Chronic disease is the leading cause of poor health, disability and death in the U.S., as well as the greatest contributor to overall health care expenditures. Despite the enormous health and cost burdens posed by preventable chronic health conditions such as type 2 diabetes, heart disease and obesity the U.S. invests very little in prevention compared to other types of health care expenditures. In 2015, of the more than $3 trillion spent nationally on health care, less than four percent was dedicated to prevention and public health. Evidence-based prevention interventions, however, have the potential to reduce long-term health care costs. A 2013 Centers for Disease Control and Prevention (CDC) report found that the average health expenditures for adults without chronic conditions was $2,367, compared with $8,478 for adults with two or three chronic conditions, and $16,257 for adults with four or more chronic conditions. These trends are also evident in the Medicaid population. In 2009, Medicaid programs spent $13,490 per capita for nonelderly adult enrollees with diabetes, compared with $5,130 for enrollees without diabetes. The benefits associated with investing in chronic disease prevention include improved quality of life, lower health care spending, less school and workplace absenteeism and increased economic productivity. Investing in prevention, however, is not always a priority. One reason why policymakers are reluctant to invest in prevention is because the benefits from these prevention programs are often deferred to the future, while costs incurred to implement interventions are immediate. Additionally, chronic diseases are often caused by multiple factors, such as personal behaviors, and social and environmental issues. Indeed, a growing body of evidence affirms that social determinants such as housing, food security and transportation have a significant impact on health outcomes and health care spending. As a result, Medicaid and other payers are increasingly trying to address these social determinants alongside clinical factors to improve health outcomes and drive down health care costs, particularly in an environment that values outcomes. As states, localities and cross-sector efforts like Accountable Communities of Health (ACHs) develop upstream prevention programs, identifying where community health workers (CHWs) can be most effective--with what population, condition and intervention--will help to inform intervention design. This brief explores the unique role CHWs can play in addressing the social needs that have tremendous impact on the burden of chronic disease, particularly among low-income populations. While the brief draws upon information gathered to help Washington State and its ACHs, it also outlines lessons for any state seeking to integrate CHWs into their chronic disease prevention and control interventions. This brief: (1) outlines a common definition and roles for CHWs; (2) examines the evidence behind incorporating CHWs into upstream prevention efforts; and (3) discusses financing options available to support CHWs. The brief starts by providing context on Washington's reform effort and its interest in utilizing CHWs to further these efforts.
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