Nah Thu Thu Win’s twin sons needed vaccinations before starting kindergarten. But she speaks little English, and the boys lacked health insurance.

William Arce and Wanda Serrano were recovering from recent surgeries. But the couple needed help sorting out their insurance and understanding their bills.

Engebretson, Win, Arce, and Serrano were fortunate to have someone to help.

They’re all paired with community health workers in Huron, a city of 14,000 people known for being home to the state fair and what’s billed as the world’s largest pheasant sculpture.

Three workers, employed by the Huron Regional Medical Center, help patients navigate the health system and address barriers, like poverty or unstable housing, that could keep them from getting care. Community health workers can also provide basic education on managing chronic health problems, such as diabetes or high cholesterol.

Community health worker programs are spreading across the U.S., including in rural areas and small cities as health providers and and governments increasingly invest in them. These initiatives gained attention during the coronavirus pandemic and to improve people’s health and access to preventive care while reducing expensive hospital visits.

Community health worker programs can address common barriers in rural areas, where people face and certain health problems, said Gabriela Boscán Fauquier, who oversees community health worker initiatives at the National Rural Health Association.

The workers are “an extension of the health care system” and serve as a link “between the formality of this health care system and the community,” she said.

The programs are often based at hospital systems or community health centers. The workers have a median pay of $23 an hour, according to the federal Bureau of Labor Statistics. Patients are typically referred to programs by clinicians who notice personal struggles or frequent visits to hospital emergency departments.

is among the states that have recently funded community health worker programs, developed training requirements for the workers, and approved Medicaid reimbursement for their services. The state’s certification program requires 200 hours of coursework and 40 hours of job shadowing.

Huron Regional Medical Center launched its initiative in fall 2022, after receiving a $228,000 federal grant. The program is now funded by the nonprofit hospital and Medicaid reimbursements.

Huron, a small city surrounded by rural areas, is mostly populated by white people. But thousands of Karen people — an ethnic minority from the Southeast Asian country of Myanmar — . Many are refugees. The city also has a significant Hispanic population from the Caribbean, Mexico, and Central and South America.

Mickie Scheibe, one of Huron’s community health workers, recently stopped by the house of client Kelly Engebretson. The 61-year-old hadn’t been able to work since he had part of his leg amputated, due to diabetes complications.

Scheibe helps with “the hoops you’ve got to jump through,” such as applying for Medicaid, Engebretson said.

He told Scheibe that he didn’t know how he was going to get to his prosthetic fitting in Sioux Falls — a two-hour drive from home. Scheibe, 54, said she would help find him a safe ride.

She also invited Engebretson to a diabetes education program.

“Put me down as a definitely absolutely,” he replied, adding that he’d invite his mother to tag along.

The same day, Scheibe’s co-worker Sau-Mei Ramos visited the apartment where William Arce and Wanda Serrano live. Arce was recovering from heart surgery, while Serrano was healing from knee and shoulder operations.

The couple, both 61, moved three years ago from Puerto Rico to be near their children in Huron. Ramos, who’s also from Puerto Rico, coordinated their appointments, answered their billing questions, and helped Arce find a walker and supplemental insurance.

Ramos, 29, handed Arce a pamphlet about heart health and asked him to read the section on angina, the pain that results when not enough blood flows to the heart.

“Qué entiende?” she said, asking Arce what he understood about his condition. Arce, speaking in Spanish, responded that he knew what angina was and what symptoms to watch for.

Later that day, Paw Wah Sa, the third community health worker in town, met with client Nah Thu Thu Win, who moved to Huron in February from Myanmar with her husband and twin 6-year-olds. The Win family, like Sa, are part of the local Karen community, whose people have been persecuted under the military rulers of Myanmar, the country formerly known as Burma.

Win, 29, had assumed the kids would qualify for Medicaid. But unlike most other states, South Dakota to children who legally immigrated into the U.S. The boys’ father hopes to eventually add them to his work-sponsored insurance.

Sa didn’t want the kids to have to wait for health care. The 24-year-old previously took the twins to a free mobile dental clinic in Huron. It turned out they needed more advanced dental work, which they could get free only in Sioux Falls. Sa helped make the arrangements.

Many Karen residents and people from rural parts of Latin America had little access to health care before moving to the U.S., Sa and Ramos said. They said a major part of their job is explaining what kind of care is available, and when it’s important to seek help.

The three community health workers sometimes take clients grocery shopping, to teach them how to understand labels and identify healthful food.

Boscán Fauquier, with the National Rural Health Association, said that because community health workers are familiar with the cultures they serve, they can suggest affordable food that clients are familiar with.

Rural America’s overall population is shrinking, but the 2020 census showed it has become as people representing ethnic minorities are drawn to jobs in industries such as farming, meatpacking, and mining. Others are attracted by rural areas’ lower crime rates and cheaper housing.

Boscán Fauquier said many rural community health worker programs serve people from minority groups, who are than white people to face barriers to health care.

She pointed to programs serving Native American reservations, the Black Belt region of the South, and Spanish-speaking communities, where the workers are called promotoras. But community health workers also serve rural white communities, such as those in Appalachia impacted by the opioid crisis.

Medicare, the federal health program for adults 65 or older, has been reimbursing community health worker services . Boscán Fauquier said advocates hope more state Medicaid programs and will allow reimbursement too.

Engebretson said he’s happy to see community health workers across South Dakota, not just in big cities.

The more they “can branch out to the people, the better it would be,” he said.

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Noneo is one of four community health representatives for the Fallon Paiute-Shoshone, which the tribe said includes about 1,160 enrolled members. The role primarily involves driving tribal members to their health appointments, whether in Fallon, a city of just under 10,000, or Reno, more than 60 miles west. Noneo said she and her colleagues have also taken patients as far away as Sacramento, California, and Salt Lake City, round trips of nearly 400 and 1,000 miles, respectively.

Public health experts contend the role Noneo and others like her fill is an integral part of ensuring people receive the care they need, especially for chronic illnesses, by helping close gaps in areas with medical provider shortages. Besides transporting patients to their appointments, community health representatives provide health education, patient advocacy, and more. Noneo said she and her colleagues spend a lot of time helping young mothers and elders, checking on the latter, taking them to get groceries, or delivering their medication.

Yet, most state Medicaid programs don’t recognize or pay for services offered by health workers, such as Noneo, who work on tribal lands. That’s despite their work being essentially the same as that of “community health workers” in nontribal communities, a classification many state Medicaid programs cover.

In Nevada, that disparity recently changed when the state began allowing workers on tribal lands to qualify for Medicaid reimbursement as community health workers. Tribal leaders say the Medicaid payments supplement existing personnel funding by covering the individual services the workers provide. That in turn should allow tribes to train and hire more community health representatives, which could expand health and support services for tribal members.

Only two other states, South Dakota and Arizona, treat community health representatives serving Native American populations as eligible for the same Medicaid reimbursement as their similarly named counterparts in nontribal areas, according to Michelle Archuleta, a community health representative program consultant for the federal Indian Health Service. However, she said, the tribes the CHRs work for have not begun billing the states’ Medicaid programs.

The Community Health Representative program, established by Congress in 1968, is among the nation’s . It’s jointly funded by each tribe and the IHS, an agency within the Department of Health and Human Services responsible for providing health care to members of federally recognized tribes. As of 2019, more than 1,600 of these tribal linchpins worked in the United States, according to the IHS.

Last year, the Centers for Medicare & Medicaid Services approved Nevada’s plan to make community health workers who complete training and certification requirements eligible for Medicaid reimbursement when they assist with chronic disease management and prevention.

And in December, leaders with the Nevada Community Health Worker Association helped tribes make sure their community health representatives would receive the necessary training for certification. The association would “fully support” tribal clinics submitting their community health representative training for recognition in the state and it would not require a change to state law, said Jay Kolbet-Clausell, program director for the group. For now, community health representatives are receiving double training to be able to file for Medicaid reimbursement.

Training and certification requirements for community health workers vary widely by state and employer, as workers are often hired by hospitals, local organizations, health departments, or federally qualified health centers. But a movement has been emerging across the country to bring more uniformity to those requirements and formalize the roles, said , a policy analyst with the Racial Equity and Health Policy program at Â鶹ŮÓÅ.

As part of this process, states are expanding coverage for community health workers under Medicaid. According to a , 28 of 47 states, and Washington, D.C., reported having policies that allow Medicaid reimbursement for services provided by community health workers. Arkansas, Georgia, and Hawaii did not respond to Â鶹ŮÓÅ’s survey.

“There’s a really robust evidence base that is growing every day that community health worker interventions can be effective in reducing health disparities, particularly in communities of color,” Haldar said.

Studies have also shown that community health worker programs are effective in for people with chronic conditions and that they .

Soon after Nevada implemented its program, about 50 community health representatives completed the requirements. Another cohort of 20 finished the curriculum later, said Kolbet-Clausell. The goal is for those who have completed the recent training to help their peers through it, they said.

Even before the tribal workers were included in the community health workforce, one of its greatest strengths was its diversity, Kolbet-Clausell said. In Nevada, the 2022 student group was made up of greater shares of people who are American Indian or Alaska Native, Hawaiian or Pacific Islander, Black, Hispanic, or from rural areas than the state’s general population. They said it’s likely one of the most diverse health programs in the state.

Community health representatives such as Noneo are typically tribal or community members themselves, which, public health experts say, allows them to connect more easily with the patients they serve and better connect them to health care.

For example, the first person she picked up that June morning was her cousin, who had a 6 a.m. dialysis appointment.

Kolbet-Clausell said they’re optimistic about the growing workforce and the support it’s getting from state leaders.

“Five, six years ago, there was a lot more resistance,” they said, because lawmakers saw the efforts to expand the community health workforce as simply spending more money. “But this actually just benefits rural communities as much as it benefits underserved urban communities. It serves everyone.”

Back in Fallon, Noneo reflected on her 27 years as a community health representative for her tribe as she prepares to retire in September. She has been there with her fellow tribal members through important and hard times in their lives — like driving an expectant mother to Reno to deliver a baby, taking people to receive treatment for mental health crises and addiction, and bringing patients to their dialysis treatments on her week off around Christmas so they wouldn’t miss their appointments.

The most challenging part of the job, she said, is experiencing the loss of someone she has regularly seen and provided years of services for.

“We all have compassion,” she said. “In this kind of job, you have to have that.”

After decades of shuttling patients, Noneo has the work down to a steady and familiar rhythm. Four hours after dropping off her cousin for dialysis, Noneo picked her up at the clinic as she dropped off the next dialysis patient. On a clipboard, she logged the hours and mileage for each appointment.

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A paramedic recently arrived at her doorstep again, but this time it wasn’t for an emergency. Jason Frye was there for a home visit as part of a new community paramedicine program.

Frye showed up in an SUV, not an ambulance. He carried a large black medical bag into Lane’s mobile home, which is on the eastern edge of the city, across from open fields and train tracks that snake between the region’s massive open-pit coal mines. Lane sat in an armchair as Frye took her blood pressure, measured her pulse, and hooked her up to a heart-monitoring machine.

“What matters to you in terms of health, goals?” Frye said.

Lane said she wants to become healthy enough to work, garden, and ride her motorcycle again.

Frye, a 44-year-old Navy veteran and former oil field worker, promised to help Lane sign up for physical therapy and offered to find an anti-slip grab bar for her shower.

Community paramedicine allows paramedics to use their skills outside of emergency settings. The goal is to help patients access care, maintain or improve their health, and reduce their dependence on costly ambulance rides and ER visits.

Such programs are expanding across the country, in , as health care providers, insurers, and state governments recognize the potential benefits to patients, ambulance services, and hospitals.

Gary Wingrove, a Florida-based leader in community paramedicine, said the concept took off in the early 2000s and now includes hundreds of sites. of 129 programs found that 55% operated in “rural” or “super rural” areas.

Community medicine can be helpful in rural areas where people have less access to health care, said Wingrove, chair of the International Roundtable on Community Paramedicine. “If we can get a community paramedic to their house,” he said, “then we can keep them connected to primary health care and all of the other services that they need.”

Frye works at Campbell County Health, a health care system based in Gillette, a city of about 33,000 in northeastern Wyoming. Leaders of the community paramedicine program plan to expand it into two adjacent, largely rural counties dotted with ranches and coal mines on the rolling prairie that stretches more than 100 miles from the Black Hills to the Bighorn Mountains.

Gillette serves as a medical hub for the region but has shortages of primary care doctors, specialists, and mental health services, according to a . People who live outside the city face additional barriers.

“A lot of them, especially older people, don’t want to come into town. And basically, those tiny communities don’t usually have health care,” Lane said. “I think it’s just kind of a pain for them to drive all the way into town, and unless they have a serious problem, I think they tend to just figure, ‘Well, it’ll work itself out.’”

Community paramedicine programs are customized to the needs and resources of each community.

“It’s not just a cookie-cutter-type operation. It’s like you can really mold it to wherever you need to mold it to,” Frye said.

Most community paramedicine programs rely on paramedics, but some also use emergency medicine technicians, nurses, social workers, and other professionals, according to the 2017 survey. Programs can offer home visits, phone check-ins, or transportation to nonemergency destinations, such as urgent care clinics and mental health centers.

Many programs support people with chronic illnesses, patients recovering from surgeries or hospital stays, or frequent users of 911 and the ER. Other programs focus on public health, behavioral health, hospice care, or post-overdose response.

Community paramedics can provide in-home vaccinations, wound care, ultrasounds, and blood tests.

They can offer exercise and nutrition tips, teach patients how to monitor their symptoms, and help with housing, economic, and social needs that can affect people’s health. For example, paramedics might inspect homes for safety hazards, provide a list of food banks, or connect lonely patients with a senior center.

Paramedics and patients said some rural residents struggle to access health care because of long distances, cost, lack of transportation, or dangerous weather. Some hesitate to seek help out of pride or because they don’t want to be a burden to others. Some limit trips to town during ranching and farming crunch times, such as calving and harvesting seasons.

Delayed care can let health problems fester until they become an emergency.

Advocates say providing in-home care, resources, and education can help patients reduce such crises and associated costs. Fewer emergencies mean fewer ambulance runs and hospital patients. That could help ambulance services and hospitals reduce costs and the time patients wait for help.

found that more studies are needed but that data so far suggests these programs reduce costs. It also found links to improved health outcomes and decreased use of ambulances and hospitals.

For example, a pilot program in Fort Worth, Texas, saw a 61% reduction in ambulance rides, . MedStar, the operator, made the effort permanent and says its 904 participants , saving an estimated $8.5 million over eight years.

But rural ambulance services, especially volunteer ones, can struggle to staff and fund community paramedicine programs.

Kesa Copps, a co-worker of Frye’s, previously worked as an emergency medical technician in Powder River County, Montana, which has fewer than 2,000 residents. Some people there must drive more than an hour to reach the nearest hospital. The area’s volunteer ambulance service started a community paramedicine program in 2019.

Copps said the program reduced hospital readmissions and extended some elderly patients’ ability to live at home before being admitted to a nursing facility. She visited patients between ambulance runs and had to leave early when a 911 call came in. That’s different from the Campbell County Health model, in which community paramedicine is a full-time position, not split with emergency work.

Adam Johnson, director of the Powder River ambulance service, said the community paramedicine program shut down in 2021 after everyone with the necessary training left the area. Johnson said paramedics are signing up for training to restart the program.

States are , and some require licensed paramedics to obtain extra training to work in the field.

Some ambulance services and health care organizations have piloted community paramedicine programs with the help of state or federal grants. If they find the service saves money, they may decide to continue the program and fund it themselves.

Private insurance companies are increasingly covering community paramedicine, Wingrove said. Wyoming and several other states allow operators to bill Medicaid for the services.

Advocates are now pushing Medicare to expand its of community paramedicine, Wingrove said. That would benefit Medicare patients and could spur more private insurers to offer coverage.

The Campbell County Health program’s home visits cost up to $240 per hour and are billed to Medicaid or Medicare, said Frye. That compares with more than $1,300 for an ambulance ride and thousands of dollars for a visit to a hospital ER.

Community paramedicine may soon expand in neighboring South Dakota, another largely rural state.

South Dakota ambulance services have experimented with community paramedicine and lawmakers to authorize and regulate it.

Eric Emery, the state representative who introduced the bill, plans to start a program on the sprawling, rural Rosebud Indian Reservation, where he works as a paramedic. He said the operation will focus on diabetes and mental health care.

Emery, a Democrat, said some people struggle to pick up their medication and attend appointments because they lack vehicles or gas money and there’s no public transportation to the hospital. He said some parents and grandparents raising children also struggle to find time to drive to appointments.

“They’re putting the needs of the younger generation or their grandkids before their own,” Emery said.

Back in Gillette, Frye also checked in on Linda Quitt, a 78-year-old facing diabetes, depression, and a lack of social support after her husband was hospitalized with dementia. Quitt said her husband was her walking buddy and helped care for her.

“I had him to wait on me, and now I have nobody,” Quitt said.

Frye said he would see if he could help start a senior walking group that Quitt could join. He told her that socializing can improve health.

“You’re not alone,” Frye told Quitt.

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“I would be getting maybe three to four a month,” recalled Lopez, a TB program supervisor with Cameron County’s health department.

In a matter of months, patients seeking care at the county’s two clinics dropped by half. “And then I wasn’t getting any at all,” he said.

As covid gripped the world’s attention, Lopez began to focus on a parallel concern: whether TB was being overlooked along the Texas-Mexico border.

“I knew there had to be TB cases out there; they just weren’t being found,” Lopez said in a recent interview.

Before 2020, advances to eradicate TB, which is spread person-to-person , were underway globally. It was considered by many public health experts to be a , since tools are available to identify and treat it. But the prevalence of the disease in Mexico, and immigration along the border, has made it a longtime health concern in these communities.

In areas with high immigrant traffic, such as Cameron County, TB is a serious health concern. Cameron sits at the southernmost tip of Texas, and each year millions of people cross to and from Mexico at the four border crossings in the Brownsville region. and largest city. In 2019, before covid, had an average TB incidence of 8.4 cases per 100,000 people — more than double that of the state overall, and nearly triple the national rate.

Since the pandemic began, though, some tuberculosis clinics in border areas have been performing fewer tests, receiving fewer referrals from local hospitals and providers, and treating fewer patients. Lopez and others who do this public health work every day on the ground agree it’s not likely less TB is circulating. Instead, they say, covid testing and treatment have claimed so much attention and energy that TB has been pushed off the radar, threatening to reverse decades of progress in eliminating it.

Lopez said his county’s tuberculosis department usually gets around 40 to 60 patients a year. “And then, all of a sudden, we went down to 20 during the covid pandemic,” he said. The numbers seem to be bouncing back. In 2022, Lopez said, the county’s clinics saw 35 TB patients. But that’s still lower than pre-pandemic levels.

Hidalgo County, which neighbors Cameron to the west, experienced a similar trend in 2020, when its number of confirmed TB cases was cut in half from the previous year, dropping from 71 cases to 36, according to Jeanne Salinas, tuberculosis program manager of the county health department. The county also performed hundreds fewer TB tests.

Since 2020, Salinas said, tuberculosis has been “overlooked” as a diagnosis for patients reporting “prolonged cough or cough with blood, losing weight, having fevers.” After covid became everyone’s overriding concern, these patients — who included new immigrants as well as people who regularly traveled across the border for work or to visit family on the other side — were tested for covid. Salinas said it was only if the symptoms persisted that patients would perhaps be evaluated for tuberculosis. This lag time allowed the illness to progress in individual patients and potentially spread in the community.

This reflects a nationwide trend. According to , U.S. tuberculosis incidence rates “decreased steadily” from 1993 to 2019. In 2020, though, there was a “sharp” decline of nearly 20% in recorded cases, which the CDC materials suggest may be due to “delayed or missed TB diagnoses or a true reduction in TB incidence related to pandemic mitigation efforts and changes in immigration and travel.” But because TB is more contagious than covid (its particles stay in the air longer), steps like masking and distancing are less effective. So, Salinas argues the former.

Convincing people of the need to test for TB was difficult even before covid, Lopez said. For starters, some health workers wrongly considered the illness a nonissue. That tuberculosis and covid share similar symptoms became another complication. When doctors and other health professionals saw those symptoms, their first concern was covid. And for a while, it was their only concern.

Other issues are diagnosis and treatment. Samples for covid rapid tests, and even the more sensitive and expensive PCR tests, can be collected with a simple nasal swab. TB screening is more invasive, done with either a skin test that requires a follow-up visit to a health professional or a blood draw that is tested in a lab. At the height of the pandemic, Lopez said, providers were so focused on getting people in and out of clinics and hospitals quickly that taking the time to conduct TB screenings wasn’t a priority.

Though TB is a curable disease, its treatment can require up to a year of prescribed antibiotics, which experts say adds to the urgency of detecting cases early on.

The Texas Department of State Health Services says on that tuberculosis rates are “higher along the Texas-Mexico border” than in the rest of the state. , chief of infectious diseases at Texas Tech University Health Sciences Center in El Paso, said that’s because “almost all cases of tuberculosis in the United States are coming from immigrants.”

, a former Texas Medical Association president who is a member of the group’s, added that many people live in Mexico but work in Texas, and vice versa, “so with that comes perhaps unclear health issues and exposure.”

There’s yet another snag. Tuberculosis, Villarreal explained, is especially hard for people’s immune system to suppress if they also have other health issues, and the border is a hot spot for diabetes and other chronic health conditions like hypertension or heart disease.

Covid, itself, is something of a comorbidity because it can make people more susceptible to tuberculosis. Some of her patients have had both illnesses, Salinas said. She suspects some who died of covid may have had tuberculosis as well, or instead.

Border areas tend to be impoverished, and “TB is a disease of the poor,” Texas Tech’s Meza said. “And who is poor in this country? The minorities, the immigrant populations, the mentally ill who live in close gatherings and shared common spaces.” Not to mention people who are uninsured and can’t afford health care.

Meza said he drives by the border often, and when he does, he sees crowds waiting on the Mexican side in Juárez, hoping to get across. If they do, he said, he hopes they get proper health screenings and care.

“To me, that’s what I’m afraid of more than covid,” Meza said. “If there is no change systematically, then that’s when things can get more complicated.”

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Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help , and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. , a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called , adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of , one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a .

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

This story was produced by , which publishes , an editorially independent service of the .

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Drug sales provide the bulk of the revenue for Genesis, a nonprofit community health center treating about 11,000 mostly low-income patients in seven clinics across South Carolina.

Those sales helped Genesis record a $19 million surplus on $52 million in revenue — a margin of 37% — in 2021, according to its audited financial statement. It was the fourth consecutive year the center’s surpluses had topped 35%, the records showed. The industry average is 5%, according to a federally funded report on health centers’ financial performance.

Genesis attributes its large margins to excellent management and says it needs the money to expand and modernize services while being less reliant on government funding. The center benefits financially from the use of a government drug discount program.

Still, Genesis’ hefty surplus stands out among nonprofit federally qualified health centers, a linchpin in the nation’s safety net for treating the poor.

The federal government pumped more than $6 billion in basic funding grants last year into around the country, which provide primary care for mostly low-income people. In 2021, the American Rescue Plan Act provided an additional $6 billion over two years for covid-19 care.

These community health centers must take all patients regardless of their ability to pay, and, in return, they receive annual government grants and higher reimbursement rates from Medicaid and Medicare than private physicians.

Yet a KHN analysis found that a handful of the centers recorded profit margins of 20% or more in at least three of the past four years. Health policy experts said the surpluses alone should not raise concerns if the health centers are planning to use the money for patients.

But they added that the high margins suggest a need for greater federal scrutiny of the industry and whether its money is being spent fast enough.

“No one is tracking where all their money is going,” said , an assistant professor at the University of Oklahoma who has studied health center finances.

The federal Health Resources and Services Administration, which regulates the centers, has limited authority under federal law over how much the centers spend on services and how they use their surpluses, said , an associate administrator.

“The expectation is they will take any profit and plow it back into the operations of the center,” Macrae said. “It’s definitely something we will look at and what they are doing with those resources,” he added about KHN’s findings.

, an accounting and health professor at Johns Hopkins University, questioned why some centers should be making profit margins of 20% or more over consecutive years.

A center with a high margin “raises questions about where did the surplus go” and its tax-exempt status, Bai said. “The centers have to provide enough benefit to deserve their public tax exemption, and what we are seeing here is a huge amount of profits,” she said.

Bai said centers must be able to answer questions about “why aren’t they doing more to help the local community by expanding their scope of service.”

Officials at the health centers defended their strong surpluses, saying the money allows them to expand services without being dependent on federal funds and helps them save for big projects, such as constructing new buildings. They pointed out that their operations are overseen by boards of directors, at least 51% of whom must be patients, ostensibly so operations meet the community’s needs.

“Health centers are expected to have operating reserves to be financially sustainable,” said Ben Money, a senior vice president at the National Association of Community Health Centers. Surpluses are necessary “as long as health centers have plans to spend the money to help patients,” he said.

Some center officials noted bottom-line profit margins can be skewed by large contributions earmarked for building projects. Grants and donations appear as revenue in the year they were given, but a project’s costs are allocated on financial statements over a longer period, often decades.

‘We Don’t Take Unnecessary Risks’

The annual federal base grant for centers makes up about 20% of their funding on average, according to HRSA. The grants have more than doubled over the past decade. These federal grants to the centers are provided on a competitive basis each year based on a complex formula that takes into account an area’s need for services and whether clinics provide care to specific populations, such as people who are homeless, agricultural workers, or residents of public housing.

The centers also receive Medicare and Medicaid reimbursements that can be as much as twice what the federal programs pay private doctors, said Jeffrey Allen, a partner with the consulting firm Forvis.

In addition, some health centers like Genesis also benefit from the 340B federal drug discount program, which allows them to buy medicines from manufacturers at deeply discounted rates. The patients’ insurers typically pay the centers a higher rate, and the clinics keep the difference. Clinics can reduce the out-of-pocket costs for patients but are not required to.

For its analysis, KHN started with research by Davlyatov that used centers’ tax filings to the IRS to identify the two dozen centers with the highest profit margins in 2019. KHN calculated bottom-line profit margin for each of the past four years (2018 through 2021) by subtracting total expenses from total revenue, which yields that year’s surplus, and then dividing that by total revenue. Money given by donors for restricted uses was excluded from revenue. After examining the centers’ finances, KHN found nine that had margins of 20% or more for at least three years.

North Mississippi Primary Health Care was one of them.

“We don’t take unnecessary risks with corporate assets,” said Christina Nunnally, chief quality officer at the center. In 2021, the center had nearly $9 million in surpluses on $36 million in revenue. More than $25 million of that revenue came from the sale of drugs.

Nunnally said the center is building a financial cushion in case the 340B program ends. Drugmakers have been seeking changes to the program.

The center recently opened a school-based health program, a dental clinic, and clinics in neighboring counties.

“There may come a day when this type of margin is not feasible anymore,” she said. If the center hits hard times, it would not want to “have to start cutting programs and people.”

In Montana, Sapphire Community Health in Hamilton, which accumulated nearly $3 million in surpluses from 2018 through 2020 and had a profit margin of more than 24% in each of those years, wants to move out of its rented quarters to a building that will cost at least $6 million to construct. “A new facility will enable us to provide services that we cannot provide due to lack of space, such as imaging, obstetrics, and dental services,” CEO Janet Woodburn said.

Outside Los Angeles, Friends of Family Health Center CEO said his high margins are the result of good management and California’s broad Medicaid coverage for low-income residents.

The center — whose profit margins topped 25% from 2018 to 2020 — opened a $1.9 million facility in Ontario last year and purchased the building that houses its main clinic, in La Habra, for $12.3 million, with plans to expand it, he said.

Bahremand added that the center also keeps administrative costs down by focusing on having more providers in relatively fewer locations.

“You shouldn’t be asking: ‘Why are we making so much money?’ You should be asking: ‘How come other clinics are not making so much money?’” Bahremand said.

Concern About Paying the Bills

In South Carolina, Genesis began as an independent clinic and was sometimes barely able to make payroll, said Tony Megna, Genesis’ CEO and general counsel. Converting to a federally qualified health center about a decade ago brought federal funding and a more solid footing. It recorded more than $65 million in surpluses from 2018 to 2021.

“Our attitude toward money is different than most because it’s so ingrained in us to be concerned about whether we are going to pay our bills,” said Katie Noyes, chief special projects officer.

The center is spending $50 million to renovate and expand its aging facilities, Megna said. In Darlington, a new $20 million building that will more than double the facility’s space is scheduled to open in 2023. And its strong bottom line helps the center pay all its workers at least $15.45 an hour, more than twice the minimum wage in the state, Megna said. Darlington County’s annual median household income is a bit over $37,000.

Megna was paid nearly $877,000 in salary and bonuses in 2021, according to Genesis’ latest IRS tax filing, an amount nearly four times the industry average.

David Corry, chairman-elect of the Genesis board of directors, said in a memo to KHN that part of that compensation made up for several years when Megna was inadvertently underpaid. “We determined early on that providing Mr. Megna an ‘average’ compensation like those of other FQHCs CEOs was not what we wanted. Mr. Megna’s extensive legal experience and education as well as his institutional and regulatory knowledge set him apart from others.”

Megna said his base salary is $503,000.

Genesis officials said the financial security afforded by the center’s surpluses has allowed them to provide extra patient services, including foot care for people with diabetes. In 2020, Genesis used $2 million to create an independent foundation to help families with food and utility bills, among other needs.

Most of Genesis’ revenue comes from the 340B program, according to its audited financial statements. Many prescriptions filled at the clinic pharmacy are for expensive specialty drugs, which treat rare or complex conditions such as cancer. Getting accredited to dispense specialty drugs was expensive, Corry said, but “paid off because it gives our patients access to extremely high-priced, and often lifesaving prescription drugs that would not otherwise be available to many of them.”

Megna, 67, a former bankruptcy lawyer, said it’s vital to keep the center financially secure to stay open for patients.

“We are very careful in how we spend our money,” Megna said.

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They converted an old farmhouse into a seven-bed medical center. They treated their first patient for a broken leg amid carpenters hammering nails. Surgeons laid their patients on a kitchen table for operations.

The hospital — then named after St. Margaret, known for her service to the poor — eventually became one of the largest in the area. Hundreds of thousands of Indiana and Illinois residents took their first, or last, breaths there.

A hundred twenty-four years later, the hospital has, in a sense, come full circle. This spring, , the nonprofit owner — still affiliated with the same Catholic order of sisters — plans to demolish most of the 226-bed Franciscan Health Hammond complex, leaving only eight beds, an emergency department, and outpatient services. The move cost 83 jobs at the hospital and 110 more at a long-term acute-care center that rented space there.

The news stung many in this Rust Belt city of nearly 80,000 people, who have watched businesses — and neighbors — flee Hammond for decades. It’s especially painful, they say, because the hospital system has dedicated more than half a billion dollars in recent years to new facilities in wealthier, less-diverse communities.

“It’s deplorable that a Catholic institution like the Franciscans would make a financially motivated decision and leave thousands of people potentially at risk,” said Mayor Thomas McDermott Jr., who complained that he was informed of the downsizing barely two hours before it was announced publicly. “I’m not trying to be alarmist, but people are gonna die because of this decision. And they know it.”

But the larger question is whether Hammond needs a hospital with hundreds of beds, given the shifts in medical practice and transportation in the 21^st century. Only 50 to 60 of its beds are full on most days, said hospital CEO Patrick Maloney. Another Franciscan Alliance hospital is only 6 miles away. Much more care today is being delivered on an outpatient or virtual basis than even five years ago.

And the Hammond site has had quality concerns. It rates only one out of five stars on , the lowest possible score and worst of any of the nine rated hospitals in its county.

“Stewardship of our resources is one of the components of our Catholic mission,” Maloney stated in an email. “Key to that is efficient delivery of care.”

He noted that Franciscan is investing $45 million to transform the campus and will continue to operate a medical clinic there for uninsured or underinsured patients, as well as services like imaging, a medical lab, and prenatal care.

While rural hospital closures often get more attention, cities like Hammond have also been prone to losing medical services, as health systems adjust to changes in care, and opt to invest in places where more people have private insurance. But the shutdowns raise questions about the changing mission of nonprofit hospitals — and whom they help.

Since the 1930s, the urban hospitals most likely to close are those serving low-income, minority populations, according to research by , professor at the Boston University School of Public Health. He calls large swaths of Detroit and New York City “medical wastelands.”

When the city hospital in Hartford, Connecticut, contracted in the 1970s, it kept its emergency room running — until that got too expensive, Sager said. “I predict, within a decade, despite the best intentions of everyone involved, it will prove financially unsustainable to support an eight-bed hospital plus ER in Hammond,” he said.

Hammond’s population is down about a third from its peak in the mid-20th century. Like other former manufacturing hubs in the Midwest and Northeast, the city has been hollowed out by deindustrialization and white flight to suburban areas. It is in the part of Indiana, affectionately known as “the Region,” that’s essentially an extension of south Chicago, crisscrossed with freight train tracks, dissected by interstates, littered with factories in various states of decay.

On a recent overcast morning, Franciscan Health Hammond’s parking garage and surrounding lots were mostly empty. A sprinkling of people trickled out of the hospital. A sign advised that birthing services had moved to the suburbs.

The that covers the hospital and its surrounding neighborhood has a poverty rate of 36%, with a median household income of $30,400. Its population is 82% Black and/or Latino. The hospital treats a large share of patients on Medicaid, the government insurance program for low-income people, which typically pays health care providers a lower rate than Medicare or private insurance.

For Franciscan Alliance, the driving factors in shrinking Franciscan Health Hammond were the costs required to maintain the aging infrastructure, and less demand for care expected in that part of “the Region,” Maloney said.

He said Hammond residents are welcome at Franciscan Alliance’s hospital 6 miles away in Munster, Indiana. The organization has spent at least $133 million in recent years on that facility, located in a wealthier suburb only a few blocks from a larger, competing hospital.

But for Carlotta Blake-King, a Hammond school board trustee, that’s not close enough, especially since the area doesn’t have much mass transit. “I’m a senior citizen. I don’t like to drive,” she said. “Everybody can’t afford a car.”

Free transportation to medical appointments, though, is offered through the and .

Franciscan Alliance has replaced older hospitals in other communities, albeit a few miles from their original locations, spending $333 million on a new medical center in Crown Point, Indiana, and $243 million in Michigan City, Indiana. In 2018, however, it shuttered a century-old hospital in Chicago Heights, Illinois, a working-class Chicago suburb demographically similar to Hammond.

The missions of many nonprofit hospital chains like Franciscan Alliance have evolved. Around the turn of the 20th century, hospitals often deliberately set up shop in less-fortunate neighborhoods, with community members providing time, money, and supplies. When St. Margaret opened, for example, local farmers donated food. The Internal Revenue Service exempted so-called charity hospitals from paying taxes.

Today, “hospitals are operating as corporations, as moneymaking business entities, and their decisions are largely driven by financial concerns,” said , a professor of accounting and health policy at Johns Hopkins University. “The line between the current nonprofit hospitals and for-profit hospitals is very, very murky.”

In 2018, nonprofit hospitals provided less unreimbursed Medicaid and charity care than their for-profit counterparts, Bai’s . However, she noted, Franciscan Alliance spent more than the average nonprofit on both fronts.

Pat Vosti, a retired nurse from Hammond, worked in the cardiology unit, so she knows how time is of the essence in health care. She’s concerned about patients who have to be diverted to other hospitals. “It’s a matter of minutes, but minutes count in some instances, you know?” she said.

However, people have been bypassing the Hammond hospital for years. Along with its sister campus in Dyer, Indiana, it has only a 15% market share, according to a 2016 bond filing, compared with 45% for Franciscan’s Michigan City facility and 38% for Crown Point.

“Now, why they haven’t been using it could be a function of management choices made 15, 20 years ago: ‘Don’t build that new ER, don’t recruit those young doctors, don’t open a service for substance abuse,’” said , an adjunct professor at the Harvard T.H. Chan School of Public Health. “This is usually a gradual death. These places don’t suddenly go bad.”

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She works in an office in the shadow of the steel mill that employed her grandfather in this shrinking city in the Greater St. Louis area. Gone with many of the steel jobs is some of the area’s stability — of Granite City’s residents live in poverty, far higher than the .

Then another destabilizer — covid-19 — hit. And so Scott stepped in: She knows how to access rental assistance for those out of work as they isolate at home with covid. She can bring people cleaning supplies or food from a local food bank. She’ll stay on the phone with clients, helping them budget their finances to keep the lights on. And the calls keep coming because people know she understands.

“I’ve been hungry. I’ve not had a car,” Scott said. “I’ve been through those things.”

Scott is one of the over 650 community health workers the Illinois Department of Public Health hired through local, community-based organizations starting last March. This Pandemic Health Navigator Program workforce was made possible by a nearly $55 million grant from the Centers for Disease Control and Prevention through the federal pandemic relief passed by Congress. The team has completed at least 45,000 assistance requests, which were referred to them through contact tracing of covid cases.

As the workers have gained the community’s trust, Scott said, new requests have poured in from people who have heard about the catch-all program, which does more than what many people may think of as public health work.

But the money is set to run out at the end of June. Workers such as Scott are uncertain about their futures and those of the people they help each day. Dr. , executive director of the American Public Health Association, said that’s the tragedy of the boom-bust nature of public health funding in the United States.

“As the dollars go away, we’re going to see some people falling off the cliff,” he said. The problem, as Benjamin sees it, is the country’s lack of a systematic vision for public health. “If you did this with your army, with your military, you could never have a sound security system.”

Community health workers were positioned as key to President Joe Biden’s public health agenda. Ideally, they are one and the same as those they serve — like a neighbor who can be trusted when help is needed. Popular in countries such as , , community health workers have been difficult to maintain in the United States without consistent ways to pay them.

Hundreds of millions of dollars were supposed to go to building a community health workforce after the American Rescue Plan Act was signed into law last March, said Denise Smith, the founding executive director of the . But, she said, much of the money is being quickly spent on health departments or national initiatives, not local, community-based organizations. And a lot of it has been going to AmeriCorps workers who may not be from the communities they work in — and make poverty-line salaries, Smith said.

“For bills and a car note, rent, or children, that’s just not sustainable,” she said. “We can’t do it for free.”

By contrast, Illinois’ program tries to hire workers from within communities. Two-thirds of its workers identify as Latino/Hispanic or Black. About 40% were previously unemployed, and hiring them injects money into the communities they serve. The jobs pay $20 to $30 an hour, and almost half include health insurance or a stipend toward it.

That’s by design, said Tracey Smith, who oversees the Pandemic Health Navigator Program for the Illinois Department of Public Health and is not related to Denise Smith. She believes paying for such workers is a necessity, not a luxury, in helping people navigate the nation’s broken health care system and disjointed government assistance programs.

Angelia Gower, a vice president of the NAACP in Madison, Illinois, is now one of those paid community health workers. “They see you out there week after week and month after month and you’re still there, they start trusting,” she said. “You’re making a connection.”

But as covid cases have waned, the number of Illinois’ pandemic health workers has decreased by nearly a third, to roughly 450, in part because they have found other opportunities.

Smith is optimistic the program will secure money to keep an estimated 300 community health workers on staff and then use the goodwill they’ve built up in communities to focus on disease prevention. The fragmented American health care system — and its systemic inequities — won’t disappear with covid, she said. Plus, millions of people are poised to lose their Medicaid coverage as pandemic benefits run out, Benjamin said, creating a hole in their safety net.

Part of the long-term funding challenge is quantifying what workers like Scott do in a day, especially if it doesn’t relate directly to covid or another communicable disease. How do you tabulate the difference made in a client’s life when you’re securing beds for their children, laptops for them to go to school, or tapping into Federal Emergency Management Agency funds to pay funeral costs after a loved one dies of covid? How do you put a dollar amount on wraparound services that may keep a family afloat, especially when a public health emergency isn’t occurring?

As Scott likes to point out, most of the time she’s helping people use resources already available to them.

The National Association of Community Health Workers’ Denise Smith is worried that even though programs like Illinois’ are doing the work to help with health inequities, they may go the way that many Affordable Care Act grants did. In 2013, she was working as a community health worker in Connecticut, helping cut the uninsured rate in her area by 50%. But the money ran dry, and the program disappeared.

She said North Carolina is an example of a state that has designed its pandemic-inspired community health worker program to be more permanent. But, nationally, Congress has yet to approve more money for — much less for longer-term public health investments.

Meanwhile, Scott can’t help but worry about people such as 40-year-old Christina Lewis.

As she leaves Lewis’ mobile home after dropping off a load of groceries, Scott reminds Lewis to keep wearing her mask even as other people are shedding theirs. Scott used her own family as an example, saying they all wear their masks in public even though people “look at me like I’ve got five heads.”

Lewis said Scott’s help — bringing over groceries, talking through budgeting — has been invaluable. Lewis has stayed home throughout the pandemic to protect her 5-year-old daughter, Briella, who was born prematurely and has chronic lung disease. The struggle to make ends meet is far from over amid rising inflation. Briella knows to turn off the lights as soon as she’s out of a room. And now they are eyeing rising gasoline prices.

“I already know I’m going to have to get a bike,” Lewis said.

Over the past months, Scott has listened and consoled Lewis as she cried over the stress of staying afloat and losing family members to covid. Scott isn’t sure what will happen to all her clients if her support disappears.

“What happens to people when it goes away?” Scott asked.

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Its message of “we want to age our way in our homes and our community” was groundbreaking at the time and commanded widespread attention. Villages would mobilize neighbors to serve neighbors, anchor older adults in their communities, and become an essential part of the infrastructure for aging in place in America, .

Today, there are 268 such villages with more than 40,000 members in the U.S., and an additional 70 are in development — a significant accomplishment, considering how hard it is to get these organizations off the ground. But those numbers are a drop in the bucket given the needs of the . And villages remain a boutique, not a mass-market, option for aging in place.

Now, people invested in the village movement are asking tough questions about its future. Can these grassroots organizations be seeded far more widely in communities across the country as baby boomers age? Can they move beyond their white, middle-class roots and attract a broader, more diverse membership? Can they forge partnerships that put them on a more stable operational and financial footing?

Villages share common features, although each is unique. Despite their name, physical structures are not part of villages. Instead, they’re membership organizations created by and for older adults whose purpose is to help people live independently while staying in their own homes. Typically, villages help arrange services for members: a handyman to fix a broken faucet, a drive to and from a doctor’s appointment, someone to clean up the yard or shovel the snow. Volunteers do most of the work.

Also, villages connect members to one another, hosting discussion groups, sponsoring outings, offering classes, and organizing social events. “I’ve lived here a long time, but I really didn’t know a lot of people living in my neighborhood,” said Nancy Serventi, 72, a retired trial lawyer who joined Beacon Hill Village nearly five years ago. “Now, because of the village, I almost always meet people on the street who I can stop and say hello to.”

In principle, this model of neighbors helping neighbors can work in all kinds of communities, adapted for particular needs. , an emeritus professor of aging at the University of California-Berkeley and a leading researcher on villages, believes the potential for growth is considerable — a view shared by several other aging experts. has found that village members have more confidence about aging in place because they expect support will be there when they need it.

In practice, however, the fierce “we’ll do it our way” independence of villages, their reliance on a patchwork of funding (membership dues, small grants, and donations), and the difficulty of keeping volunteers and members engaged have been significant obstacles to growth.

“Villages’ long-term sustainability requires more institutional support and connection, whether from local or state governments, or Older American[s] Act programs, or partnerships with health care providers,” Scharlach told me.

“We have been brilliant about creating a sense of community and giving people a sense of belonging and being cared for,” said , 88, a co-founder of Beacon Hill Village. “But can what we do be scaled broadly? That’s the critical question.”

Consider how small villages are. According to the latest data from the , a national organization that disseminates best practices, 35% have 50 or fewer members; only 6% have more than 400. Budgets are modest, with two-thirds of villages operating on $75,000 a year or less and only 3% spending more than $400,000.

“What you have are a lot of fiercely independent, hyperlocal organizations scrambling to keep their head above water, and a lot of inefficiencies,” said Joel Shapira, who served on the board of the Village to Village Network for six years. “What you need are a lot more orchestrated efforts to bring villages together.”

That’s happening in California, where a coalition of villages is working in sync to expand its impact and seek state funding. Recently, Village Movement California, representing 44 villages with about 7,000 collective members, submitted a $3 million funding request to the state, which has embraced volunteerism and aging in place in its new Master Plan for Aging. Priorities include bringing new and existing villages into underserved communities and creating a training institute to promote equity and inclusion, said , Village Movement California’s executive director.

Early discussions are underway with , a California organization dedicated to Black women.

“This concept, people in the community taking care of each other, is not new to the African American community,” said Carlene Davis, a Sistahs Aging co-founder. “But having it in a formalized structure surrounding aging in place intentionally doesn’t exist. We’re at the stage where we’re asking, ‘Can we envision a village model that is culturally responsive to the needs of our community?’”

Another coalition, Washington Area Villages Exchange, represents 75 villages that have opened or are under development in the Washington, D.C., metropolitan area. Affiliates in the district are supported, in part, by city funding, which rose to nearly $1 million annually during the pandemic, according to Gail Kohn, coordinator of Age-Friendly D.C.

On a $50,000 annual budget, Legacy Collaborative Senior Village helps 321 low-income adults in the district, most of them African Americans, access transportation, food, and home and community-based services, and learn how to advocate for themselves with service providers.

“The seniors in our communities are very neighborly, but we had to show them how they could do things on a larger scale if they worked collectively,” said Katrina Polk, the village’s interim executive director and CEO of Dynamic Solutions for the Aging, a consulting firm.

In Colorado, A Little Help has pursued another strategy that many villages are contemplating: forging closer ties with organizations such as , senior centers, and senior housing complexes. “Covid inspired a fresh look at how we can work together with partners in our communities,” said Barbara Hughes Sullivan, national director of the Village to Village Network.

Since January 2020, A Little Help — which has 970 members in metropolitan Denver, northern Colorado, and the western part of the state — has received $200,000 to $250,000 a year from local Area Agencies on Aging. Services supported by this funding stream include frequent “how are you doing” calls, in-person visits, and “kindness kits” of books, puzzles, or treats that are dropped on members’ doorsteps — all of which eased social isolation during the pandemic, said , A Little Help’s executive director.

Because services are government-funded, A Little Help doesn’t charge membership fees, which can be prohibitively high for many older adults. (Beacon Hill Village’s are $675 a year for an individual and $975 for a couple, with lower subsidized fees for 20% of members.) Instead, it asks for voluntary contributions, which constitute 2.5% of its $1 million annual budget. The largest portion, 42%, comes from in-kind services donated by 4,000 volunteers.

Working with Medicare Advantage plans is also an emerging area of interest. Since 2020, plans have been able to offer supplemental benefits that address nonmedical concerns such as home modifications or “social needs,” explained of ATI Advisory, a consulting firm that has worked with Village Movement California. “There’s a lot that villages do to promote health and well-being, and I would love to see a health plan really work with villages to help support their growth,” Cromer said.

That won’t be easy, however, without a stronger research base that can help villages make the case for collaboration, but that is likely “years away,” said Kohn of Washington, D.C. “We need to show that villages and the social engagement that is their mainstay are making an impact on people’s health and longevity,” she said. “If we can do that, we should be able to get funding through health plans and health systems for villages.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit  to submit your requests or tips.

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“Good morning! We’re here to talk about covid-19 today! Do you have a minute?” she said in Spanish.

After a brief conversation, Garcia learned the man had no internet connection or phone of his own but was 66 years old and wanted to get the covid vaccine. He had tried to visit a pharmacy in person, but the shots were all out for the day. Garcia took down his name and the phone number of a friend, so she could reach the driver later about a mobile vaccine clinic that her organization, El Sol Neighborhood Educational Center, was putting together for the remote desert city sometime in April.

Then it was on to the next car. And the next. As the line started moving, she and fellow health worker Erika Marroquin jogged up and down the sidewalk, taking down names, phone numbers and preexisting conditions. It was the first mild, sunny day the High Desert region had seen in weeks, and the exercise made them sweat.

After 90 minutes, the food bank was done for the day, and Garcia and Marroquin had spoken to people in 54 cars. They had found six people eager for the covid vaccine and eligible for it immediately. Ten more wanted to be put on a waiting list for leftover doses.

The rollout of vaccinations in California, as in many states, has been slow and chaotic. More than in the nation’s most populous state have been at least partially vaccinated, while an additional 5.6 million are fully vaccinated. Come April 15, all adults in California will be eligible to sign up for a vaccine, and by early summer the goal is to have plenty of vaccine for any adult who wants it.

But the country needs to get the to keep the virus from easily spreading — a level called herd immunity by experts on infectious diseases. But even that figure assumes the population is homogenous in terms of vaccination. That’s why the state’s ability to stave off another covid surge may rely on people like Garcia and Marroquin — community health workers and organizers doing time-intensive, laborious work — to prevent pockets of the population with low vaccination rates in remote or isolated communities from becoming a tinderbox for a new covid surge.

“When you have geographical or social pockets of unvaccinated people, it really messes up herd immunity,” said Daniel Salmon, director at the Institute for Vaccine Safety at Johns Hopkins University’s Bloomberg School of Public Health.

in recent years provide a sobering example. State and national vaccine coverage is quite high, “but then you’d have these communities where a lot of people would refuse vaccines, and then measles would be imported and create an outbreak,” Salmon said. Outbreaks have hit certain Orthodox Jewish communities in New York, Somali immigrants in Minnesota and affluent pockets of Southern California where anti-vaccine parents lived.

The coronavirus is still circulating widely in California, though at much lower levels than two months ago. The virus, especially an increasingly common, more contagious variant, could easily rip through vulnerable communities with low levels of immunity. In Adelanto, where 29% of residents live in poverty, had been fully vaccinated by March 20.

As of March 26, most of the more than 15.9 million vaccine doses distributed since December had gone to in the state. Community-based organizations like nonprofits and churches are clamoring for more funding — and trust — to carry the vaccine the final mile to the people they’ve been serving for years.

El Sol’s success in getting Black, Latino and other underrepresented populations vaccinated debunks the idea that these groups won’t get the shot, said Juan Carlos Belliard, assistant vice president for community partnerships at Loma Linda University Health in San Bernardino County. Loma Linda is collaborating with El Sol to staff and provide doses for clinics. The people who show up are ready for their vaccine, though some are a bit hesitant, he said.

“They’re not like our middle-class folks who are literally crying for the vaccine,” Belliard said. “These folks are still nervous about it, but you’ve removed almost all of these other barriers for them.”

El Sol’s community workers were supported by a $52.7 million combined effort from state and philanthropic funding that provided grants to 337 organizations considered “trusted messengers” in their communities. The money was pushed out to groups like El Sol that had proven track records of shoe-leather canvassing for voter registration or census surveys.

El Sol received $120,000 from the public-private initiative to support its general outreach and educational efforts for covid vaccination. But the group was in the dark about whether it would get any reimbursement for the mobile vaccination events it has organized in San Bernardino County, said executive director Alex Fajardo.

El Sol held a pop-up vaccination event Feb. 17 at Centro Cristiano Luz y Esperanza, a church located off a two-lane expressway in Adelanto, surrounded by desert scrub. Medical staffers, students and vaccines arrived from Loma Linda University Health, about an hour away, to vaccinate 250 people, and returned a month later to give people their second doses.

Patricia Perez, 47, and Rosa Hernandez, 69, a mother-daughter pair, were among those who got their vaccines at Centro Cristiano.

Perez’s father, who works in a supermarket dairy department, fell ill with covid in June and was unable to return to work for six months. No one else in the seven-member household ended up testing positive, but Rosa Hernandez is a cancer survivor and her daughter was worried about her.

Despite multiple calls to a county phone line, Perez had been unable to line up a vaccine for her mom. The family’s internet connection, in the nearby town of Hesperia, was spotty, and Perez couldn’t really navigate the websites or find any information in Spanish, the language she’s most comfortable with.

She jumped at the chance when she heard about El Sol’s pop-up event through someone at her church. Perez also managed to snag an additional dose for herself after someone didn’t show up for their appointment. Now she and her mom are fully vaccinated, Perez said, and it wouldn’t have happened without El Sol.

The group plans to do three more vaccination pop-ups in the High Desert area. But future support for its clinics, vaccine outreach and education are murky, said Fajardo.

“What is going to happen after?” he said. “When we need you, we pay you. When we don’t need you, ‘Bye-bye.’”

“That’s a very fair assessment,” said Susan Watson, program director for the Together Toward Health initiative of the Public Health Institute, the philanthropic funder behind some of El Sol’s work. “There’s an opportunity here for people to be thinking about the future, and how we do things that doesn’t necessarily leave community groups permanently on the outside, only tapped into when there’s an emergency.”

Community Coalition, a South Los Angeles nonprofit founded in 1990, also received grants from the public-private partnership to raise awareness about covid vaccines, but no additional funding to deliver vaccines to the people. Still, it mobilized staff to knock on doors, text and email eligible people to turn out for a two-week pop-up vaccination event at a neighborhood park in early March — providing 4,487 people with their first vaccine dose, said the group’s chief operating officer, Corey Matthews.

Dr. Mark Ghaly, the state’s secretary for health and human services, promised to provide more money for groups that are getting their communities vaccinated. “This is not a volunteer job,” he told KHN at a news briefing. “This is real work, and I want to be part of the team that makes that a reality for all of them.”

Los Angeles County department of public health Director Barbara Ferrer echoed that sentiment. “They were there before the pandemic started, they’ve been there the entire time during the pandemic, and they’ll be here long after the pandemic,” she said.

Whether or not those promises hold up, community groups say, they want to be part of the vaccination effort.

“Even if they don’t give us money, we’ll keep doing the work,” said Fajardo.

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Nah Thu Thu Win’s twin sons needed vaccinations before starting kindergarten. But she speaks little English, and the boys lacked health insurance.

William Arce and Wanda Serrano were recovering from recent surgeries. But the couple needed help sorting out their insurance and understanding their bills.

Engebretson, Win, Arce, and Serrano were fortunate to have someone to help.

They’re all paired with community health workers in Huron, a city of 14,000 people known for being home to the state fair and what’s billed as the world’s largest pheasant sculpture.

Three workers, employed by the Huron Regional Medical Center, help patients navigate the health system and address barriers, like poverty or unstable housing, that could keep them from getting care. Community health workers can also provide basic education on managing chronic health problems, such as diabetes or high cholesterol.

Community health worker programs are spreading across the U.S., including in rural areas and small cities as health providers and and governments increasingly invest in them. These initiatives gained attention during the coronavirus pandemic and to improve people’s health and access to preventive care while reducing expensive hospital visits.

Community health worker programs can address common barriers in rural areas, where people face and certain health problems, said Gabriela Boscán Fauquier, who oversees community health worker initiatives at the National Rural Health Association.

The workers are “an extension of the health care system” and serve as a link “between the formality of this health care system and the community,” she said.

The programs are often based at hospital systems or community health centers. The workers have a median pay of $23 an hour, according to the federal Bureau of Labor Statistics. Patients are typically referred to programs by clinicians who notice personal struggles or frequent visits to hospital emergency departments.

is among the states that have recently funded community health worker programs, developed training requirements for the workers, and approved Medicaid reimbursement for their services. The state’s certification program requires 200 hours of coursework and 40 hours of job shadowing.

Huron Regional Medical Center launched its initiative in fall 2022, after receiving a $228,000 federal grant. The program is now funded by the nonprofit hospital and Medicaid reimbursements.

Huron, a small city surrounded by rural areas, is mostly populated by white people. But thousands of Karen people — an ethnic minority from the Southeast Asian country of Myanmar — . Many are refugees. The city also has a significant Hispanic population from the Caribbean, Mexico, and Central and South America.

Mickie Scheibe, one of Huron’s community health workers, recently stopped by the house of client Kelly Engebretson. The 61-year-old hadn’t been able to work since he had part of his leg amputated, due to diabetes complications.

Scheibe helps with “the hoops you’ve got to jump through,” such as applying for Medicaid, Engebretson said.

He told Scheibe that he didn’t know how he was going to get to his prosthetic fitting in Sioux Falls — a two-hour drive from home. Scheibe, 54, said she would help find him a safe ride.

She also invited Engebretson to a diabetes education program.

“Put me down as a definitely absolutely,” he replied, adding that he’d invite his mother to tag along.

The same day, Scheibe’s co-worker Sau-Mei Ramos visited the apartment where William Arce and Wanda Serrano live. Arce was recovering from heart surgery, while Serrano was healing from knee and shoulder operations.

The couple, both 61, moved three years ago from Puerto Rico to be near their children in Huron. Ramos, who’s also from Puerto Rico, coordinated their appointments, answered their billing questions, and helped Arce find a walker and supplemental insurance.

Ramos, 29, handed Arce a pamphlet about heart health and asked him to read the section on angina, the pain that results when not enough blood flows to the heart.

“Qué entiende?” she said, asking Arce what he understood about his condition. Arce, speaking in Spanish, responded that he knew what angina was and what symptoms to watch for.

Later that day, Paw Wah Sa, the third community health worker in town, met with client Nah Thu Thu Win, who moved to Huron in February from Myanmar with her husband and twin 6-year-olds. The Win family, like Sa, are part of the local Karen community, whose people have been persecuted under the military rulers of Myanmar, the country formerly known as Burma.

Win, 29, had assumed the kids would qualify for Medicaid. But unlike most other states, South Dakota to children who legally immigrated into the U.S. The boys’ father hopes to eventually add them to his work-sponsored insurance.

Sa didn’t want the kids to have to wait for health care. The 24-year-old previously took the twins to a free mobile dental clinic in Huron. It turned out they needed more advanced dental work, which they could get free only in Sioux Falls. Sa helped make the arrangements.

Many Karen residents and people from rural parts of Latin America had little access to health care before moving to the U.S., Sa and Ramos said. They said a major part of their job is explaining what kind of care is available, and when it’s important to seek help.

The three community health workers sometimes take clients grocery shopping, to teach them how to understand labels and identify healthful food.

Boscán Fauquier, with the National Rural Health Association, said that because community health workers are familiar with the cultures they serve, they can suggest affordable food that clients are familiar with.

Rural America’s overall population is shrinking, but the 2020 census showed it has become as people representing ethnic minorities are drawn to jobs in industries such as farming, meatpacking, and mining. Others are attracted by rural areas’ lower crime rates and cheaper housing.

Boscán Fauquier said many rural community health worker programs serve people from minority groups, who are than white people to face barriers to health care.

She pointed to programs serving Native American reservations, the Black Belt region of the South, and Spanish-speaking communities, where the workers are called promotoras. But community health workers also serve rural white communities, such as those in Appalachia impacted by the opioid crisis.

Medicare, the federal health program for adults 65 or older, has been reimbursing community health worker services . Boscán Fauquier said advocates hope more state Medicaid programs and will allow reimbursement too.

Engebretson said he’s happy to see community health workers across South Dakota, not just in big cities.

The more they “can branch out to the people, the better it would be,” he said.

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Noneo is one of four community health representatives for the Fallon Paiute-Shoshone, which the tribe said includes about 1,160 enrolled members. The role primarily involves driving tribal members to their health appointments, whether in Fallon, a city of just under 10,000, or Reno, more than 60 miles west. Noneo said she and her colleagues have also taken patients as far away as Sacramento, California, and Salt Lake City, round trips of nearly 400 and 1,000 miles, respectively.

Public health experts contend the role Noneo and others like her fill is an integral part of ensuring people receive the care they need, especially for chronic illnesses, by helping close gaps in areas with medical provider shortages. Besides transporting patients to their appointments, community health representatives provide health education, patient advocacy, and more. Noneo said she and her colleagues spend a lot of time helping young mothers and elders, checking on the latter, taking them to get groceries, or delivering their medication.

Yet, most state Medicaid programs don’t recognize or pay for services offered by health workers, such as Noneo, who work on tribal lands. That’s despite their work being essentially the same as that of “community health workers” in nontribal communities, a classification many state Medicaid programs cover.

In Nevada, that disparity recently changed when the state began allowing workers on tribal lands to qualify for Medicaid reimbursement as community health workers. Tribal leaders say the Medicaid payments supplement existing personnel funding by covering the individual services the workers provide. That in turn should allow tribes to train and hire more community health representatives, which could expand health and support services for tribal members.

Only two other states, South Dakota and Arizona, treat community health representatives serving Native American populations as eligible for the same Medicaid reimbursement as their similarly named counterparts in nontribal areas, according to Michelle Archuleta, a community health representative program consultant for the federal Indian Health Service. However, she said, the tribes the CHRs work for have not begun billing the states’ Medicaid programs.

The Community Health Representative program, established by Congress in 1968, is among the nation’s . It’s jointly funded by each tribe and the IHS, an agency within the Department of Health and Human Services responsible for providing health care to members of federally recognized tribes. As of 2019, more than 1,600 of these tribal linchpins worked in the United States, according to the IHS.

Last year, the Centers for Medicare & Medicaid Services approved Nevada’s plan to make community health workers who complete training and certification requirements eligible for Medicaid reimbursement when they assist with chronic disease management and prevention.

And in December, leaders with the Nevada Community Health Worker Association helped tribes make sure their community health representatives would receive the necessary training for certification. The association would “fully support” tribal clinics submitting their community health representative training for recognition in the state and it would not require a change to state law, said Jay Kolbet-Clausell, program director for the group. For now, community health representatives are receiving double training to be able to file for Medicaid reimbursement.

Training and certification requirements for community health workers vary widely by state and employer, as workers are often hired by hospitals, local organizations, health departments, or federally qualified health centers. But a movement has been emerging across the country to bring more uniformity to those requirements and formalize the roles, said , a policy analyst with the Racial Equity and Health Policy program at Â鶹ŮÓÅ.

As part of this process, states are expanding coverage for community health workers under Medicaid. According to a , 28 of 47 states, and Washington, D.C., reported having policies that allow Medicaid reimbursement for services provided by community health workers. Arkansas, Georgia, and Hawaii did not respond to Â鶹ŮÓÅ’s survey.

“There’s a really robust evidence base that is growing every day that community health worker interventions can be effective in reducing health disparities, particularly in communities of color,” Haldar said.

Studies have also shown that community health worker programs are effective in for people with chronic conditions and that they .

Soon after Nevada implemented its program, about 50 community health representatives completed the requirements. Another cohort of 20 finished the curriculum later, said Kolbet-Clausell. The goal is for those who have completed the recent training to help their peers through it, they said.

Even before the tribal workers were included in the community health workforce, one of its greatest strengths was its diversity, Kolbet-Clausell said. In Nevada, the 2022 student group was made up of greater shares of people who are American Indian or Alaska Native, Hawaiian or Pacific Islander, Black, Hispanic, or from rural areas than the state’s general population. They said it’s likely one of the most diverse health programs in the state.

Community health representatives such as Noneo are typically tribal or community members themselves, which, public health experts say, allows them to connect more easily with the patients they serve and better connect them to health care.

For example, the first person she picked up that June morning was her cousin, who had a 6 a.m. dialysis appointment.

Kolbet-Clausell said they’re optimistic about the growing workforce and the support it’s getting from state leaders.

“Five, six years ago, there was a lot more resistance,” they said, because lawmakers saw the efforts to expand the community health workforce as simply spending more money. “But this actually just benefits rural communities as much as it benefits underserved urban communities. It serves everyone.”

Back in Fallon, Noneo reflected on her 27 years as a community health representative for her tribe as she prepares to retire in September. She has been there with her fellow tribal members through important and hard times in their lives — like driving an expectant mother to Reno to deliver a baby, taking people to receive treatment for mental health crises and addiction, and bringing patients to their dialysis treatments on her week off around Christmas so they wouldn’t miss their appointments.

The most challenging part of the job, she said, is experiencing the loss of someone she has regularly seen and provided years of services for.

“We all have compassion,” she said. “In this kind of job, you have to have that.”

After decades of shuttling patients, Noneo has the work down to a steady and familiar rhythm. Four hours after dropping off her cousin for dialysis, Noneo picked her up at the clinic as she dropped off the next dialysis patient. On a clipboard, she logged the hours and mileage for each appointment.

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A paramedic recently arrived at her doorstep again, but this time it wasn’t for an emergency. Jason Frye was there for a home visit as part of a new community paramedicine program.

Frye showed up in an SUV, not an ambulance. He carried a large black medical bag into Lane’s mobile home, which is on the eastern edge of the city, across from open fields and train tracks that snake between the region’s massive open-pit coal mines. Lane sat in an armchair as Frye took her blood pressure, measured her pulse, and hooked her up to a heart-monitoring machine.

“What matters to you in terms of health, goals?” Frye said.

Lane said she wants to become healthy enough to work, garden, and ride her motorcycle again.

Frye, a 44-year-old Navy veteran and former oil field worker, promised to help Lane sign up for physical therapy and offered to find an anti-slip grab bar for her shower.

Community paramedicine allows paramedics to use their skills outside of emergency settings. The goal is to help patients access care, maintain or improve their health, and reduce their dependence on costly ambulance rides and ER visits.

Such programs are expanding across the country, in , as health care providers, insurers, and state governments recognize the potential benefits to patients, ambulance services, and hospitals.

Gary Wingrove, a Florida-based leader in community paramedicine, said the concept took off in the early 2000s and now includes hundreds of sites. of 129 programs found that 55% operated in “rural” or “super rural” areas.

Community medicine can be helpful in rural areas where people have less access to health care, said Wingrove, chair of the International Roundtable on Community Paramedicine. “If we can get a community paramedic to their house,” he said, “then we can keep them connected to primary health care and all of the other services that they need.”

Frye works at Campbell County Health, a health care system based in Gillette, a city of about 33,000 in northeastern Wyoming. Leaders of the community paramedicine program plan to expand it into two adjacent, largely rural counties dotted with ranches and coal mines on the rolling prairie that stretches more than 100 miles from the Black Hills to the Bighorn Mountains.

Gillette serves as a medical hub for the region but has shortages of primary care doctors, specialists, and mental health services, according to a . People who live outside the city face additional barriers.

“A lot of them, especially older people, don’t want to come into town. And basically, those tiny communities don’t usually have health care,” Lane said. “I think it’s just kind of a pain for them to drive all the way into town, and unless they have a serious problem, I think they tend to just figure, ‘Well, it’ll work itself out.’”

Community paramedicine programs are customized to the needs and resources of each community.

“It’s not just a cookie-cutter-type operation. It’s like you can really mold it to wherever you need to mold it to,” Frye said.

Most community paramedicine programs rely on paramedics, but some also use emergency medicine technicians, nurses, social workers, and other professionals, according to the 2017 survey. Programs can offer home visits, phone check-ins, or transportation to nonemergency destinations, such as urgent care clinics and mental health centers.

Many programs support people with chronic illnesses, patients recovering from surgeries or hospital stays, or frequent users of 911 and the ER. Other programs focus on public health, behavioral health, hospice care, or post-overdose response.

Community paramedics can provide in-home vaccinations, wound care, ultrasounds, and blood tests.

They can offer exercise and nutrition tips, teach patients how to monitor their symptoms, and help with housing, economic, and social needs that can affect people’s health. For example, paramedics might inspect homes for safety hazards, provide a list of food banks, or connect lonely patients with a senior center.

Paramedics and patients said some rural residents struggle to access health care because of long distances, cost, lack of transportation, or dangerous weather. Some hesitate to seek help out of pride or because they don’t want to be a burden to others. Some limit trips to town during ranching and farming crunch times, such as calving and harvesting seasons.

Delayed care can let health problems fester until they become an emergency.

Advocates say providing in-home care, resources, and education can help patients reduce such crises and associated costs. Fewer emergencies mean fewer ambulance runs and hospital patients. That could help ambulance services and hospitals reduce costs and the time patients wait for help.

found that more studies are needed but that data so far suggests these programs reduce costs. It also found links to improved health outcomes and decreased use of ambulances and hospitals.

For example, a pilot program in Fort Worth, Texas, saw a 61% reduction in ambulance rides, . MedStar, the operator, made the effort permanent and says its 904 participants , saving an estimated $8.5 million over eight years.

But rural ambulance services, especially volunteer ones, can struggle to staff and fund community paramedicine programs.

Kesa Copps, a co-worker of Frye’s, previously worked as an emergency medical technician in Powder River County, Montana, which has fewer than 2,000 residents. Some people there must drive more than an hour to reach the nearest hospital. The area’s volunteer ambulance service started a community paramedicine program in 2019.

Copps said the program reduced hospital readmissions and extended some elderly patients’ ability to live at home before being admitted to a nursing facility. She visited patients between ambulance runs and had to leave early when a 911 call came in. That’s different from the Campbell County Health model, in which community paramedicine is a full-time position, not split with emergency work.

Adam Johnson, director of the Powder River ambulance service, said the community paramedicine program shut down in 2021 after everyone with the necessary training left the area. Johnson said paramedics are signing up for training to restart the program.

States are , and some require licensed paramedics to obtain extra training to work in the field.

Some ambulance services and health care organizations have piloted community paramedicine programs with the help of state or federal grants. If they find the service saves money, they may decide to continue the program and fund it themselves.

Private insurance companies are increasingly covering community paramedicine, Wingrove said. Wyoming and several other states allow operators to bill Medicaid for the services.

Advocates are now pushing Medicare to expand its of community paramedicine, Wingrove said. That would benefit Medicare patients and could spur more private insurers to offer coverage.

The Campbell County Health program’s home visits cost up to $240 per hour and are billed to Medicaid or Medicare, said Frye. That compares with more than $1,300 for an ambulance ride and thousands of dollars for a visit to a hospital ER.

Community paramedicine may soon expand in neighboring South Dakota, another largely rural state.

South Dakota ambulance services have experimented with community paramedicine and lawmakers to authorize and regulate it.

Eric Emery, the state representative who introduced the bill, plans to start a program on the sprawling, rural Rosebud Indian Reservation, where he works as a paramedic. He said the operation will focus on diabetes and mental health care.

Emery, a Democrat, said some people struggle to pick up their medication and attend appointments because they lack vehicles or gas money and there’s no public transportation to the hospital. He said some parents and grandparents raising children also struggle to find time to drive to appointments.

“They’re putting the needs of the younger generation or their grandkids before their own,” Emery said.

Back in Gillette, Frye also checked in on Linda Quitt, a 78-year-old facing diabetes, depression, and a lack of social support after her husband was hospitalized with dementia. Quitt said her husband was her walking buddy and helped care for her.

“I had him to wait on me, and now I have nobody,” Quitt said.

Frye said he would see if he could help start a senior walking group that Quitt could join. He told her that socializing can improve health.

“You’re not alone,” Frye told Quitt.

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“I would be getting maybe three to four a month,” recalled Lopez, a TB program supervisor with Cameron County’s health department.

In a matter of months, patients seeking care at the county’s two clinics dropped by half. “And then I wasn’t getting any at all,” he said.

As covid gripped the world’s attention, Lopez began to focus on a parallel concern: whether TB was being overlooked along the Texas-Mexico border.

“I knew there had to be TB cases out there; they just weren’t being found,” Lopez said in a recent interview.

Before 2020, advances to eradicate TB, which is spread person-to-person , were underway globally. It was considered by many public health experts to be a , since tools are available to identify and treat it. But the prevalence of the disease in Mexico, and immigration along the border, has made it a longtime health concern in these communities.

In areas with high immigrant traffic, such as Cameron County, TB is a serious health concern. Cameron sits at the southernmost tip of Texas, and each year millions of people cross to and from Mexico at the four border crossings in the Brownsville region. and largest city. In 2019, before covid, had an average TB incidence of 8.4 cases per 100,000 people — more than double that of the state overall, and nearly triple the national rate.

Since the pandemic began, though, some tuberculosis clinics in border areas have been performing fewer tests, receiving fewer referrals from local hospitals and providers, and treating fewer patients. Lopez and others who do this public health work every day on the ground agree it’s not likely less TB is circulating. Instead, they say, covid testing and treatment have claimed so much attention and energy that TB has been pushed off the radar, threatening to reverse decades of progress in eliminating it.

Lopez said his county’s tuberculosis department usually gets around 40 to 60 patients a year. “And then, all of a sudden, we went down to 20 during the covid pandemic,” he said. The numbers seem to be bouncing back. In 2022, Lopez said, the county’s clinics saw 35 TB patients. But that’s still lower than pre-pandemic levels.

Hidalgo County, which neighbors Cameron to the west, experienced a similar trend in 2020, when its number of confirmed TB cases was cut in half from the previous year, dropping from 71 cases to 36, according to Jeanne Salinas, tuberculosis program manager of the county health department. The county also performed hundreds fewer TB tests.

Since 2020, Salinas said, tuberculosis has been “overlooked” as a diagnosis for patients reporting “prolonged cough or cough with blood, losing weight, having fevers.” After covid became everyone’s overriding concern, these patients — who included new immigrants as well as people who regularly traveled across the border for work or to visit family on the other side — were tested for covid. Salinas said it was only if the symptoms persisted that patients would perhaps be evaluated for tuberculosis. This lag time allowed the illness to progress in individual patients and potentially spread in the community.

This reflects a nationwide trend. According to , U.S. tuberculosis incidence rates “decreased steadily” from 1993 to 2019. In 2020, though, there was a “sharp” decline of nearly 20% in recorded cases, which the CDC materials suggest may be due to “delayed or missed TB diagnoses or a true reduction in TB incidence related to pandemic mitigation efforts and changes in immigration and travel.” But because TB is more contagious than covid (its particles stay in the air longer), steps like masking and distancing are less effective. So, Salinas argues the former.

Convincing people of the need to test for TB was difficult even before covid, Lopez said. For starters, some health workers wrongly considered the illness a nonissue. That tuberculosis and covid share similar symptoms became another complication. When doctors and other health professionals saw those symptoms, their first concern was covid. And for a while, it was their only concern.

Other issues are diagnosis and treatment. Samples for covid rapid tests, and even the more sensitive and expensive PCR tests, can be collected with a simple nasal swab. TB screening is more invasive, done with either a skin test that requires a follow-up visit to a health professional or a blood draw that is tested in a lab. At the height of the pandemic, Lopez said, providers were so focused on getting people in and out of clinics and hospitals quickly that taking the time to conduct TB screenings wasn’t a priority.

Though TB is a curable disease, its treatment can require up to a year of prescribed antibiotics, which experts say adds to the urgency of detecting cases early on.

The Texas Department of State Health Services says on that tuberculosis rates are “higher along the Texas-Mexico border” than in the rest of the state. , chief of infectious diseases at Texas Tech University Health Sciences Center in El Paso, said that’s because “almost all cases of tuberculosis in the United States are coming from immigrants.”

, a former Texas Medical Association president who is a member of the group’s, added that many people live in Mexico but work in Texas, and vice versa, “so with that comes perhaps unclear health issues and exposure.”

There’s yet another snag. Tuberculosis, Villarreal explained, is especially hard for people’s immune system to suppress if they also have other health issues, and the border is a hot spot for diabetes and other chronic health conditions like hypertension or heart disease.

Covid, itself, is something of a comorbidity because it can make people more susceptible to tuberculosis. Some of her patients have had both illnesses, Salinas said. She suspects some who died of covid may have had tuberculosis as well, or instead.

Border areas tend to be impoverished, and “TB is a disease of the poor,” Texas Tech’s Meza said. “And who is poor in this country? The minorities, the immigrant populations, the mentally ill who live in close gatherings and shared common spaces.” Not to mention people who are uninsured and can’t afford health care.

Meza said he drives by the border often, and when he does, he sees crowds waiting on the Mexican side in Juárez, hoping to get across. If they do, he said, he hopes they get proper health screenings and care.

“To me, that’s what I’m afraid of more than covid,” Meza said. “If there is no change systematically, then that’s when things can get more complicated.”

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Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help , and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. , a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called , adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of , one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a .

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

This story was produced by , which publishes , an editorially independent service of the .

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Drug sales provide the bulk of the revenue for Genesis, a nonprofit community health center treating about 11,000 mostly low-income patients in seven clinics across South Carolina.

Those sales helped Genesis record a $19 million surplus on $52 million in revenue — a margin of 37% — in 2021, according to its audited financial statement. It was the fourth consecutive year the center’s surpluses had topped 35%, the records showed. The industry average is 5%, according to a federally funded report on health centers’ financial performance.

Genesis attributes its large margins to excellent management and says it needs the money to expand and modernize services while being less reliant on government funding. The center benefits financially from the use of a government drug discount program.

Still, Genesis’ hefty surplus stands out among nonprofit federally qualified health centers, a linchpin in the nation’s safety net for treating the poor.

The federal government pumped more than $6 billion in basic funding grants last year into around the country, which provide primary care for mostly low-income people. In 2021, the American Rescue Plan Act provided an additional $6 billion over two years for covid-19 care.

These community health centers must take all patients regardless of their ability to pay, and, in return, they receive annual government grants and higher reimbursement rates from Medicaid and Medicare than private physicians.

Yet a KHN analysis found that a handful of the centers recorded profit margins of 20% or more in at least three of the past four years. Health policy experts said the surpluses alone should not raise concerns if the health centers are planning to use the money for patients.

But they added that the high margins suggest a need for greater federal scrutiny of the industry and whether its money is being spent fast enough.

“No one is tracking where all their money is going,” said , an assistant professor at the University of Oklahoma who has studied health center finances.

The federal Health Resources and Services Administration, which regulates the centers, has limited authority under federal law over how much the centers spend on services and how they use their surpluses, said , an associate administrator.

“The expectation is they will take any profit and plow it back into the operations of the center,” Macrae said. “It’s definitely something we will look at and what they are doing with those resources,” he added about KHN’s findings.

, an accounting and health professor at Johns Hopkins University, questioned why some centers should be making profit margins of 20% or more over consecutive years.

A center with a high margin “raises questions about where did the surplus go” and its tax-exempt status, Bai said. “The centers have to provide enough benefit to deserve their public tax exemption, and what we are seeing here is a huge amount of profits,” she said.

Bai said centers must be able to answer questions about “why aren’t they doing more to help the local community by expanding their scope of service.”

Officials at the health centers defended their strong surpluses, saying the money allows them to expand services without being dependent on federal funds and helps them save for big projects, such as constructing new buildings. They pointed out that their operations are overseen by boards of directors, at least 51% of whom must be patients, ostensibly so operations meet the community’s needs.

“Health centers are expected to have operating reserves to be financially sustainable,” said Ben Money, a senior vice president at the National Association of Community Health Centers. Surpluses are necessary “as long as health centers have plans to spend the money to help patients,” he said.

Some center officials noted bottom-line profit margins can be skewed by large contributions earmarked for building projects. Grants and donations appear as revenue in the year they were given, but a project’s costs are allocated on financial statements over a longer period, often decades.

‘We Don’t Take Unnecessary Risks’

The annual federal base grant for centers makes up about 20% of their funding on average, according to HRSA. The grants have more than doubled over the past decade. These federal grants to the centers are provided on a competitive basis each year based on a complex formula that takes into account an area’s need for services and whether clinics provide care to specific populations, such as people who are homeless, agricultural workers, or residents of public housing.

The centers also receive Medicare and Medicaid reimbursements that can be as much as twice what the federal programs pay private doctors, said Jeffrey Allen, a partner with the consulting firm Forvis.

In addition, some health centers like Genesis also benefit from the 340B federal drug discount program, which allows them to buy medicines from manufacturers at deeply discounted rates. The patients’ insurers typically pay the centers a higher rate, and the clinics keep the difference. Clinics can reduce the out-of-pocket costs for patients but are not required to.

For its analysis, KHN started with research by Davlyatov that used centers’ tax filings to the IRS to identify the two dozen centers with the highest profit margins in 2019. KHN calculated bottom-line profit margin for each of the past four years (2018 through 2021) by subtracting total expenses from total revenue, which yields that year’s surplus, and then dividing that by total revenue. Money given by donors for restricted uses was excluded from revenue. After examining the centers’ finances, KHN found nine that had margins of 20% or more for at least three years.

North Mississippi Primary Health Care was one of them.

“We don’t take unnecessary risks with corporate assets,” said Christina Nunnally, chief quality officer at the center. In 2021, the center had nearly $9 million in surpluses on $36 million in revenue. More than $25 million of that revenue came from the sale of drugs.

Nunnally said the center is building a financial cushion in case the 340B program ends. Drugmakers have been seeking changes to the program.

The center recently opened a school-based health program, a dental clinic, and clinics in neighboring counties.

“There may come a day when this type of margin is not feasible anymore,” she said. If the center hits hard times, it would not want to “have to start cutting programs and people.”

In Montana, Sapphire Community Health in Hamilton, which accumulated nearly $3 million in surpluses from 2018 through 2020 and had a profit margin of more than 24% in each of those years, wants to move out of its rented quarters to a building that will cost at least $6 million to construct. “A new facility will enable us to provide services that we cannot provide due to lack of space, such as imaging, obstetrics, and dental services,” CEO Janet Woodburn said.

Outside Los Angeles, Friends of Family Health Center CEO said his high margins are the result of good management and California’s broad Medicaid coverage for low-income residents.

The center — whose profit margins topped 25% from 2018 to 2020 — opened a $1.9 million facility in Ontario last year and purchased the building that houses its main clinic, in La Habra, for $12.3 million, with plans to expand it, he said.

Bahremand added that the center also keeps administrative costs down by focusing on having more providers in relatively fewer locations.

“You shouldn’t be asking: ‘Why are we making so much money?’ You should be asking: ‘How come other clinics are not making so much money?’” Bahremand said.

Concern About Paying the Bills

In South Carolina, Genesis began as an independent clinic and was sometimes barely able to make payroll, said Tony Megna, Genesis’ CEO and general counsel. Converting to a federally qualified health center about a decade ago brought federal funding and a more solid footing. It recorded more than $65 million in surpluses from 2018 to 2021.

“Our attitude toward money is different than most because it’s so ingrained in us to be concerned about whether we are going to pay our bills,” said Katie Noyes, chief special projects officer.

The center is spending $50 million to renovate and expand its aging facilities, Megna said. In Darlington, a new $20 million building that will more than double the facility’s space is scheduled to open in 2023. And its strong bottom line helps the center pay all its workers at least $15.45 an hour, more than twice the minimum wage in the state, Megna said. Darlington County’s annual median household income is a bit over $37,000.

Megna was paid nearly $877,000 in salary and bonuses in 2021, according to Genesis’ latest IRS tax filing, an amount nearly four times the industry average.

David Corry, chairman-elect of the Genesis board of directors, said in a memo to KHN that part of that compensation made up for several years when Megna was inadvertently underpaid. “We determined early on that providing Mr. Megna an ‘average’ compensation like those of other FQHCs CEOs was not what we wanted. Mr. Megna’s extensive legal experience and education as well as his institutional and regulatory knowledge set him apart from others.”

Megna said his base salary is $503,000.

Genesis officials said the financial security afforded by the center’s surpluses has allowed them to provide extra patient services, including foot care for people with diabetes. In 2020, Genesis used $2 million to create an independent foundation to help families with food and utility bills, among other needs.

Most of Genesis’ revenue comes from the 340B program, according to its audited financial statements. Many prescriptions filled at the clinic pharmacy are for expensive specialty drugs, which treat rare or complex conditions such as cancer. Getting accredited to dispense specialty drugs was expensive, Corry said, but “paid off because it gives our patients access to extremely high-priced, and often lifesaving prescription drugs that would not otherwise be available to many of them.”

Megna, 67, a former bankruptcy lawyer, said it’s vital to keep the center financially secure to stay open for patients.

“We are very careful in how we spend our money,” Megna said.

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They converted an old farmhouse into a seven-bed medical center. They treated their first patient for a broken leg amid carpenters hammering nails. Surgeons laid their patients on a kitchen table for operations.

The hospital — then named after St. Margaret, known for her service to the poor — eventually became one of the largest in the area. Hundreds of thousands of Indiana and Illinois residents took their first, or last, breaths there.

A hundred twenty-four years later, the hospital has, in a sense, come full circle. This spring, , the nonprofit owner — still affiliated with the same Catholic order of sisters — plans to demolish most of the 226-bed Franciscan Health Hammond complex, leaving only eight beds, an emergency department, and outpatient services. The move cost 83 jobs at the hospital and 110 more at a long-term acute-care center that rented space there.

The news stung many in this Rust Belt city of nearly 80,000 people, who have watched businesses — and neighbors — flee Hammond for decades. It’s especially painful, they say, because the hospital system has dedicated more than half a billion dollars in recent years to new facilities in wealthier, less-diverse communities.

“It’s deplorable that a Catholic institution like the Franciscans would make a financially motivated decision and leave thousands of people potentially at risk,” said Mayor Thomas McDermott Jr., who complained that he was informed of the downsizing barely two hours before it was announced publicly. “I’m not trying to be alarmist, but people are gonna die because of this decision. And they know it.”

But the larger question is whether Hammond needs a hospital with hundreds of beds, given the shifts in medical practice and transportation in the 21^st century. Only 50 to 60 of its beds are full on most days, said hospital CEO Patrick Maloney. Another Franciscan Alliance hospital is only 6 miles away. Much more care today is being delivered on an outpatient or virtual basis than even five years ago.

And the Hammond site has had quality concerns. It rates only one out of five stars on , the lowest possible score and worst of any of the nine rated hospitals in its county.

“Stewardship of our resources is one of the components of our Catholic mission,” Maloney stated in an email. “Key to that is efficient delivery of care.”

He noted that Franciscan is investing $45 million to transform the campus and will continue to operate a medical clinic there for uninsured or underinsured patients, as well as services like imaging, a medical lab, and prenatal care.

While rural hospital closures often get more attention, cities like Hammond have also been prone to losing medical services, as health systems adjust to changes in care, and opt to invest in places where more people have private insurance. But the shutdowns raise questions about the changing mission of nonprofit hospitals — and whom they help.

Since the 1930s, the urban hospitals most likely to close are those serving low-income, minority populations, according to research by , professor at the Boston University School of Public Health. He calls large swaths of Detroit and New York City “medical wastelands.”

When the city hospital in Hartford, Connecticut, contracted in the 1970s, it kept its emergency room running — until that got too expensive, Sager said. “I predict, within a decade, despite the best intentions of everyone involved, it will prove financially unsustainable to support an eight-bed hospital plus ER in Hammond,” he said.

Hammond’s population is down about a third from its peak in the mid-20th century. Like other former manufacturing hubs in the Midwest and Northeast, the city has been hollowed out by deindustrialization and white flight to suburban areas. It is in the part of Indiana, affectionately known as “the Region,” that’s essentially an extension of south Chicago, crisscrossed with freight train tracks, dissected by interstates, littered with factories in various states of decay.

On a recent overcast morning, Franciscan Health Hammond’s parking garage and surrounding lots were mostly empty. A sprinkling of people trickled out of the hospital. A sign advised that birthing services had moved to the suburbs.

The that covers the hospital and its surrounding neighborhood has a poverty rate of 36%, with a median household income of $30,400. Its population is 82% Black and/or Latino. The hospital treats a large share of patients on Medicaid, the government insurance program for low-income people, which typically pays health care providers a lower rate than Medicare or private insurance.

For Franciscan Alliance, the driving factors in shrinking Franciscan Health Hammond were the costs required to maintain the aging infrastructure, and less demand for care expected in that part of “the Region,” Maloney said.

He said Hammond residents are welcome at Franciscan Alliance’s hospital 6 miles away in Munster, Indiana. The organization has spent at least $133 million in recent years on that facility, located in a wealthier suburb only a few blocks from a larger, competing hospital.

But for Carlotta Blake-King, a Hammond school board trustee, that’s not close enough, especially since the area doesn’t have much mass transit. “I’m a senior citizen. I don’t like to drive,” she said. “Everybody can’t afford a car.”

Free transportation to medical appointments, though, is offered through the and .

Franciscan Alliance has replaced older hospitals in other communities, albeit a few miles from their original locations, spending $333 million on a new medical center in Crown Point, Indiana, and $243 million in Michigan City, Indiana. In 2018, however, it shuttered a century-old hospital in Chicago Heights, Illinois, a working-class Chicago suburb demographically similar to Hammond.

The missions of many nonprofit hospital chains like Franciscan Alliance have evolved. Around the turn of the 20th century, hospitals often deliberately set up shop in less-fortunate neighborhoods, with community members providing time, money, and supplies. When St. Margaret opened, for example, local farmers donated food. The Internal Revenue Service exempted so-called charity hospitals from paying taxes.

Today, “hospitals are operating as corporations, as moneymaking business entities, and their decisions are largely driven by financial concerns,” said , a professor of accounting and health policy at Johns Hopkins University. “The line between the current nonprofit hospitals and for-profit hospitals is very, very murky.”

In 2018, nonprofit hospitals provided less unreimbursed Medicaid and charity care than their for-profit counterparts, Bai’s . However, she noted, Franciscan Alliance spent more than the average nonprofit on both fronts.

Pat Vosti, a retired nurse from Hammond, worked in the cardiology unit, so she knows how time is of the essence in health care. She’s concerned about patients who have to be diverted to other hospitals. “It’s a matter of minutes, but minutes count in some instances, you know?” she said.

However, people have been bypassing the Hammond hospital for years. Along with its sister campus in Dyer, Indiana, it has only a 15% market share, according to a 2016 bond filing, compared with 45% for Franciscan’s Michigan City facility and 38% for Crown Point.

“Now, why they haven’t been using it could be a function of management choices made 15, 20 years ago: ‘Don’t build that new ER, don’t recruit those young doctors, don’t open a service for substance abuse,’” said , an adjunct professor at the Harvard T.H. Chan School of Public Health. “This is usually a gradual death. These places don’t suddenly go bad.”

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She works in an office in the shadow of the steel mill that employed her grandfather in this shrinking city in the Greater St. Louis area. Gone with many of the steel jobs is some of the area’s stability — of Granite City’s residents live in poverty, far higher than the .

Then another destabilizer — covid-19 — hit. And so Scott stepped in: She knows how to access rental assistance for those out of work as they isolate at home with covid. She can bring people cleaning supplies or food from a local food bank. She’ll stay on the phone with clients, helping them budget their finances to keep the lights on. And the calls keep coming because people know she understands.

“I’ve been hungry. I’ve not had a car,” Scott said. “I’ve been through those things.”

Scott is one of the over 650 community health workers the Illinois Department of Public Health hired through local, community-based organizations starting last March. This Pandemic Health Navigator Program workforce was made possible by a nearly $55 million grant from the Centers for Disease Control and Prevention through the federal pandemic relief passed by Congress. The team has completed at least 45,000 assistance requests, which were referred to them through contact tracing of covid cases.

As the workers have gained the community’s trust, Scott said, new requests have poured in from people who have heard about the catch-all program, which does more than what many people may think of as public health work.

But the money is set to run out at the end of June. Workers such as Scott are uncertain about their futures and those of the people they help each day. Dr. , executive director of the American Public Health Association, said that’s the tragedy of the boom-bust nature of public health funding in the United States.

“As the dollars go away, we’re going to see some people falling off the cliff,” he said. The problem, as Benjamin sees it, is the country’s lack of a systematic vision for public health. “If you did this with your army, with your military, you could never have a sound security system.”

Community health workers were positioned as key to President Joe Biden’s public health agenda. Ideally, they are one and the same as those they serve — like a neighbor who can be trusted when help is needed. Popular in countries such as , , community health workers have been difficult to maintain in the United States without consistent ways to pay them.

Hundreds of millions of dollars were supposed to go to building a community health workforce after the American Rescue Plan Act was signed into law last March, said Denise Smith, the founding executive director of the . But, she said, much of the money is being quickly spent on health departments or national initiatives, not local, community-based organizations. And a lot of it has been going to AmeriCorps workers who may not be from the communities they work in — and make poverty-line salaries, Smith said.

“For bills and a car note, rent, or children, that’s just not sustainable,” she said. “We can’t do it for free.”

By contrast, Illinois’ program tries to hire workers from within communities. Two-thirds of its workers identify as Latino/Hispanic or Black. About 40% were previously unemployed, and hiring them injects money into the communities they serve. The jobs pay $20 to $30 an hour, and almost half include health insurance or a stipend toward it.

That’s by design, said Tracey Smith, who oversees the Pandemic Health Navigator Program for the Illinois Department of Public Health and is not related to Denise Smith. She believes paying for such workers is a necessity, not a luxury, in helping people navigate the nation’s broken health care system and disjointed government assistance programs.

Angelia Gower, a vice president of the NAACP in Madison, Illinois, is now one of those paid community health workers. “They see you out there week after week and month after month and you’re still there, they start trusting,” she said. “You’re making a connection.”

But as covid cases have waned, the number of Illinois’ pandemic health workers has decreased by nearly a third, to roughly 450, in part because they have found other opportunities.

Smith is optimistic the program will secure money to keep an estimated 300 community health workers on staff and then use the goodwill they’ve built up in communities to focus on disease prevention. The fragmented American health care system — and its systemic inequities — won’t disappear with covid, she said. Plus, millions of people are poised to lose their Medicaid coverage as pandemic benefits run out, Benjamin said, creating a hole in their safety net.

Part of the long-term funding challenge is quantifying what workers like Scott do in a day, especially if it doesn’t relate directly to covid or another communicable disease. How do you tabulate the difference made in a client’s life when you’re securing beds for their children, laptops for them to go to school, or tapping into Federal Emergency Management Agency funds to pay funeral costs after a loved one dies of covid? How do you put a dollar amount on wraparound services that may keep a family afloat, especially when a public health emergency isn’t occurring?

As Scott likes to point out, most of the time she’s helping people use resources already available to them.

The National Association of Community Health Workers’ Denise Smith is worried that even though programs like Illinois’ are doing the work to help with health inequities, they may go the way that many Affordable Care Act grants did. In 2013, she was working as a community health worker in Connecticut, helping cut the uninsured rate in her area by 50%. But the money ran dry, and the program disappeared.

She said North Carolina is an example of a state that has designed its pandemic-inspired community health worker program to be more permanent. But, nationally, Congress has yet to approve more money for — much less for longer-term public health investments.

Meanwhile, Scott can’t help but worry about people such as 40-year-old Christina Lewis.

As she leaves Lewis’ mobile home after dropping off a load of groceries, Scott reminds Lewis to keep wearing her mask even as other people are shedding theirs. Scott used her own family as an example, saying they all wear their masks in public even though people “look at me like I’ve got five heads.”

Lewis said Scott’s help — bringing over groceries, talking through budgeting — has been invaluable. Lewis has stayed home throughout the pandemic to protect her 5-year-old daughter, Briella, who was born prematurely and has chronic lung disease. The struggle to make ends meet is far from over amid rising inflation. Briella knows to turn off the lights as soon as she’s out of a room. And now they are eyeing rising gasoline prices.

“I already know I’m going to have to get a bike,” Lewis said.

Over the past months, Scott has listened and consoled Lewis as she cried over the stress of staying afloat and losing family members to covid. Scott isn’t sure what will happen to all her clients if her support disappears.

“What happens to people when it goes away?” Scott asked.

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Its message of “we want to age our way in our homes and our community” was groundbreaking at the time and commanded widespread attention. Villages would mobilize neighbors to serve neighbors, anchor older adults in their communities, and become an essential part of the infrastructure for aging in place in America, .

Today, there are 268 such villages with more than 40,000 members in the U.S., and an additional 70 are in development — a significant accomplishment, considering how hard it is to get these organizations off the ground. But those numbers are a drop in the bucket given the needs of the . And villages remain a boutique, not a mass-market, option for aging in place.

Now, people invested in the village movement are asking tough questions about its future. Can these grassroots organizations be seeded far more widely in communities across the country as baby boomers age? Can they move beyond their white, middle-class roots and attract a broader, more diverse membership? Can they forge partnerships that put them on a more stable operational and financial footing?

Villages share common features, although each is unique. Despite their name, physical structures are not part of villages. Instead, they’re membership organizations created by and for older adults whose purpose is to help people live independently while staying in their own homes. Typically, villages help arrange services for members: a handyman to fix a broken faucet, a drive to and from a doctor’s appointment, someone to clean up the yard or shovel the snow. Volunteers do most of the work.

Also, villages connect members to one another, hosting discussion groups, sponsoring outings, offering classes, and organizing social events. “I’ve lived here a long time, but I really didn’t know a lot of people living in my neighborhood,” said Nancy Serventi, 72, a retired trial lawyer who joined Beacon Hill Village nearly five years ago. “Now, because of the village, I almost always meet people on the street who I can stop and say hello to.”

In principle, this model of neighbors helping neighbors can work in all kinds of communities, adapted for particular needs. , an emeritus professor of aging at the University of California-Berkeley and a leading researcher on villages, believes the potential for growth is considerable — a view shared by several other aging experts. has found that village members have more confidence about aging in place because they expect support will be there when they need it.

In practice, however, the fierce “we’ll do it our way” independence of villages, their reliance on a patchwork of funding (membership dues, small grants, and donations), and the difficulty of keeping volunteers and members engaged have been significant obstacles to growth.

“Villages’ long-term sustainability requires more institutional support and connection, whether from local or state governments, or Older American[s] Act programs, or partnerships with health care providers,” Scharlach told me.

“We have been brilliant about creating a sense of community and giving people a sense of belonging and being cared for,” said , 88, a co-founder of Beacon Hill Village. “But can what we do be scaled broadly? That’s the critical question.”

Consider how small villages are. According to the latest data from the , a national organization that disseminates best practices, 35% have 50 or fewer members; only 6% have more than 400. Budgets are modest, with two-thirds of villages operating on $75,000 a year or less and only 3% spending more than $400,000.

“What you have are a lot of fiercely independent, hyperlocal organizations scrambling to keep their head above water, and a lot of inefficiencies,” said Joel Shapira, who served on the board of the Village to Village Network for six years. “What you need are a lot more orchestrated efforts to bring villages together.”

That’s happening in California, where a coalition of villages is working in sync to expand its impact and seek state funding. Recently, Village Movement California, representing 44 villages with about 7,000 collective members, submitted a $3 million funding request to the state, which has embraced volunteerism and aging in place in its new Master Plan for Aging. Priorities include bringing new and existing villages into underserved communities and creating a training institute to promote equity and inclusion, said , Village Movement California’s executive director.

Early discussions are underway with , a California organization dedicated to Black women.

“This concept, people in the community taking care of each other, is not new to the African American community,” said Carlene Davis, a Sistahs Aging co-founder. “But having it in a formalized structure surrounding aging in place intentionally doesn’t exist. We’re at the stage where we’re asking, ‘Can we envision a village model that is culturally responsive to the needs of our community?’”

Another coalition, Washington Area Villages Exchange, represents 75 villages that have opened or are under development in the Washington, D.C., metropolitan area. Affiliates in the district are supported, in part, by city funding, which rose to nearly $1 million annually during the pandemic, according to Gail Kohn, coordinator of Age-Friendly D.C.

On a $50,000 annual budget, Legacy Collaborative Senior Village helps 321 low-income adults in the district, most of them African Americans, access transportation, food, and home and community-based services, and learn how to advocate for themselves with service providers.

“The seniors in our communities are very neighborly, but we had to show them how they could do things on a larger scale if they worked collectively,” said Katrina Polk, the village’s interim executive director and CEO of Dynamic Solutions for the Aging, a consulting firm.

In Colorado, A Little Help has pursued another strategy that many villages are contemplating: forging closer ties with organizations such as , senior centers, and senior housing complexes. “Covid inspired a fresh look at how we can work together with partners in our communities,” said Barbara Hughes Sullivan, national director of the Village to Village Network.

Since January 2020, A Little Help — which has 970 members in metropolitan Denver, northern Colorado, and the western part of the state — has received $200,000 to $250,000 a year from local Area Agencies on Aging. Services supported by this funding stream include frequent “how are you doing” calls, in-person visits, and “kindness kits” of books, puzzles, or treats that are dropped on members’ doorsteps — all of which eased social isolation during the pandemic, said , A Little Help’s executive director.

Because services are government-funded, A Little Help doesn’t charge membership fees, which can be prohibitively high for many older adults. (Beacon Hill Village’s are $675 a year for an individual and $975 for a couple, with lower subsidized fees for 20% of members.) Instead, it asks for voluntary contributions, which constitute 2.5% of its $1 million annual budget. The largest portion, 42%, comes from in-kind services donated by 4,000 volunteers.

Working with Medicare Advantage plans is also an emerging area of interest. Since 2020, plans have been able to offer supplemental benefits that address nonmedical concerns such as home modifications or “social needs,” explained of ATI Advisory, a consulting firm that has worked with Village Movement California. “There’s a lot that villages do to promote health and well-being, and I would love to see a health plan really work with villages to help support their growth,” Cromer said.

That won’t be easy, however, without a stronger research base that can help villages make the case for collaboration, but that is likely “years away,” said Kohn of Washington, D.C. “We need to show that villages and the social engagement that is their mainstay are making an impact on people’s health and longevity,” she said. “If we can do that, we should be able to get funding through health plans and health systems for villages.”

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“Good morning! We’re here to talk about covid-19 today! Do you have a minute?” she said in Spanish.

After a brief conversation, Garcia learned the man had no internet connection or phone of his own but was 66 years old and wanted to get the covid vaccine. He had tried to visit a pharmacy in person, but the shots were all out for the day. Garcia took down his name and the phone number of a friend, so she could reach the driver later about a mobile vaccine clinic that her organization, El Sol Neighborhood Educational Center, was putting together for the remote desert city sometime in April.

Then it was on to the next car. And the next. As the line started moving, she and fellow health worker Erika Marroquin jogged up and down the sidewalk, taking down names, phone numbers and preexisting conditions. It was the first mild, sunny day the High Desert region had seen in weeks, and the exercise made them sweat.

After 90 minutes, the food bank was done for the day, and Garcia and Marroquin had spoken to people in 54 cars. They had found six people eager for the covid vaccine and eligible for it immediately. Ten more wanted to be put on a waiting list for leftover doses.

The rollout of vaccinations in California, as in many states, has been slow and chaotic. More than in the nation’s most populous state have been at least partially vaccinated, while an additional 5.6 million are fully vaccinated. Come April 15, all adults in California will be eligible to sign up for a vaccine, and by early summer the goal is to have plenty of vaccine for any adult who wants it.

But the country needs to get the to keep the virus from easily spreading — a level called herd immunity by experts on infectious diseases. But even that figure assumes the population is homogenous in terms of vaccination. That’s why the state’s ability to stave off another covid surge may rely on people like Garcia and Marroquin — community health workers and organizers doing time-intensive, laborious work — to prevent pockets of the population with low vaccination rates in remote or isolated communities from becoming a tinderbox for a new covid surge.

“When you have geographical or social pockets of unvaccinated people, it really messes up herd immunity,” said Daniel Salmon, director at the Institute for Vaccine Safety at Johns Hopkins University’s Bloomberg School of Public Health.

in recent years provide a sobering example. State and national vaccine coverage is quite high, “but then you’d have these communities where a lot of people would refuse vaccines, and then measles would be imported and create an outbreak,” Salmon said. Outbreaks have hit certain Orthodox Jewish communities in New York, Somali immigrants in Minnesota and affluent pockets of Southern California where anti-vaccine parents lived.

The coronavirus is still circulating widely in California, though at much lower levels than two months ago. The virus, especially an increasingly common, more contagious variant, could easily rip through vulnerable communities with low levels of immunity. In Adelanto, where 29% of residents live in poverty, had been fully vaccinated by March 20.

As of March 26, most of the more than 15.9 million vaccine doses distributed since December had gone to in the state. Community-based organizations like nonprofits and churches are clamoring for more funding — and trust — to carry the vaccine the final mile to the people they’ve been serving for years.

El Sol’s success in getting Black, Latino and other underrepresented populations vaccinated debunks the idea that these groups won’t get the shot, said Juan Carlos Belliard, assistant vice president for community partnerships at Loma Linda University Health in San Bernardino County. Loma Linda is collaborating with El Sol to staff and provide doses for clinics. The people who show up are ready for their vaccine, though some are a bit hesitant, he said.

“They’re not like our middle-class folks who are literally crying for the vaccine,” Belliard said. “These folks are still nervous about it, but you’ve removed almost all of these other barriers for them.”

El Sol’s community workers were supported by a $52.7 million combined effort from state and philanthropic funding that provided grants to 337 organizations considered “trusted messengers” in their communities. The money was pushed out to groups like El Sol that had proven track records of shoe-leather canvassing for voter registration or census surveys.

El Sol received $120,000 from the public-private initiative to support its general outreach and educational efforts for covid vaccination. But the group was in the dark about whether it would get any reimbursement for the mobile vaccination events it has organized in San Bernardino County, said executive director Alex Fajardo.

El Sol held a pop-up vaccination event Feb. 17 at Centro Cristiano Luz y Esperanza, a church located off a two-lane expressway in Adelanto, surrounded by desert scrub. Medical staffers, students and vaccines arrived from Loma Linda University Health, about an hour away, to vaccinate 250 people, and returned a month later to give people their second doses.

Patricia Perez, 47, and Rosa Hernandez, 69, a mother-daughter pair, were among those who got their vaccines at Centro Cristiano.

Perez’s father, who works in a supermarket dairy department, fell ill with covid in June and was unable to return to work for six months. No one else in the seven-member household ended up testing positive, but Rosa Hernandez is a cancer survivor and her daughter was worried about her.

Despite multiple calls to a county phone line, Perez had been unable to line up a vaccine for her mom. The family’s internet connection, in the nearby town of Hesperia, was spotty, and Perez couldn’t really navigate the websites or find any information in Spanish, the language she’s most comfortable with.

She jumped at the chance when she heard about El Sol’s pop-up event through someone at her church. Perez also managed to snag an additional dose for herself after someone didn’t show up for their appointment. Now she and her mom are fully vaccinated, Perez said, and it wouldn’t have happened without El Sol.

The group plans to do three more vaccination pop-ups in the High Desert area. But future support for its clinics, vaccine outreach and education are murky, said Fajardo.

“What is going to happen after?” he said. “When we need you, we pay you. When we don’t need you, ‘Bye-bye.’”

“That’s a very fair assessment,” said Susan Watson, program director for the Together Toward Health initiative of the Public Health Institute, the philanthropic funder behind some of El Sol’s work. “There’s an opportunity here for people to be thinking about the future, and how we do things that doesn’t necessarily leave community groups permanently on the outside, only tapped into when there’s an emergency.”

Community Coalition, a South Los Angeles nonprofit founded in 1990, also received grants from the public-private partnership to raise awareness about covid vaccines, but no additional funding to deliver vaccines to the people. Still, it mobilized staff to knock on doors, text and email eligible people to turn out for a two-week pop-up vaccination event at a neighborhood park in early March — providing 4,487 people with their first vaccine dose, said the group’s chief operating officer, Corey Matthews.

Dr. Mark Ghaly, the state’s secretary for health and human services, promised to provide more money for groups that are getting their communities vaccinated. “This is not a volunteer job,” he told KHN at a news briefing. “This is real work, and I want to be part of the team that makes that a reality for all of them.”

Los Angeles County department of public health Director Barbara Ferrer echoed that sentiment. “They were there before the pandemic started, they’ve been there the entire time during the pandemic, and they’ll be here long after the pandemic,” she said.

Whether or not those promises hold up, community groups say, they want to be part of the vaccination effort.

“Even if they don’t give us money, we’ll keep doing the work,” said Fajardo.

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