---
type: source
title: "NASHP CHW Policy Trends 2024-2025: More Than Half of State Medicaid Programs Now Cover CHW Services"
author: "National Academy for State Health Policy (NASHP)"
url: https://nashp.org/state-community-health-worker-policies-2024-2025-policy-trends/
date: 2025-01-01
domain: health
secondary_domains: []
format: policy-report
status: unprocessed
priority: medium
tags: [community-health-workers, chw, medicaid, state-policy, spa, reimbursement, scaling, workforce]
---

## Content

NASHP annual update on state community health worker Medicaid policies, tracking progress from the 2024-2025 policy cycle.

**Progress since Session 1 baseline:**
- Session 1 (March 10): 20 states with full SPAs for CHW reimbursement
- Updated status: "more than half of state Medicaid programs now have SOME form of CHW/P/CHR coverage and payment policy"
- Four new SPAs approved in 2024-2025: Colorado, Georgia, Oklahoma, Washington
- Total SPAs: approximately 24-25 (from the 20 baseline)
- 7 states now have dedicated CHW offices (up from fewer in Session 1)
- 15 states with Section 1115 waivers for CHW services (stable from Session 1)

**Infrastructure developments:**
- Community care hub model emerging as coordination layer between payers, CBOs, and CHW workforce
- Milbank Memorial Fund published model SPA guidance (November 2025 update) — standardizing the implementation template
- Milbank August 2025 piece: "State Strategies for Engaging Community Health Workers Amid Federal Policy Shifts" — signals states protecting CHW infrastructure in response to federal uncertainty

**Payment rate variation (January 2025):**
- FFS rates range from $18 to $50 per 30 minutes — large variation
- Race-to-bottom risk in states paying lowest rates (can't attract qualified CHWs at $18/30min)
- KFF issue brief on state policies indicates managed care contracting is more common than FFS

**Federal uncertainty:**
- DOGE and Medicaid funding cuts threaten the federal matching funds that make SPAs financially viable
- States building CHW infrastructure in direct response to federal policy uncertainty — anticipating needing to fund CHWs without federal match
- Milbank's August 2025 framing: state-level infrastructure as resilience against federal instability

**Barriers still present:**
- Transportation: largest overhead for CHW programs, Medicaid still doesn't cover as CHW program cost
- CBO contracting: many CBOs still lack the administrative capacity to bill Medicaid directly
- Billing infrastructure: slow code uptake even in states with approved SPAs

## Agent Notes

**Why this matters:** This is the continuity check from Session 1's CHW scaling thread. The finding: more states are moving toward CHW coverage (more than half now have SOME policy), but the barriers identified in Session 1 remain. The new element is federal funding uncertainty — DOGE-era Medicaid cuts threaten the matching fund structure that makes state SPAs financially viable. States are building resilience infrastructure precisely because federal support is uncertain.

**What surprised me:** The Milbank framing (August 2025): states are explicitly planning for CHW infrastructure WITHOUT federal matching funds as a hedge. This is the inverse of the food-as-medicine situation: for CHWs, states are building infrastructure anticipating federal pullback. For FIM, the federal government is simultaneously cutting funding (VBID) while advocating rhetorically (MAHA). CHW states are responding to real threats with infrastructure; FIM advocacy is outpacing its funding reality.

**What I expected but didn't find:** Any evidence that the 30 states WITHOUT SPAs are accelerating toward adoption. The 24-25 SPA count suggests steady but slow progress — roughly 1-2 new SPAs per year. At that rate, nationwide SPA coverage is 10-15 years away.

**KB connections:**
- Updates the Session 1 CHW baseline (20 SPAs → ~24-25 with some form of policy in more than half of states)
- Confirms the infrastructure-as-barrier claim from Session 1: CHW programs have strong RCT evidence, implementation is blocked by payment infrastructure
- The Milbank federal uncertainty framing is new — adds a federal funding risk dimension to the scaling analysis

**Extraction hints:**
- Update the Session 1 CHW claim: "more than half of Medicaid programs now have some CHW coverage policy, but full SPA coverage remains at ~24-25 states with the same administrative barriers (CBO contracting, transportation, code uptake)"
- The federal funding uncertainty is extractable as a new risk to the CHW scaling trajectory
- The "state infrastructure as federal resilience" framing is interesting for Leo — states building policy capacity specifically to survive federal pullback

**Context:** NASHP is the authoritative tracker of state CHW policies. Their annual update is the canonical source for this data. The update was published in January 2025 (before the full scale of DOGE/Medicaid cuts became clear) — a later 2025 update may show more significant impact from federal funding uncertainty.

## Curator Notes

PRIMARY CONNECTION: Session 1 CHW scaling claim — updated baseline from 20 to >24 SPAs with coverage in more than half of states
WHY ARCHIVED: Annual CHW policy update — tracks progress on the infrastructure scaling that Session 1 identified as the binding constraint
EXTRACTION HINT: Don't just extract the number of states. Extract the pattern: steady incremental progress on CHW coverage is now threatened by federal funding uncertainty from DOGE/Medicaid cuts, adding a new risk dimension to the scaling timeline.
