Attendant care costs the state approximately 30 percent less than nursing home care. (Kate Groetzinger)

Texans with Disabilities are Struggling to Find Health Care Attendants. Lawmakers Didn’t Do Much to Help.

Community attendants had their $8-per-hour base wage boosted by only 11 cents this session — significantly less than what the governor and state health department requested.


Disability rights advocates say there is a crisis facing community attendants and the people who rely on them. Statewide, about 300,000 attendants help disabled Medicaid patients with basic tasks like getting out of bed, bathing, cooking and transportation to doctor appointments. Their assistance allows about 200,000 Texans with disabilities the freedom to live in their own homes.

But because of paltry and stagnant wages — a base of $8 an hour with no benefits — community attendants are struggling to make ends meet, or leaving the field altogether. That’s creating a shortage of attendants that is forcing patients into nursing homes or other institutional facilities against their will, advocates say.

“Being in a nursing home is like being in prison,” said Bob Kafka, who founded ADAPT of Texas, a disability rights group, a decade after he broke his neck in a car crash in 1973, leaving him paralyzed. “They think they own you.”

Bob Kafka
Bob Kafka, founder of ADAPT of Texas, a disability rights group.  Kate Groetzinger

Both Governor Greg Abbott and the state health department, citing “difficulties hiring and retaining qualified attendants,” asked lawmakers to allocate $150 million to increase the base hourly wage by 50 cents this session. But the Senate did not include a single cent to raise the base wage in its proposed budget, and the House initially proposed a 10-cent raise.

The final state budget, released last week, includes an increase of only 11 cents — bringing the base pay of attendants to $8.11 an hour.

It’s “a slap in the face,” said Cathy Cranston, a member of ADAPT who also founded the Personal Attendant Coalition of Texas.

“At that wage, there’s no way to attract people,” she said. “Buc-ee’s [gas station] is paying people $13 to $17 an hour.”

For Kafka, 73, the issue is personal. Nelson Peet, Kafka’s friend and a member of ADAPT, couldn’t find an attendant last year, so he ended up in a nursing home where he contracted pneumonia and died at the age of 62, Kafka said.

“If he had been able to find a community attendant, he would be here today,” said Nancy Crowthers, another member of ADAPT who knew Peet.

community attendants meeting
Activists with ADAPT of Texas meet with staff for state Representative Sarah Davis, R-West University Place.  Kate Groetzinger

Disability advocates carried Peet’s photo through the halls of the Capitol this session as they shared similar stories with lawmakers and staff. ADAPT members, led by Cranston and Kafka, gathered almost every Tuesday and Thursday to visit legislators and ask them to raise attendant pay to $15 an hour to keep up with rising demand and costs.

The advocates also made a fiscal case for the raises, which they say would save Texas money since the state is required to cover nursing home expenses for Medicaid patients. Attendant care costs the state approximately 30 percent less than nursing home care, according to a 2008 study by the state health department.

Lawmakers say they support keeping people in their homes and understand there is a problem, but they don’t believe it is their responsibility. Representative Sarah Davis, R-West University Place, and Senator Lois Kolkhorst, R-Brenham, chaired the budget subcommittees that oversee health care funding. When asked about attendant services, Davis said that she and Kolkhorst believe that managed care organizations (MCOs) are responsible.

State Senator Lois Kolkhorst, R-Brenham  Patrick Michels

“We want to see the market solve this problem,” Davis said.

MCOs are private companies that receive a set amount of money from the state and federal governments to care for Medicaid patients. Under state law, MCOs are required to maintain an adequate network of service providers, but Davis said the MCOs may not be doing so.

“Really it’s a matter of crunching the numbers,” said Davis, who passed legislation requiring the state to study whether MCOs are maintaining an adequate network of staffing agencies and to look into recruitment and retention of attendants.

State Representative Sarah Davis, R-West University Place  Sarah Davis 134

But advocates like Dennis Borel, director of the Coalition of Texans with Disabilities, say that MCOs are not the problem. The Legislature, they say, is not allocating enough money to MCOs.

“This is a legislative issue,” Borel said. “It’s easy for [lawmakers] to say, ‘We’re not going to give the MCOs more funding,’ and demand they offer a market rate. But I don’t see how that’s possible without adding more money.”

Borel’s group released a report in 2017 that shows attendant pay had fallen by 30 percent since the program was established in 1968. Five decades ago, attendants made a base hourly wage equivalent to $11.11 in 2017 dollars, according to the report. Meanwhile, demand for attendant services has been growing. The report estimates that the attendant workforce will need to add 100,000 employees by 2024 to serve the state’s aging population. That would require raising wages to at least $13 an hour to attract enough people willing to do the job, the group said.

Data shows that attendants are struggling to make ends meet. From 2012 to 2014, almost half of home health workers in Texas relied on some form of public assistance, compared to 30 percent of nursing home workers, according to a study by PHI, a New York-based group that advocates for people with disabilities.

Until the issues caused by low attendant wages become something lawmakers can’t ignore, Borel said, he doesn’t expect the Legislature to make a significant investment in raising attendant wages.

“What we have is a crisis management Legislature,” he said. “This year it was public education, last session it was CPS. In both cases the response was to recognize the people doing the direct work and to give them very direct wage raises. This is the same, but this issue has not become elevated to the same level.”