In my prior post, I pointed out that although New York City’s poverty rate is 55% higher than the national average, its private, mostly non-profit employment in the Social Assistance sub-sector relative to population is 154% higher than the national average — 2 ½ times that average. Yet, despite all these people hired, at first glance, to tend to their well being, advocates and analysts say the city’s poor are not well off compared with poor people elsewhere. Disaggregating 2004 annual average employment relative to population for this sub-sector into specific industries, on finds a complex picture that raises many issues, but let’s put the headline up front. Excluding one industry, one finds that New York City employment in the rest of the Social Assistance sector relative to population is just 54% higher than the national average, dead on what one would expect given the city’s higher poverty rate. On a net basis, therefore, that one industry can explain all the additional Social Assistance employment in excess of what one would expect given the city’s higher poverty rate. In that industry, New York City’s employment per 100,000 residents is seven times the national average, a greater disproportion than for just about any other sector. That industry is…
NAICS industry code 624120 Services for the Elderly and Persons with Disabilities: “This industry comprises establishments primarily engaged in providing nonresidential social assistance services to improve the quality of life for the elderly, persons diagnosed with mental retardation, or persons with disabilities. These establishments provide for the welfare of these of individuals in such areas as day care, non-medical home care or homemaker services, social activities, group support, and companionship (emphasis mine).” New York City private employment in this industry: 992 workers per 100,000 residents. The national average is 141, the rest of New York State 277, and New Jersey just 82. This industry accounts for 75% of NYC’s additional employment in the Social Assistance sector.
Hmmm. What is this? What else do I know that can explain this?
Let’s start by describing what is not included here.
One thing not included here is Home Health Care, which is considered part of the Health Care sub-sector and not the Social Assistance sub-sector. We’ve got plenty of that too, with 532 people employed in NYC per 100,000 residents, roughly double the national average of 270, the rest of New York State at 310, and New Jersey at 307. Home health care workers are “primarily engaged in providing skilled nursing services in the home, along with a range of the following: personal care services; homemaker and companion services; physical therapy; medical social services; medications; medical equipment and supplies; counseling; 24-hour home care; occupation and vocational therapy; dietary and nutritional services; speech therapy; audiology; and high-tech care, such as intravenous therapy.” Thus, while “homemaker and companion” services are sometimes included, it certainly appears that Home Health Care workers require medical training. New York State accounted for 8.4% of the nation’s poor people age 65 or more in 2002, but according to my tabulation of 2002 Medicaid data from the Center for Medicare and Medicaid, it accounted for 22.4% of those receiving Home Health Care Services under Medicaid that year. According to New York State Department of Health data, New York City accounted for 81% of Home Health Care Services spending in the state that year.
Also not included: nursing home care and other residential care industries such as residential facilities for the mentally retarded, mentally ill and substance abusers. These are also part of Health Care sector rather than Social Assistance: New York City employment is above average relative to employment in each of these categories as well, but not to the same extent, though it is below average in “community care facilities for the elderly.”
What the industry in question, “Services for the Elderly and Persons with Disabilities,” appears to contain is non-medical care for senior citizens in their homes, presumably intended to keep them in their homes. Shopping. Cleaning. Transport. Adult day care. These are the kind of services that many elderly people receive from family members, at least until they are overwhelmed by the burden of care. Most of these services fall into the “personal support services” Medicaid category. In 1997, New York State accounted for 50% of all the Medicaid personal support spending in the United States. By 2002 that was down to 21.5%, still a large share. That year New York City accounted for 83% of all the “personal support services” Medicaid spending in New York State.
“Services for the Elderly and Persons with Disabilities” is part of the broader “Individual and Family Services” industry, which has been growing explosively since the 1980s. When I mentioned to a more politically tuned-in city planner that the city was sure paying for a lot of social workers, he pointed out that in fact all the money was going to housekeepers and valets for the seniors, many of whom were not poor, much provided through non-profits owned and occupied by members of the state legislature, their family members and associates. I also recall a scandal where most of the nation’s “adult day care” money was going to one politically connected non-profit in Brooklyn, for social activities for seniors who were not actually sick. And, of course, our legislators are likely to prefer a rather large staff in their own organizations to, say, a fair share of state school aid.
In any event, clearly these non-profits and the eldercare lobby sees no need to limit the demand for this kind of services. And, apparently high home health care and personal care employment and Medicaid spending has not reduced employment in or Medicaid spending at NYC nursing homes. New York State accounted for 15.7% of U.S. nursing home expenditures in 2002, with more than half of that in NYC, which also had above average employment relative to population in the nursing home industry. Although, as mentioned, employment in “community care facilities for the elderly” was below average. So no wonder I doubt providing even more services for seniors, assuming these are actually being provided, will save on nursing home care. We’ve already done that, in spades.
There are other issues raised the numbers (attached, please download, think about, and discuss), and the care of the frail elderly is worthy of its own book, let alone its own post. It is one of the biggest issues we will face 20 years from now, along with global warming, infrastructure collapse and public debts (yes, in the long run these worry me more than terrorism).
The bottom line is much of the city’s additional “social services” spending does not go to poor and troubled families in general; it goes to services for senior citizens. That’s what is the most out of line relative to the national average and other parts of the state.