most vulnerable residents, scheduled to take place at the end of the year—widely called the “Medicaid Cliff.” “The U.S. territories face unique healthcare and public health challenges and the support provided through the Medicaid program allows us to care for Americans who live on these islands in their communities,” says Chutaro. “It is vital that we prioritize public health for Americans living in the U.S. territories,” says Nate Smith, secretary of health at the Arkansas Department of Health and ASTHO president. “Ensuring access to care is essential to protect and ensure health equity among and well-being within this population. As state health officials, we know that what benefits the territories will help us in our quest to bring optimal health to all.” “We are grateful for the bipartisan and bicameral legislation which provides a two-year increase in funds and federal match for the Medicaid program in the U.S. territories," says Muña. “The increased funding will allow the health care and public health systems in the U.S. territories to further improve access and quality of care to the population. This funding continues to be vital to all of the U.S. territories, and while we are grateful for this temporary fix, we must find a long-term solution to Medicaid funding to provide stability to our system of care. In the upcoming year, we look forward to working collaboratively with Congress and the Trump Administration to further bolster health care and public health systems to build healthy and resilient communities throughout the U.S. territories.” ASTHO Press Release Boilerplate PIHOA Boilerplate website yes

ASTHO Launches National Campaign to Support Healthy Communities, Aligning with NACCHO and the U.S. Surgeon General ARLINGTON, VA—The Association of State and Territorial Health Officials (ASTHO) announced this week the launch of a multi-year initiative to build healthier and more resilient communities across the country. The challenge, “Building Healthy and Resilient Communities,” will be led by ASTHO’s president and director of the Rhode Island Department of Health, Nicole Alexander-Scott, MD, MPH, in partnership with the National Association of County and City Health Officials (NACCHO) and aligned with the U.S. Surgeon General’s focus on community health and economic prosperity. The challenge calls on state, territorial, local, and tribal health officials to align strategic investments and promote community-driven, place-based solutions to empower communities to be as healthy as possible, reduce health disparities, and stimulate economic development. Examples of such initiatives include Rhode Island’s Health Equity Zones, Purpose Built Communities in Georgia, the Fort Worth Blue Zones Project, and Live Well San Diego. Activities to support the challenge will center on creating opportunities for health officials to mobilize community advocates and partners towards making lasting systems and policy changes that improve living conditions at the community level. Using this platform, ASTHO and its partners, along with NACCHO and the U.S. Surgeon General, will connect public health officials with business leaders, policymakers, and other cross-sector stakeholders to shift investments to promote sustainable, equitable community development. “Health officials have a critical role to play ensuring that everyone in every community has an equal opportunity to be as healthy as they can be, regardless of their zip code,” says Dr. Alexander-Scott. “My vision is for ASTHO, along with NACCHO and the U.S. Surgeon General, to empower all public health leaders to build stronger, more connected communities that have the assets and resources they need to create the conditions for success to be as healthy as possible. By funding and implementing sustainable strategies that are tailor-made for each community, we can amplify the community’s voice and transform public health for generations to come.” “America’s greatest assets are its communities, so we should turn to them more often,” says VADM Jerome Adams, MD, MPH. “We have the best healthcare system in the world, yet life expectancy in the United States is lower than in many other high-income countries. State and local health officials know their communities best and should be inspired to change the community environment to make sure that healthy behaviors are easy behaviors that are available to everyone.” “We’re pleased to lead this challenge with ASTHO and recognize there are great synergies between state and local health officials that will allow us to be successful in equipping and encouraging communities to think more strategically about health at the community level,” says Kevin Sumner, MPH, NACCHO president and health officer for the Middle-Brook Regional Health Commission in New Jersey. View ASTHO’s President’s Challenge for more information. ASTHO Press Release Boilerplate website yes

On Dec. 3, the International Day of People with Disabilities commemorates disability rights and brings awareness to essential issues for those with disabilities by promoting the “well-being of persons with disabilities in all spheres of society.” While the ADA laid a critical foundation for disability rights, the work to ensure equitable access to services and needs continues, including access to state and local emergency preparedness and response activities like crisis communication, access to resources, allocation of vaccine and other medical countermeasures, and transportation.

If there is any word to describe 2020 it is “unprecedented,” with the work of health agencies front and center since COVID-19 emerged in the U.S. But as we approach Public Health Thank You Day and the Thanksgiving season, ASTHO wants to send a special appreciation to our entire state and territorial public health workforce. We have been so impressed by your tireless work to address COVID-19 in your jurisdictions and you have wowed us all with your dedication and commitment to the work of health protection and improvement. Thank you all for all you do to keep your communities healthy!

Over the years evidence has expanded on community health workers (CHWs) improving outcomes and even reducing disparities in heart disease and many other public health priority areas. However, their presence in state and local public health workforce is still modest. A number of efforts have sought to expand the role of CHWs in medical care settings by developing reimbursement through third party payers, along with including them in managed care contracts and incorporating them in state Medicaid plans. The experience and lessons of the COVID-19 pandemic could substantially change the way we practice public health in the future, and provides opportunities to expand the role and presence of CHWs in the state and local public health workforce.

Guest post by Jennifer Orme-Zavaleta, PhD. Last month, I had the pleasure of joining ASTHO’s Vice President for Health Security, Meredith Allen, EPA Administrator Michael Regan, and the president of the Environmental Council of States (ECOS) Patrick McDonnell at the ECOS Spring Meeting. The event marked the start of a strong state-federal relationship under the new EPA leadership, highlighted by the extension of a formal Memorandum of Agreement (MOA) reaffirming a partnership between our three organizations to advance cooperative initiatives in pursuit of environmental health.

On Nov. 13, 2024, ASTHO announced the launch of the Innovation Advisory Council.

Readout of CDC/ASTHO/CSTE/APHL Call Regarding Avian Influenza Preparedness ARLINGTON, VA—On Friday, Nirav D. Shah, CDC’s Principal Deputy Director, Dr. Demetre Daskalakis, Director of CDC’s National Center for Immunization and Respiratory Diseases, and Dr. Vivien Dugan, Director of CDC’s Influenza Division, met with members of the Association of State and Territorial Health Officials (ASTHO), the Council of State and Territorial Epidemiologists (CSTE), and the Association of Public Health Laboratories (APHL) to discuss avian influenza planning. CDC officials emphasized that, although the risk to the public remains low, the agency wants state public health officials to be prepared to respond. CDC recommended that state public health officials engage with their state veterinarians and agriculture department officials to ensure that they have up-to-date operational plans to respond to avian influenza at the state level. For example, CDC emphasized the importance of having plans in place to quickly test and provide treatment to potentially impacted farm workers following positive results among cattle herds. CDC also encouraged state health officials to communicate about any challenges they are facing. ASTHO, CSTE, and APHL members support CDC’s recommendations and look forward to continuing their partnership with their state agriculture counterparts, as well as CDC and other federal agencies, as part of their preparedness efforts. ASTHO Press Release Boilerplate website yes