By: Regan Kelso
I was driving home from a field visit at the end of a workday when I ran over a pothole and damaged my car. I heard the popping sound right before feeling the weight of my car drop from underneath me, like it had been swallowed by the road. I went into sheer panic looking in the rear view mirror hoping cars would slow down and see that I was stopped in the middle of the street. Although I was in a residential neighborhood, it was rush hour, the time of day when everyone, like myself, was trying to get home. I flashed my emergency lights before getting out of my car to assess the harm. A piece of metal dangled from under my car’s cabin. Panic turned into anger at myself and the city. I was upset that I did not swerve around to avoid the potholes like I do every night. And, I was annoyed with my city for its neglect.
The potholes, like the people and boarded up houses and businesses, were abandoned by the city without urgency to fix what was broken. My damaged car was now another unfortunate hardship. I’d spend the next couple of days looking for low-cost repairs to fix a broken axle, while rearranging school drop-offs for my kids and rescheduling patient home visits.
I was tired. I had little money to last until the end of the month and now I was without a car. I searched for local city and state transportation resources that could help my situation with the thought: if this is happening to me, it may happen to others in my community too. I had a hunch that I would need to share the resources I found for myself with someone else soon.
When I told my CHW Central colleagues that I wanted to write about ways CHWs earn additional money with side jobs, I had just spent $1300 on car repairs I couldn’t afford. I looked for second jobs to recoup the money I put into my car. I knew of several CHWs who made additional income working as consultants, doulas, or selling items on Etsy. And, I wanted to learn and share with other CHWs how to market their skills into entrepreneurship.
I was passionate about using my communication skills to empower other CHWs who needed to supplement their income. But, when I sat down to write, my enthusiasm turned into frustration when I asked myself: Why do CHWs need side jobs to earn a living wage?
I called my CHW friends to ask their thoughts on CHW wages. Everyone I talked to had something to say about feeling underpaid, and overworked. My friends shared the same sentiment of feeling undervalued. Beneath the frustration was hope for driving change with remuneration as a solution to increase pay and promote CHWs.
I decided that if I wrote anything related to CHWs and money, I would discuss the biggest social determinant of health for CHWs—income. CHWs must earn more pay.
According to Indeed.com, CHWs in the US earn an average of $35,884 annually. In California, where I live, CHWs earn $38,799 annually, which is 8 percent above the national average. Indeed’s data comes from CHWs who shared their salary on the website. The numbers reported seemed accurate and reflective of what I have been offered and paid by previous employers.
In a 2021 study, The Bureau of Economic Analysis reported that, on average, it costs $53,082 a year to live in California¹ٰ ². Which means, if a single full-time CHW makes $38,799 a year and the cost of living is $53,082, then this CHW would need $14,283 more a year to earn a sustainable wage. If not having enough income determines a person’s poverty level, I wonder what these numbers mean for a full-time CHW with a family of four?
From my lived experience, not earning a sustainable wage means that difficult choices are made when it comes to prioritizing basic needs. Running out of money at the end of the month was not determined by poor money management as suggested by some financial guru correspondents who judge poorer families. Not having enough money for food was not determined by my family’s preference of what we like to eat, but how we allocate our limited resources between shelter or food. And, when a person is living with a chronic illness, going without basic needs will always negatively affect health outcomes. I mothered children with severe allergies who required special diets. In these cases, following an elimination dietary plan was not chosen to accommodate a trendy California lifestyle, it was a health necessity.
In both the US and across the globe, there are unpaid CHWs who work voluntarily or receive a stipend. Community Health Impact Coalition research found that “only 14% of CHWs in Africa receive wages.³” Stipends will not sufficiently pay CHWs enough to afford food and housing costs. Sadly, CHWs in Africa may use their stretched stipends to purchase basic medical needs for the families they serve.
Similarly to Africa, some CHWs in the US are unpaid, working voluntarily while using their personal resources to reach out and engage members. Too many CHWs use their own money for gas to travel to patients’ homes or use personal cell phones for communication without full reimbursement.
Alisa Howard, founder of Minority Health Consultants, is an experienced CHW and instructor who has worked in the field for ten years. Alisa advocates for Nevada’s CHW workforce and has helped Nevada pass AB191, making Community Health Work a mandatory paid field in her state. Alisa pointed out to me that, “It’s important for Community Health Workers to be paid well, as they are frontline public health workers who have been known to save the medical and healthcare systems tons of money in their states. Therefore, if they’re saving states money, then they should be compensated well.” And she is right. A policy briefing released by the CDC found, “Yet another program used CHWs for outreach to people in need of home and community-based services, which resulted in lower growth in Medicaid spending among program participants and an estimated savings of $3.5 million in Medicaid expenditures.⁴” After accounting for program costs, Medicaid realized net savings of $2.6 million.” 2.6 million dollars! And that amount is what’s trackable.
A few years ago, I worked at a private doctor’s office with a patient who had uncontrollable hypertension and a lack of reliable transportation. This patient did not know how to use his blood pressure cuff. Because he did not trust medical staff, he would not allow any of the nurses to teach him how to use his cuff properly.
After building rapport with this patient, he gave me consent to visit his home. During the home visit, I taught him how to use his blood pressure cuff. While doing a teach-back, the patient took his blood pressure. The reading was moderately high. I called the nurse at the doctor’s office who reported to the doctor the patient’s reading and symptoms. The doctor ordered a fast-acting medication to lower the patient’s blood pressure, called the pharmacy and requested same-day delivery. I helped the patient schedule a next-day doctor’s appointment and showed the patient how to request transportation (covered by insurance) to all future appointments. This patient soon became an empowered patient. He took his own blood pressure and called the nurse’s line to communicate his symptoms. As a result, he avoided additional emergency room visits and inpatient admissions related to his hypertension. My support helped empower this patient to care for himself, saving the state and the healthcare system a lot of money.
Yet, for this home visit, I traveled 6.6 miles round trip from the doctors office to the patient’s home. Gas prices had just increased to $4.81 per gallon. I’d wait three to four weeks to be reimbursed for the visit. And in that same week, I’d make several home visits using my personal money on gas. That was money I needed that week to feed my family and transport kids to school. I also used my personal cell phone. I was reimbursed $20 a month for using my personal phone 160 hours a month.
While the state saves money for the reduction of healthcare costs, I am exhausting my personal resources, living paycheck to paycheck, waiting for reimbursements that amount to less than what I actually spend to help patients.
At times, I’ve felt exploited while doing this work. It becomes an issue of morale when CHWs are asked to rescue community members downstream with the same resources we need to continue rescuing ourselves. Sometimes, it feels like I am drowning too because I can barely keep my head above water.
CHWs fill the potholes of a healthcare infrastructure broken into pieces. We reach out to communities driving through the gaps in the road to engage our most vulnerable members. Yet, we are exposed to the same social determinants that make healthcare inaccessible to our clients.
It is my hope that CHW employers and stakeholders recognize the emotional, physical, and mental load of CHW work and advocate for us so we CHWs can continue to advocate and help heal our communities.
I do this work because I understand the social barriers my community faces. I have experienced many of the same challenges. I’ll never forget the doctor, who one day held my hand and walked me from the patient room down the hall to another specialty department to find someone to link me to resources to help me manage my son’s chronic illness diagnosis.
My friend, Silvia Ortega, told me that despite all of the barriers CHWs face, she does this work because “Time is medicine” something people in our community are not afforded. And, I agree. I use her phrases all the time. But, you know what else is time…? CHWs must earn a living wage.
- Bureau of Economic Analysis. “Personal Consumption Expenditures by State, 2021”. Bureau of Economic Analysis. October 6, 2022. https://www.bea.gov/news/2022/personal-consumption-expenditures-state-2021
- SoFi. “Cost of Living in California”. SoFi. March 13, 2023. https://www.sofi.com/cost-of-living-in-california/
- Community Health Impact Coalition. “Pay CHWs”. Community Health Impact Coalition. 2023. https://joinchic.org/resources/pay-chws/
- National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). “Policy Options for Facilitating the Use of Community Health Workers in Health Delivery Systems”. Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/dhdsp/pubs/docs/CHW_Policy_Brief_508.pdf