Long-term care crisis worsening in Texas


Boram Kim


In 2018, the Texas Health Care Association (THCA) brought attention to a workforce crisis facing nursing homes and long-term care facilities in the state.


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Its report pointed to crisis levels of workforce availability and nursing turnover rates that affected the quality of care at these homes where older residents, many of whom are diagnosed with debilitating diseases, require skilled nurses to deliver complex care.

In the 4 years since the report was published, the crisis has only deepened, said THCA CEO Kevin Warren.

Warren said that between 2020 and 2021, burnout from the pandemic prompted some 9,000 long-term care workers in Texas, most of whom are skilled nurses, to leave their positions for other opportunities.

“There’s been a significant decline and loss of staff within the nursing area—registered nurses, licensed vocational nurses and certified nursing assistants,” Warren said.

“[There are] two significant issues impacting the [nursing home and long-term care] facilities. One is you’ve got a lack of adequate Medicaid funding that allows these providers to compete in today’s very hyper-competitive labor markets in terms of the funding available for recruitment and retention, wages and salaries, and being able to compete with hospitals and particularly in staffing agencies.”

Nearly 13% of Texans—3.7 million people—are aged 65 and older, a population that is growing and projected to reach 8.3 million by 2050.

The gap between adequate Medicaid funding, which is the primary funding mechanism paying for more than 60% of the resident’s in long-term care, and operational costs has grown larger over the past decade.



The Texas Legislature has consistently appropriated the base Medicaid reimbursement funding for nursing home and long-term care facilities below what the methodology for rate setting outlines, amounting to a more than $50 shortfall on average between funding and expenses in 2020.

Texas has already seen some 30 long-term care facility closures since January of 2020. With current inflationary pressures accelerating cost increases across every aspect of operations, Warren says the 40% of facilities that are at risk financially will face the same fate without intervention, putting enormous strain on an already taxed system and the health and lives of hundreds of thousands of older Texans at risk.

“We’re seeing anywhere between a 20% to 25% increase in the cost of staff. The increased utilization and reliance on staffing agencies are two and three times [the cost of] what providers are able to pay for those staff. While [federal] funding has been enormously helpful, it’s also scheduled to come to an end with the public health emergency. Yet all of these costs, the salaries, wages, the competitive labor market, [are] still going to be there in full force and put further pressures on providers in order to be able to maintain the staffing necessary to care for their residents.”

THCA will be working with lawmakers to introduce legislation in the next session aimed at increasing the Medicaid base rate and further addressing workforce shortages. One potential measure is forgiving student loan debt for those who become certified care professionals and commit to serving in nursing home and long-term care settings.

“The other issue [is] there is a need for long-term care workforce pipelines,” Warren said. “We have got to create long-term care [workforce] pipelines by working with higher education [on] expanding classroom capacity in nursing schools. We want to work with the legislature on student loan repayment programs and other incentives to encourage potential employees to see long-term care as a long-term profession.”