Trusted, But Undervalued: Community Health Workers, Representatives, & Promotoras

California’s health care system cannot meet the needs of its communities without the people who serve as trusted messengers and health navigators: community health workers, promotoras, and community health representatives (CHW/P/Rs). These frontline workers bring deep cultural knowledge and lived experience to their roles, helping them connect with patients and deliver critical care. Many are women of color who have supported their communities for decades. Yet despite their vital contributions, they remain underpaid, under-recognized, and under-supported.

In recent years, state leaders have taken steps to better integrate CHW/P/Rs into the health system. The most significant was the launch of a new Medi-Cal benefit in 2022, which allows CHW/P/Rs and service providers to be reimbursed for specific services delivered through Medi-Cal (Medi-Cal is California’s Medicaid program). This year, state policymakers have the opportunity to support the long-term sustainability of this essential workforce by increasing rates and improving data reporting.

Community Health Workers Bridge Gaps in Access

CHW/P/Rs are trusted members of the communities they serve. They help people navigate complex health and social service systems, often in ways that are culturally and linguistically responsive to their communities. Their work spans health education, chronic disease management, behavioral health navigation, enrollment in programs like Medi-Cal, and outreach during public health emergencies such as wildfires and the COVID-19 pandemic.

They are especially effective in communities of color, where medical mistrust, language barriers, and systemic discrimination often prevent individuals from accessing the care they need. CHW/P/Rs help close these gaps not just by providing services, but by building relationships grounded in trust, cultural understanding, and lived experience.

Community Health Workers Make a Difference: A Case Study

During the COVID-19 pandemic, El Sol Neighborhood Educational Center played a vital role in supporting communities across the Inland Empire — a story highlighted in a blog post by the California Health Care Foundation. El Sol mobilized quickly to assess community needs and provide timely support. Community health workers reached out to residents across San Bernardino and Riverside Counties, making more than 16,000 phone calls to check in with families and identify the assistance they needed most.

As part of their outreach efforts, community health workers distributed more than 1,360 hygiene kits, 50,000 face masks, and 12,450 food boxes. They also helped individuals who tested positive for COVID-19 connect with health care services and other essential supports. When dedicated funding became available, the organization expanded its team of community health workers and began training other community-based groups to launch similar campaigns.

In addition to direct outreach, the organization used creative approaches like comic books, community theater, and music videos to deliver accurate, culturally relevant health information. These efforts helped combat misinformation, promote vaccine confidence, and build stronger connections between public health systems and the communities they serve. This case shows how CHW/P/Rs can drive high-impact, community-led responses when they have the tools and resources to succeed.

State Leaders Have Taken Initial Steps to Integrate CHW/P/Rs

State leaders have taken initial steps to integrate community health workers and promotoras into the Medi-Cal workforce. In July 2022, the California Department of Health Care Services (DHCS) established a community health worker benefit within Medi-Cal, allowing community health workers, promotoras, and community representatives to be reimbursed for certain services. This benefit was intended to better integrate CHW/P/Rs into California’s health delivery system and support their work as trusted messengers. It allows CHW/P/Rs to be reimbursed for activities such as:

• Preventing and managing chronic and infectious diseases.
• Supporting behavioral health and mental well-being.
• Providing perinatal, sexual, and reproductive health education and support.
• Assisting with oral health care.
• Addressing aging-related health needs.
• Promoting safety and providing support related to domestic violence and community violence prevention.
• Responding to environmental and climate-related health risks.

While this was an important first step, implementation can be improved. During an informational hearing in 2023, the California Department of Health Care Services reported that fewer than 6,000 Medi-Cal members had used the benefit and less than $1 million in reimbursements had been issued statewide. This limited uptake raises concerns about barriers to accessing the benefit, particularly for community-based organizations that may lack the administrative infrastructure to bill Medi-Cal.

Underinvestment in CHW/P/Rs Threatens the Workforce and Their Impact

Despite their central role in advancing health equity — the principle that everyone should have a fair and just opportunity to be healthy — CHW/P/Rs remain underpaid and undervalued. Many positions are funded through short-term grants, and the Medi-Cal reimbursement rates are not enough to support community-based organizations sustainably. This makes it difficult for organizations to recruit, retain, and fairly compensate CHW/P/Rs.

In recent years, health advocates successfully advanced a budget proposal to increase reimbursement rates for community health workers. The 2024 Budget Act included $5 million from the state’s General Fund Managed Care Organization (MCO) tax to fund a modest, regionally adjusted rate increase in the first year. However, the increase was ultimately eliminated after voters approved Proposition 35 in November 2024, which redirected MCO tax revenue toward other health care investments. As a result, any future rate increase would depend on General Fund support.

Without meaningful increases, many plans are now re-evaluating their own CHW/P/R compensation structures, and some community-based organizations are finding that the current reimbursement is not cost-effective due to high administrative overhead. A rate study is currently being requested by advocates to better understand how the state can sustain the CHW/P/R workforce and enhance uptake and utilization of the Medi-Cal benefit, but without immediate action, the benefit risks becoming symbolic rather than substantive.

Additional ongoing investments are needed to develop a strong pipeline of community health workers and also to ensure that workers are paid fair wages. Without reliable funding and workforce infrastructure, the state risks losing ground on efforts to improve community health and equity.

Latino Coalition for a Healthy California Promotora/CHW Fortina Hernández shares emergency preparedness resources while canvassing in the Los Angeles community.

Better Data Is Key to Expanding Access

A major challenge in evaluating and expanding the CHW/P/R workforce is the lack of reliable, centralized data. Policymakers and advocates don’t have access to key information, including how many CHW/P/Rs are delivering Medi-Cal services, who they’re reaching, and what outcomes they are achieving. While the federal Bureau of Labor Statistics collects limited data, it does not capture specific roles, pay sources, or population reach.

New proposed legislation aims to address some of these information gaps by requiring the California Department of Health Care Services (DHCS) to report on Medi-Cal benefit utilization. The bill aims to increase the Legislature’s understanding of the CHW/P/R benefit’s status through an annual report on the utilization data, which will enhance legislative oversight and inform any future legislation needed to strengthen and fund this vital program.

While this is an important step, the legislation alone is not enough. California lacks consistent, disaggregated workforce data across counties and managed care plans. DHCS has said it cannot collect some data, such as a health plan’s negotiated rate for CHW/P/R services, due to its contractual relationships with health plans, highlighting the need for greater transparency and accountability.

Without better data, the state cannot measure the benefit’s effectiveness or track whether the workforce is growing. Early signs suggest limited progress, and stakeholders are concerned that the benefit is not living up to its original promise of building and sustaining a robust CHW/P/R workforce.

Conclusion

Community health workers, promotoras, and community health representatives (CHW/P/Rs) are central to achieving health equity in California. They are trusted, experienced, and deeply embedded in the communities they serve. However, current policies and funding structures fall short of recognizing and sustaining their contributions to keeping communities healthy.

Promotoras and community health advocates at the State Capitol during Latino Coalition for a Healthy California’s 2024 Day at the Capitol.

To deliver on California’s commitment to health equity, state leaders should support better pay and career pathways for these essential health care workers. Policymakers can do this by raising reimbursement rates under Medi-Cal, implementing AB 403 with transparency, and investing in workforce data infrastructure. Policymakers should also support career pathways and certification processes that honor the lived experience and skills that CHW/P/Rs bring to the table.

CHW/P/Rs are not a new idea — they are a proven solution that supports access to health care, improves health outcomes, and builds trust in underserved communities. What they need now is real investment.