On my first day as a community health worker (CHW) at a federally qualified health center (FQHC), a young mother stepped into the food pantry within our clinic, a resource available to patients and community members once a week. She had no health insurance, spoke Spanish, and was looking for food to carry her family through the week; she was my very first patient. At the beginning, my role was to welcome visitors, listen, and connect them with the available resources we had on hand. As the weeks passed, my responsibilities stretched far beyond distributing food. I found myself calling pharmacies in search of low-cost medications, helping families fill out applications for prescription assistance programs, and contacting local housing and transportation nonprofits to connect patients with additional resources. Patient encounters like these became my daily routine, and over time, I soon felt the weight of having to act as the bridge across the systemic gaps our patients were falling through.
Witnessing Community Pain and Pushing for Change
CHWs have been institutionalized as “frontline public health workers” who share a close understanding with the communities they serve. While this definition highlights proximity, it fails to capture the depth of labor and responsibility CHWs actually carry. In practice, CHWs build trust through sustained relationships, navigate complex health and social service systems, provide interpretation and advocacy, and often fill critical gaps in care that institutions overlook. This means CHWs do far more than simply connecting people to services. We perform the emotional and practical work of ensuring that underserved communities are not left behind, all while being underpaid or unpaid.
Here, the first-responder/last-resort paradox becomes clear. One day, I might be the first person to help a newly arrived immigrant family schedule specialist appointments, while another day, I am securing an emergency hotel voucher for a family facing eviction and homelessness. Officially, we are “liaisons between health, social services, and the community.” Unofficially, we are both the initial point of contact and the fallback safety net when no one else steps in.
Because the healthcare system routinely fails to meet the needs of marginalized communities, CHWs become more than service providers and we witness how healthcare policies translate to realities on the ground. For example, federal law bars undocumented immigrants from enrolling in Medicaid, Medicare, Children’s Health Insurance Program (CHIP), or purchasing ACA marketplace insurance, and many “lawful” permanent residents face a 5-year waiting period before becoming eligible. As a result, in 2023, half of undocumented immigrants and one in five “lawfully” present immigrants were uninsured compared to 8% of U.S.-born residents. Throughout my time as a CHW, I met Latine families afraid to seek help because of language barriers or fears about immigration enforcement. I met diabetic patients rationing insulin because their low-wage jobs offered no health benefits. Each story was a testament to the needs that our public health and healthcare systems often overlook. CHWs are the first to learn of these precarious realities at the point of contact and the last to disengage because no other service is structured to stay with families through each barrier.
Over time, CHWs become more than service providers. Many CHWs find themselves raising their voices about these injustices. We start by advocating for individual clients, speaking up to a doctor who is not listening to a non-English-speaking patient, or calling a state agency to argue for someone’s eligibility. In my case, it led me down a path of public health and social work, where I sought macro solutions to the problems I encountered one-on-one. I am not alone in this evolution. Research shows that CHWs are often political actors and advocates. When given advocacy and leadership training, they are 2–4 times more likely to engage in political and civic advocacy compared to peers without such training. In other words, empower a CHW with skills and a platform, and they can channel community experience into policy change.
In fact, some CHWs have organized and testified for better healthcare access, translation services, or housing reforms. In California, promotoras de salud (CHWs rooted in Latine communities) mobilized alongside advocacy groups to push for a Medi-Cal benefit that would reimburse CHW services. They gathered testimonies from patients and presented lived experiences at legislative hearings to demonstrate how their work addresses systemic gaps in care. This effort led to the creation of a new Medi-Cal benefit in 2022, allowing CHWs, promotoras, and community health representatives to be reimbursed for activities ranging from chronic disease management to violence prevention to climate-related health response.
This kind of organizing illustrates what it means to call CHWs political actors. They are trusted messengers and navigators who also advocate and leverage community relationships to shift policy, secure resources, and demand accountability from health systems. By turning community needs into political action, CHWs become first responders to systemic neglect of marginalized communities, in addition to individual health needs.
And yet, herein lies another great paradox.
Essential Work, Expendable Workers
At the beginning of the COVID-19 pandemic, CHWs were hailed as heroes, delivering food and masks, helping people quarantine safely, and connecting families to numerous resources. Their relationships were grounded in cultural understanding, shared lived experience, and trust, enabling CHWs to reach people that the public health agencies often neglected in pandemic response. For example, when our Packard Health team set up vaccine pop-ups in neighborhoods across Ann Arbor and Ypsilanti, it was CHWs who called families, reassured them in their own language, and scheduled their appointments. Across the country, public officials praised the CHW outreach effort. It was affirming to be recognized as part of the public health response.
During the first peak of COVID-19, CHWs were temporarily resourced through emergency funding to conduct outreach, distribute supplies, and provide health education. When government restrictions were lifted and the immediate crisis was treated as over, much of that funding disappeared even though the underlying social safety net issues that were broken before the pandemic continued. This flashpoint of investment revealed how CHWs are seen as expendable despite their essential status. In many places, CHWs are hired on grant-funded projects or short-term initiatives, making them among the first to be let go when budgets tighten or the federal government targets grants. Low wages and unstable funding have long undermined the sustainability of this workforce. Nationally, this precarity is common: CHW turnover rates are higher than the U.S. workforce average, with many workers leaving due to short-term funding, low pay, and lack of recognition. The result is a fragile workforce and more instability for the very communities that rely on them.
Health systems, as currently designed and operated, are unable to meet and simply do not prioritize the needs of underserved communities without CHWs. At Packard Health, for example, there was a period when I was one of only two CHWs responsible for hundreds of patients. Even as the team grew, the number of people needing support expanded faster. In the Transitions Clinic Network, formerly incarcerated CHWs channel their lived experience to not only build healthcare trust with returning citizens, but also support them in rebuilding their lives that were destabilized by incarceration. These types of programs often run on limited budgets with minimal support, leaving us feeling overstretched and undervalued. Because CHWs are personally rooted in the communities they serve, the work becomes more than a professional role confined to a typical 9-to-5. We carry the stories home and respond to needs outside formal duties, leaving our phones on and hearts open. This emotional tether often develops without a myriad of structural supports, leading to burnout and, eventually, turnover.
It is in these cracks that CHWs prove their necessity. We navigate the complex intersections of health, housing, food, and legal systems, translating bureaucracy into human terms. If a patient misses appointments because they lack transportation, a CHW secures a bus pass. If a child’s asthma worsens due to mold in their apartment, a CHW connects the family to housing and legal resources. Most healthcare systems are not designed to provide these services, but they are the everyday needs that CHWs address while working within these systems. Positioned at the overlap of public health and social work, CHWs hold together broken safety nets that were never designed to solve the real-world realities of poor health driven by racism, poverty, migration, and marginalization.
So, what needs to change? As someone who has been a part of community work and health systems, I see several initial steps forward:
- Secure and sustainable funding: We must move beyond pilot projects and integrate CHWs as core staff in health teams, with stable salaries (including benefits) funded by insurance reimbursement or public investment. Long-budget lines need to replace short-term grants.
- Career paths and training: CHWs deserve opportunities for professional development and advancement that support them to remain in the field. They should have supervision, support, and be respected as skilled professionals.
- Inclusion in decision-making: Whether it is designing patient outreach or setting priorities for a health department, CHWs need to inform decision-making and have decision-making power due to their unique positioning within communities.
- Upstream structural change: CHWs cannot indefinitely serve as a patchwork for a fractured safety net. Policies must address the underlying drivers of racism, poverty, migration, and marginalization that make CHWs necessary as harm reducers. This means investing in affordable housing, food access, immigrant protections, and equitable social services alongside strengthening the CHW workforce.
My recommendations are based on personal experience during my time in the field as well as research and theoretical frameworks that highlight the effectiveness of CHWs when adequately resourced and supported. The Social Determinants of Health reminds us that upstream drivers like housing and food insecurity must be addressed for health equity to be possible. The concept of structural competency underscores why CHWs are essential in navigating systems amidst systemic racism and poverty, but also why relying on them as stopgaps is unsustainable. Finally, Community-Based Participatory Research principles demonstrate that health systems improve when communities and CHWs are active participants in shaping interventions and decision-making. Together, these frameworks explain why CHWs are pulled into first response and why, without upstream change, they remain the last resort.
CHWs will continue to be treated as expendable as long as the structural drivers of inequality persist. Health systems exploit CHWs’ deep community ties, underpaying and under-supporting them, while shifting the burden of a broken infrastructure onto their shoulders. This paradox expands CHW roles, pushing them to fill the gaps left by policy failures. To truly value CHWs, we must integrate them into planning, budgets, and decision-making and also address the systemic inequities that make their uncompensated labor necessary in the first place.
Authored by Wolfgang V. Bahr
Wolfgang V. Bahr is a former Spanish-speaking community health worker who served at Packard Health in Ann Arbor, Michigan. He has a dual master’s degree in public health and social work from the University of Michigan and is now a PhD student in Health Behavior at the University of North Carolina at Chapel Hill, focusing on the structural and social factors that influence access to health and social services for Latine people.
