State Use of Medicaid Funding Mechanisms for Community Health Workers: Implications for Rural Populations

Community health workers (CHWs) serve on the frontlines of health care in rural and urban areas, representing an essential component of value-based care. Medicaid offers pathways for states to support the use of CHW services, including Section 1115 demonstration waivers and state plan amendments (SPAs). However, limited research has examined why and how states are using Section 1115 waivers versus SPAs to support these services, particularly in rural areas where workforce shortages and service gaps are especially acute. The purpose of this project is to describe and compare state use of two Medicaid mechanisms—Section 1115 waivers and SPAs—to support CHW services, with a focus on any implications for rural populations. By understanding how states are navigating and applying these mechanisms, it may provide insights into innovative approaches for integrating CHWs into health care in rural areas.

This project will apply a multi-stage, qualitative design to explore state use of Section 1115 waivers and SPAs for CHW services. First, we will conduct key informant interviews to gather information on the structures and processes of each mechanism. Interviews will explore topics such as mechanism requirements, timelines, reporting, and any rural or geographic considerations. Second, for states identified as using one or both mechanisms to support CHW services, we will complete a document review of publicly available supporting documents for their Section 1115 waivers and SPAs. Multiple elements will be extracted, with a focus on the intersection of any CHW descriptions and any rural or other geographic considerations. Lastly, we will conduct key informant interviews with a purposive sample of states using Section 1115 waivers and/or SPAs for CHW services. States with supporting documents that combine rural or geographic considerations with CHW provisions will be of particular interest. Interviews will expand on the document review, providing insight into the rationale for and structure of the state's mechanism, areas of innovation, and subsequent implications, particularly for rural populations. Ultimately, this design will provide a national lens on the use of each funding mechanism, followed by state-level considerations for selecting a specific mechanism and potential innovations.