California turned to them to close health gaps, then retreated

The Role and Challenges of Community Health Workers in California

Fortina Hernández is often referred to as “the one who knows it all.” For over two decades, she has served as a community health worker in southeast Los Angeles, supporting hundreds of families by helping them access food assistance, share information about affordable health coverage, and manage medications for chronic illnesses. Her work is guided by the saying, “an ounce of prevention is worth a pound of cure.”

Despite her critical role, Hernández earns only around $20 per hour from her organization and must take on a second job to make ends meet. “They pay us very little and expect too much,” she said in Spanish. “We build trust. We offer support. We’re the shoulder people rely on, but we don’t get fair wages.”

California aimed to professionalize thousands of community health workers like Hernández to improve the health of immigrant populations, particularly Hispanic residents, who often face higher rates of chronic diseases, are more likely to be uninsured, and encounter cultural and linguistic barriers when accessing services. Studies show that their work may reduce hospitalizations and emergency room visits.

The state followed expert recommendations from 2019 to standardize training, integrate these workers into the healthcare system, and provide fair wages, including Medi-Cal reimbursements. However, six years later, many of these initiatives have been abandoned.

State Initiatives and Their Impact

The state eliminated a certification program and rolled back nearly all funding for training and expanding this workforce, despite setting a goal of 25,000 workers by this year. While Medi-Cal began covering their services, participating health plans set uneven billing requirements, making it difficult for workers to get reimbursed. Additionally, the state did not follow through on a planned pay raise.

With federal funding cuts and President Donald Trump targeting immigrants for deportation—even sharing personal Medicaid data with the Department of Homeland Security—advocates fear California is abandoning its health equity initiative for immigrants, people of color, and low-income individuals when they need it most.

“We're in a very dire situation right now,” said Cary Sanders, senior policy director for the California Pan-Ethnic Health Network, a statewide health equity advocacy group.

The Growing Workforce and Its Challenges

There are more than 60,000 community health workers nationwide, including roughly 9,200 in California, and this workforce is projected to grow 13% over the next decade, three times faster than for all occupations, according to 2024 data from the U.S. Bureau of Labor Statistics. However, experts say these numbers are an undercount given the various titles these workers hold and the fact that many work outside traditional health care and governmental institutions.

Community health workers, often known as promotores, tend to be women who work in clinics, hospitals, public health departments, and local nonprofits. They are trusted figures who understand their communities' most pressing health needs. Beyond managing chronic illnesses, they promote reproductive health, children’s health, and oral hygiene, and help seniors with dementia prevent injuries and review medications. They also assist in reporting domestic violence and connect people to housing and food assistance.

“The community health worker is not sitting at a desk,” Hernández said. “Our office is on the street.”

Policy Changes and Funding Issues

In 2019, the California Future Health Workforce Commission recommended integrating community health workers into the health care system. In 2022, the state authorized $281 million over three years for the California Department of Health Care Access and Information to recruit, train, and certify them. However, due to budget constraints, the state slashed $250 million in funding last year, and the certification program was officially eliminated this year.

Spokesperson Andrew DiLuccia said the agency is now considering a program to accredit community organizations rather than individual workers and plans to spend its remaining $12 million on technical assistance, workforce development, and salaries for those working with immigrant communities.

According to the National Academy for State Health Policy, 32 other states offer a voluntary or mandatory community health worker certification program. Some advocates argue that California is missing an opportunity to create a career path for this workforce. Currently, some courses require fees, degrees, English fluency, or prior experience, and most are concentrated in urban areas, leaving training deserts in much of the state.

Medi-Cal's Role and Challenges

Medi-Cal began covering community health workers’ services in July 2022, but the state suspended a planned pay increase after voters approved Proposition 35, which raised the pay of physicians, hospitals, and other providers. Since then, the state has yet to establish a uniform system for how health plans should contract with organizations that employ community health workers.

“We have to jump through hoops,” said Maria Lemus, executive director at Visión y Compromiso, a Los Angeles-based nonprofit representing community health workers. “It just causes havoc, because each plan could have different requirements.”

Advocates say that Medi-Cal reimbursements are insufficient, with payments ranging from $9.46 to $27.54 for 30 minutes of work. They believe workers should earn at least $30 per visit, with benefits, but many earn about $21 per hour, often without benefits.

The Future of Community Health Workers

With health funding cuts from the Trump administration and the GOP’s tax and spending legislation, advocates fear there will be even less funding and support for community health worker positions, shrinking a workforce tackling health disparities. Fresno County’s Department of Public Health recently cut its community health workers by more than half, from 49 positions to 20.

Yet, outreach is more crucial than ever. As the Trump administration continues immigration raids, which appear to have targeted at least one health clinic in the state, advocates and policy researchers say community health workers could act as intermediaries for immigrant patients afraid to seek medical care in hospitals and clinics.

Without a state certification program, no raises, and dwindling training funds, the path to professionalizing community health workers remains unclear, leaving workers feeling left behind.

"The community trusts me," said Hernández, "but at the government level, there’s still a long way to go before this work is valued and fairly compensated."