The U.S. Bureau of Labor Statistics released re-benchmarked annual average Current Employment Survey data, for 2018 and earlier years, a week ago. In past years, I’ve used this data source to document the trend in local government employment for New York City as compared with the Rest of New York State, something I will summarize briefly at the end of this post. There is, however, a far more spectacular trend. New York City’s private employment in the Home Health Care industry has apparently gone exponential.
It isn’t a surprise that Home Health Care employment is rising, given the needs of an aging population and family breakdown. But as is the case for the state and local government tax burden, police staffing, and school spending, etc., New York City is (figuratively) off the charts. The pace of increase is now so great that one wonders about the actual existence of both the beneficiaries and the workers.
Exponential is not just a figure of speech. Home Health Care employment nearly doubled in the part of New York State outside New York City from 1990 to 2018, and increased five times in the U.S. as a whole. In New York City, however, the Home Health Care employment has increased by nearly twelve times.
This is in contrast with local government employment, which soared in the Rest of New York State during the Pataki years, when it functioned as a high-end welfare program for those who “deserved better” than people in New York City, even as the city’s own local government employment was restrained.
The real explosion in Home Health Care employment in New York City, compared with the Rest of New York State, started in 2013.
Most home health care aides take care of seniors. Slow-growth New York State was relatively old in 1990, compared with the U.S. as a whole, but the rest of the country has been catching up. The change in the senior citizen population certainly doesn’t explain the growth in Home Health Care industry employment. In New York City the population age 75 or older increased 17.3% from 2005 to 2017, while Home Health Care industry employment more than tripled. Home Health Care employment increased somewhat faster than the old age population in the Rest of New York State and the U.S. over these years as well, but the difference as not extreme.
At-home care for seniors is promoted as a more humane and cheaper alternative to nursing home care, but in New York City it apparently isn’t an alternative. While Home Health Care industry employment has soared, Nursing and Residential Care industry employment hasn’t decreased.
I recently saw a Frontline documentary on the care of the mentally ill and disabled in New York City. Such people were dumped out of state institutions in the 1960s and 1970s on “freedom” grounds, with many ending up dying the streets and others placed in adult homes – the “residential care” portion of the “nursing and residential care” industry. A similar lawsuit, also in the name of “freedom,” required New York City and State to pay for 4,000 of these people to be allowed to live on their own and placed in apartments. Frontline questioned this policy.
Frontline didn’t explore whether this policy has had anything to do with seeming anecdotal increase in mentally ill people committing acts of violence in New York City, nor did the documentary compare New York with other places where public funding for the mentally ill is vastly lower than it is here. Perhaps because if the goal is more funding, better to demand more in places that already spend more than in places where spending and taxes are low, based the trends in our society. And each of the mentally ill people in the documentary was clearly a New York City native, not someone who somehow ended up here on a bus from one of the Red States. Whereas when Gothamist went out and interviewed young drug addicts living on New York City streets, they were pretty much all from somewhere else.
The mentally disabled people in the documentary ended up harmed, sick and abused, in one case until he died, in another until he was returned to an adult home, and in a third until a home health aide was provided for three hours a day, something that was not supposed to be part of “living independently.” One visit every week or so to check in was supposed to suffice, but the documentary implied, was not enough. At the three hours per day, a home health care aide could probably care for just two people. Is that the explanation for the increase in Home Health Care industry employment?
No. Allowing for weekends and vacations, even if New York City decided to provide home health care aides to all 4,000 of those released, that would require just 3,000 more aides. Let’s say, moreover, that there are 40,000 people with such disabilities living independently in total (I can’t find the actual number), most of whom were less needy than the recent 4,000, and the city decided, what the heck, to provide home health care aides to all of them. That would still be just 30,000 additional home health care aides. Home Health Care industry employment has increased by 60,000 in New York City in just the past three years.
In addition, back in the 1990s, when New York City’s Home Health Care employment was far lower, many of the aides were caring for people dying from AIDS. A situation that, for now, is much less common.
To be fair, the Rest of New York State had far more Nursing and Residential Care employment than New York City. Employment as measured by the Current Employment Survey includes everyone working in these industries, whether funded by Medicaid or not, although given its cost custodial care eventually leads to most people needing Medicaid assistance.
Under New York State’s Medicaid program, since New York City has more Home Health Care employment and the Rest of New York State has more Nursing and Residential Care employment, the State of New York requires local governments to pick up 25 percent of Home Health Care costs, but just 10 percent of Nursing and Residential Care costs. This is one of the main reasons why the “local share” of Medicaid costs is much higher in New York City than it is in the Rest of New York State, something politicians elsewhere in the state want to make even worse for NYC as discussed here.
Yet adding Home Health Care employment and Nursing and Residential Care employment together, New York City has more of it that the Rest of New York State, even though the Rest of New York State has a higher population overall, and a higher population age 75-plus in particular. So a substitution for nursing home care is not the explanation for this explosion of Home Health Care employment in New York City.
In fact, given the lower overall cost of living Upstate, and thus presumably (hopefully) lower senior care costs, to the extent that these costs are funded by Medicaid it is likely that it would be cheaper for New York City to send seniors for nursing home care there than to provide home health care here – even as the standard of living of those providing the care would be higher there.
Observing the last years of my grandparents, and then my wife’s parents, and the family members of some friends, my impression is that families can provide for most of their needs themselves, perhaps with a little help, provided the disabilities are merely physical. As long as those families are close, and close by.
Once mental disabilities set in, however, a senior eventually needs 24/7 monitoring, and that because overwhelming and makes it impossible to go to work.
That was the situation in the past. But now Generation Greed, the most entitled and self-serving in U.S. history, will be moving into deep old age. Generations that, in far larger percentages that generations that preceded, them put their own needs and preferences ahead of their children when the were in middle age. So in fairness, a higher share of those children might feel less obligation to care for aged parents who had not been there for them. Meaning more and more of those detached seniors will be demanding that the government strip even more resources from their children and grandchildren in tax increases and service cuts to provide for their needs. So now what?
Looking at the situation in New York City compared with the rest of the state and the U.S., however, I don’t think of social trends. I think of scams by New York’s infamous non-profiteers.
The New York State Legislature leads the nation in hypocritically pretending to provide for the poor and needy, to make the public less upset about all it extracts in state and local taxes, but then diverting much of the money to the politically connected non-poor and non-needy. The generous spirit and good intentions of New Yorkers are repeatedly abused by self-dealers, as even seemingly good ideas turn into public pillage.
Take this one, for example. Dementia and mental illness aside, most old and declining adults are, in fact, taken care of by family members, who take on a big burden that would otherwise fall on the broader community. So why not help them by providing government funded adult day care services, so they can have a break? That worked out about as well as the massive increase in New York City school spending “for the kids” and the $billions spent to connect the Long Island Railroad to Grand Central Terminal.
And you wonder why social trust is going down. Are non-needy seniors that greedy? Perhaps not in the past, but I saw how this happens decades ago. It is the service providers seeking to increase their revenues – as they do in other industries – who are looking to cash in. And they use a similar pitch. “You are entitled to this!” “You deserve it!” “Everybody’s doing it!” With one added twist. “It’s free!”
So they go along. That was before Generation Greed seniors. What will happen once the beneficiaries are members of that generation?
The profits on public funds would, of course, be greater if those receiving services didn’t actually need them, reducing the cost to provide them. And higher still if the seniors didn’t actually exist. And even higher than that if the workers not providing services that were not needed to seniors who did not exist also did not exist. Other data shows the boom in home health care employment is concentrated in Brooklyn. Is this what is going on?
Speaking of lost social trust, the Centers for Medicaid and Medicare has stopped making data on Medicaid beneficiaries and expenditures, by type of service and by age group, available by state. Data that I once compiled annually to write posts such as this one.
The data was from the Medicaid Statistical Information System (MSIS), which was shut down and replaced by the Transformed Medicaid Statistical Information System (TMSIS). The last data available from MSIS was for 2012, and I was told there would be no new data until TMSIS went live. I waited “patiently” for years for the new system, and once it went live I went searching and searching for the kind of summery level data by state I used to get. Then sent an e-mail, with this response.
The publicly available MSIS data marts were created out of granular, person-level MSIS data submitted by states. T-MSIS is similar to MSIS in this respect in that it is also granular and person-level. Presently, however, T-MSIS data is not publicly available in any form. The MSIS tables linked to below are the most current publicly available form of Medicaid data. Additional data may be made publicly available at a later time.
Here is a link to Medicaid data tables posted on CMS.gov, they are the most recent as of now.
Which is the data from back in 2012. No public data? So no summary tables to compare different states with regard to their Medicaid spending on different types of services and different age groups, against other statistics such as the population by age and the population in poverty?
Why is this? Lack of time and funding, as federal agencies are gutted and experience periodic shutdowns because our sleazebag politicians? Red State sleazebag politicians who don’t what people to see how little, relatively, their states spend on the health care needs of the less well off? New York sleazebag politicians who don’t want people to see just how off the charts NY’s Medicaid spending is in some categories, while not being that high at all in other categories? After all, similar comparisons led to the discovery of this scam in the part of New York State outside New York City.
It is worth nothing again that may of these health and social services businesses and non-profits are owned and operated by the friends, relatives, and political supporters (including ballot access signature collectors) of perpetual incumbent New York State legislators. The non-profiteers. Some of whom have managed to be so brazen and obvious about what they are doing that they ended up in jail.
In New York, which has the highest state and local tax burden in the country, the health and social service scammers notoriously steal from Medicaid, which is half funded by state and local government. In Florida, which has the lowest state and local tax burden of any state, the health and social service scammers notoriously steal from Medicare, which is entirely federally funded.
Given the history, as I watch in shock as New York City Home Health Care employment goes hyperbolic (this isn’t hyperbole I mean this literally – see the second chart above), what am I to think? It looks like one person telling two other people “Hey, did you hear about this new special deal? It’s easy, and no one is checking!” And then each of those people tells two other people. Etc
A few notes on local government. Some folks have noticed that New York City local government employment went up by nearly 20,000 from 2013 to 2018, during the DeBlasio Administration. Presumably more dues paying union members to gain political support for a run for higher office, as has been seen in this city and over and over again in the past. No wonder the Mayor, like the Governor, basically lied about providing money for the 2015 to 2019 MTA Capital Plan, to maintain the subways.
The three largest areas of public spending are public safety, education, and health care, but public spending on health care generally goes to the private sector, as in the Home Health Care industry employment above. So when you are talking about local government employment, you are really talking about police/correction and schools.
Since the large millennial generation has exited school, and later born generations have been far less criminal (here and nationwide) than those who came of age from the mid-1960s to the mid-1990s, one might expect NYC local government employment to be flat to falling. It was for a long time, but has increase recently. Especially since the public unions and contractors are constantly claiming, with no politician daring to say the opposite and data on how much they are getting now starting to disappear, that New Yorker deserve little and less because they aren’t getting enough money. Then again, the population has also increased. So I’ll reserve judgment.
Another nationwide trend is fewer and fewer state and local government tax dollars going to working public employees, and more and more going to retired public employees, due to past retroactive pension increases and pension underfunding to benefit Generation Greed, as described in this post.
Putting it on an index, with 1990 equal to 100, the trend in local government employment for different parts of New York State can be seen in this chart. A lot different than the different trend in Home Health Care industry employment, isn’t it? Different needs, or different campaign contributions and political supporters?
One can see the impact of former Governor Pataki’s “everybody onto the payroll and into the pension system” welfare plan for the rest of the state. As the number of well paid manufacturing and corporate headquarters jobs decreased in these areas, there was a demand by politically connected people for jobs with health insurance and early retirement pensions in government.
The beneficiaries are retiring to Florida, for lower taxes and better weather, leaving the next, much poorer generations to pay for them. No wonder rich Nassau, Westchester and Rockland counties have fiscal problems – and are desperately trying to shift even more of those burdens to New York City. Those affluent suburban areas are broke like the affluent suburban states of New Jersey and Connecticut are broke, except those states don’t have a New York City to exploit.
And now local government employment is rising in New York City as well.
The data I used in this post (and some more) are in this spreadsheet. In the future, one could select “series report” on the BLS website, along with “multi-series table,” and get the same data for future months, or years.