The ranks of home health care workers are exploding, and that’s a problem.
When The New York Times interviewed random commuters at Columbus Circle in 2024 (for a story about children selling candy in the subway) two out of the three people quoted happened to have the same occupation. It was a telling coincidence, because they were both home health aides — the low-paid, mostly taxpayer-financed jobs that are taking over New York City's economy.
Employment in the city's home care industry has more than doubled over the past decade to 546,000. It now accounts for one in nine members of the workforce. Home health aides have become by far the most common occupation in New York, outnumbering retail clerks by roughly three-to-one.
Many of these aides unquestionably do vital work. Their help with the basic daily tasks of the elderly and infirm — helping them bathe, eat, go to the bathroom, take their medications, get out of bed — makes it possible for thousands of New Yorkers to survive outside of institutions.
Yet over the past decade, the ranks of home health aides in New York City have ballooned out of all proportion to the size of New York's elderly population, or any other available benchmark of need.
From 2014 to 2024, the number of city residents aged 65 or older grew by 35%, according to the Census Bureau. Over the same period, the city's home health workforce soared by 131%, or almost four times as fast, according to the Bureau of Labor Statistics. Is that because all those aging New Yorkers needed disproportionately that much more help at home? Seems unlikely.
Home care has been growing in the rest of the country, too, but at nowhere near the same rate. As of this year, New York City's home care industry employs 361 workers for every 1,000 residents over 65. The national average is 88.
There's no obvious reason why the city's population would need such a disproportionate level of help. According to the Census Bureau, the share of the city's population who are over 65, and the share of under-65 people with disabilities, are both lower than the norm.
These statistics should set off two sets of alarm bells for New York's leaders.
First, they raise obvious concern that Medicaid, the state-run health plan that pays for most home care, is being overused, abused or defrauded — at considerable cost to taxpayers. Non-institutional long-term care, which is what home health aides represent, is the fastest-growing expense for Medicaid. It currently accounts for roughly one-third of New York's $111 billion Medicaid budget, which is by far the costliest in the U.S. on a per-capita basis.
Albany leaders sometimes defend this spending as a worthwhile investment to keep disabled people in the community — but it doesn't seem to be working. As of 2024, 2.6% of elderly New York City residents lived in nursing homes. The national rate is 2.0%.
The second cause for alarm is what the job numbers reveal about the city's economy. Home health has accounted for more than half of its employment growth since 2014 and all of its net growth since 2019. The seemingly bottomless supply of these low-paying jobs has kept the unemployment rate down, but it also helps to explain why inflation-adjusted average wages have been dropping in the city since the pandemic, even as they have improved nationwide.
The broader field of healthcare has traditionally been a strong point for the city and its economy. A concentration of world-renowned hospitals and medical schools have pioneered life-saving breakthroughs while also supporting thousands of jobs for doctors, nurses and other professionals who typically command high salaries. They also have helped make New York City, for many, a nice place to retire. Although hospital employment dipped during the pandemic, it now stands 16% higher than in 2019, compared to a mere 4% increase for all categories of employment.
Yet the rebound for hospitals pales in comparison to the 54% growth in home care jobs since 2019. For these workers, wages lie at the other end of the spectrum — typically about $20 an hour, or $3 above the minimum.
The conditions in these jobs can be challenging. In some cases, aides work 24-hour shifts but get paid for only 13, on the assumption that they are sleeping or eating for the rest of the time. Aides and activists recently staged a hunger strike in support of a City Council bill that would ban that unusual policy. Critics warned that such a ban would run afoul of state and federal payment policies, and that attempting to enforce it could strand clients without necessary care.
At the same time, most home care jobs require minimal training and no prior experience, making them an attractive option — or at least a viable option — for recent immigrants and others with limited education or English skills.
What is going on? Why is this sector within a sector surging, and what might be done to correct this problematic shift in the city's economy?
The answers trace largely to Medicaid policies set in Albany.
In the middle of the past decade, during former Gov. Andrew Cuomo's first term, the state made two big choices that compounded the state's already heavy investment in home care.
First, it put Medicaid home care mostly under the control of companies known as managed long-term care plans, which were supposed to find efficiencies but also had a financial incentive to boost enrollment.
Second, the state loosened the eligibility rules for an option known as the Consumer-Directed Personal Assistance Program, CDPAP, in which disabled people could directly hire their own caregivers, including friends and family members, instead of going through an agency. Officials believed this would save money compared to traditional home care, but it proved to be unexpectedly popular.
These changes to CDPAP triggered the formation of hundreds of businesses known as "fiscal intermediaries," which handled payroll processing for recipients. These companies recruited customers with advertising on subways and television and helped them sign up for Medicaid coverage. Enrollment and spending boomed.
State officials sought to corral the program, but their efforts were sporadic and halting. They tried to restrict the advertising, only to be sued in federal court. They tightened eligibility rules, only to have the federal government freeze those reforms during the pandemic emergency.
After Gov. Kathy Hochul took over, she vowed to tackle what she described as a "racket." Her solution was to consolidate CDPAP under a single statewide fiscal intermediary. While this held the promise of administrative efficiency, it also put hundreds of thousands of caregivers under the auspices of a single employer. This paved the way for them to be organized by the powerful union 1199 SEIU, which will now have a vested interest in seeing the program grow further.
The outlier scale of New York's home care has caught the attention of the Trump administration, which sees it as an example of broader fraud, waste and abuse in Medicaid. A federal crackdown on the program may soon force a reckoning in Albany.
For now, though, many city and state policymakers remain complacent, if not outright oblivious, about this massive and costly conundrum.
The New York Caring Majority, which advocates on behalf of disabled people and their caregivers, asserts that New York's home care industry has "the worst worker shortage in the U.S." – even as the city's per capita employment level is more than four times the national average.
Scholars from Manhattan's Weill Cornell Medical School recently published a study analyzing the "challenges accessing home care" among Medicaid beneficiaries in New York. The study deplored the "complexities" of the process without so much as mentioning, let alone explaining, the city's off-the-charts enrollment and employment levels.
A first step toward a more sustainable home care program would be understanding how the city came to be such an outlier. New York needs a clear-eyed analysis of who is getting which services and why, and how its rules and policies diverge from national norms.
The city's unhealthy overdependence on home health jobs is putting immense strain on taxpayers and distorting the city's economy while seemingly failing at its primary goal, which is to keep disabled people out of institutions. A city that counts on home health jobs for the majority of its employment growth is a city doomed to decline.
Until city and state leaders grapple with those realities, they cannot hope to change them.
