Laurie Buonanno, Frank Ciaccia, and Lisa Parshall (June 15, 2024, last update November 21, 2025)
INTRODUCTION
As of 2024, there are 16 county-operated nursing homes in 15 counties and two skilled-nursing facilities operated as units withn public corporations (in Erie and Nassau counties). Yet in 1997 there were 44 county operated nursing facilities operating in 40 of New York State’s counties. What happened?
THE POOR HOUSE
The county home has an interesting and rather fraught history that serves as an excellent case study because it is one of the earliest “unfunded mandates” Albany “imposed” on NYS counties. It is also instructive for understanding the relationship between Albany and counties: with Albany insisting counties are “handmaidens of the state” (as creatures of the state and in most respects, its servants), while counties, from their inception, have fostered a sense of local/sub regional identity. But perhaps, most importantly, the county home’s history demonstrates the historical difficulty NYS’s counties have experienced in providing food and shelter, education, and rehabilitation of indigent, disabled, and abandoned residents and their perennial demands for more State assistance for them to properly care for their indigent residents.
The county home/nursing home concept has its origins in the seventeenth century when English settlers brought the concept of public workhouses and almshouses (aka “poorhouses”) to America. In colonial New York, the General Assembly (colonial legislature) required that each town must care for its poor, with justices of the peace auditing compliance.
Broome County Almshouse residents (Men’s Dormitory) (1890) – Broome County Historical Society
Many children while growing up remember their father’s response to requests they buy an item with, “You’re going to put me in the poor house!” The response was not meritless because at one time each NYS county maintained a poorhouse/poorhouse farm for individuals who had nowhere to live. NYS’s county poorhouses date to 1824 when the state legislature passed legislation requiring counties to erect one or more poorhouses to care for the “worthy poor,” with counties responsible for building and maintaining poorhouses through county levied taxes. The legislation required counties to purchase “one or more tracts of land not to exceed 200 acres” for building poorhouses (Livingston County, 2023). Counties had no choice but to comply. The Genesee County Board of Supervisors, for example, established its county poorhouse in 1826 followed by an announcement placed in the Batavia Times newspaper (Conklin, nd):
Notice is hereby given that the Genesee County Poorhouse will be ready for the reception of paupers on the first day of January 1827 … The Overseers of the Poor of the several towns of the County of Genesee are requested, in all cases of removal of paupers to the county poorhouse, to send with them their clothing, beds, bedding and such other articles belonging to the paupers as may be necessary and useful to them.
An observer (a prominent Buffalo industrialist and philanthropist) observed, “town and city almshouses, county poorhouses, and county infirmaries (are) institutions differing only in name” (Letchworth, 1894). Indeed, these county poorhouses became “warehouses” for all manners of county residents who could not care form themselves: “habitual drunkards,” paupers (a person who had no means of income – which included children) , “state paupers” (a person who was blind, lame, old or disabled with no income source), and “lunatics” (Conklin, nd). Some poorhouses were able to provide separate quarters for mentally-ill individuals, but many did not, and the result was that “inmates” deemed harmful to themselves or others were often shackled. This was a particular problem in rural counties, because unlike in New York’s cities, rural areas did not have hospitals available with psychiatric wards. The poorhouses were particularly crowded during the winter when unhoused people sleeping in the rough risked succumbing to hypothermia in New York’s winter climate. In many poorhouses, the inhabitants suffered throughout the winter due to lack of fuel, warm clothing and shoes, and warm bedding (Willard, 1865). Some people spent their entire lives in the county poorhouse. Genesee County historian Susan Conklin (nd) uncovered an obituary of a Phebe White who lived in the poor house for 58 years, entering in 1828 at age nine and listed as “idiotic,” with her total care costing the county $7,000. Children were also vulnerable. William Letchworth (1894), a member of the Board of Charities of New York reported horrible conditions for children in the county poorhouse in 1874 when the New York State Board of Charities investigated.
By the mid-nineteenth century Governor Fenton and the NYS legislature began to recognize pleas to do something about the situation. The county poorhouses were severely overcrowded, perennially underfunded, conditions were less than ideal (“deplorable” would be a better description) and most of the long-term residents were mentally-ill (Higgins, nd).
The State’s first attempt to treat the mentally-ill was the New York State Lunatic Asylum opened in 1843 in Utica. The Utica facility was built as an “acute facility,” for “curable” patients transferred from the poorhouses for treatment, and when deemed “cured,” were transferred back to the county poorhouse. In 1864 the NYS legislature authorized Dr. Sylvester Willard, Secretary of the Medical Society of the State of New York, to “investigate the condition of the insane poor in the various poor houses, alms houses, insane asylums, and other institutions, where the insane poor are kept…” (Willard, 1865, p. 5). In many of the counties, one-quarter of the residents of the county poor houses were deemed “lunatics.” By this time, the NYS legislature had also by special act created a county insane asylum in Monroe County (Rochester), which was controlled by the county’s board of supervisors and in Ontario County (Canandaigua) there was a dedicated wing of the county poor house “Brigham Hall Asylum for the Insane.” But even in these dedicated facilities, the mentally-ill were not being given medical treatment, afforded recreation, or provided with programs.
In fact, Willard’s report was shocking. He reported that some poor houses confined the mentally-ill to cages and others to cells “dark and prison-like.” Few had bathing facilities. Some inmates were “besmeared with their own excrements” and some were naked and sleeping on straw and living in overcrowded conditions. Few had the “provision for exercise in the open air.” The attendants of the mentally-ill were themselves “pauper inmates” who “in many instances are depraved by vice, cold, sordid, selfish from poverty, utterly incapable of taking care of themselves” (Willard, 1865, pp. 12-14). Willard recommended removing the “insane poor” from the counties (Willard, 1865, p. 15). In response, the NYS legislature passed the Willard Asylum Act (1865), which required removal of all individuals diagnosed as insane from the county poor houses to either the Utica State Asylum (curables) or to the newly-opened Willard Asylum for the Chronic Insane (located in Ovid, New York). Soon other state asylums opened to absorb New York’s indigent mentally-ill, including the Buffalo State Asylum. So, for example, in the case of the aforementioned Genesee County Poorhouse, “the insane were housed at the County Home until 1887 when the Board of Supervisors agreed to send ‘persons suffering with acute insanity to the Buffalo State Asylum and cases of violent, chronic insanity to Willard’” (Conklin, nd).
Ten years after enacting the Willard Asylum Act, there were still 3,000 children living in various poorhouses and almshouses throughout NYS (Letchworth, 1894) when in 1875 New York State enacted the Act to Provide for the Better Care of Pauper and Destitute Children (“Children’s Act). This Act ordered the removal of children between the ages of 3 and 16 from the county homes to orphanages (often called “orphan asylums”) by January 1876.
The County Home and the County Nursing Home
When New York State and the federal government began to implement social welfare programs such as public housing, Medicaid, food stamps (since 2012, Supplemental Nutrition Assistance Program or SNAP), the poor (including the indigent elderly) there was less demand for the county home as a refuge for the poor. Therefore, during the Great Society expansion of social welfare during the Kennedy and Johnson administrations (1960-1968), county homes began to shift to provide for the elderly who faced a need for medical services and could no longer live in their residences. Importantly, while NYS’ counties are mandated to provide social service programs they are not mandated to provide public nursing homes. Indeed, with counties providing services for their residents with special needs including social service programs for the poor, youth programs for the young, senior centers for their elderly, veteran services for those who served their country, county leaders did not want to leave out their frail elderly and made the policy decision too transform the “county home” to nursing homes for those elderly who could not live alone and needed 24/7 care.
Benefits of County-run Nursing Homes
There are so many benefits of the county-run nursing home, it can be difficult to understand why counties close or sell theirs!
- Unique mission in providing high-quality services to its indigent elderly and those with disabilities considered “hard to place.”
- Accept difficult-to-serve and often costly-to-serve residents that non-public nursing homes are reluctant to admit. County nursing homes have tended to serve a higher proportion of younger residents (under 65) who require more staff time to address behavioral issues
- Mission rather than “profit” driven.
- In rural counties, may be the only skilled nursing facility available.
- Oversight the responsiblity of elected officials.
- Operate at a lower margin than profit and nonprofit – especially so when compared to the private equity firms that have been buying up nursing homes.
- Significant source of employment for residents of rural counties.
- Local dollars stay in the community.
New York’s Counties under Stress
At one time, supporting nursing homes had been a rather straightforward endeavor for counties because they operated as Enterprise Funds in county budgets (financially self-sufficient requiring no allocation from the county’s General Fund). Specifically, nursing home operating costs were offset by revenues to the county home from Medicaid, Medicare, private pay, and the all-important state financing system of the Intergovernmental Transfer Program, known as the IGT.
Over the past forty years, New York’s counties have been struggling with fiscal stress, particularly rural counties with less flexibility to raise property taxes and are unable to attract new businesses. Over this period, county budgets have been increasingly squeezed by several factors – regulations, mandates, the Property Tax Cap, and the Berger Commission’s recommendations to close nursing homes.
Factors contributing to the demise of the county home
1) complying with federal and state regulations on nursing homes,
2) state mandates for county-level delivery of specific services, particularly Medicaid,
3) limits on the county’s ability to generate more income from property taxes
4) implementation of recommendations by Governor Pataki’s task force Commission on Health Care Facilities in the Twenty-First Century (Berger Commission Report).
Given this precarious situation, a fiscal crisis would severely limit the ability of counties to find their way out of a crisis on their own. Yet the prospect of Albany imposing a fiscal control stability board was something that county officials had learned from Erie County they should avoid at all costs. Mark Polancarz, Erie County Executive, commented, “If there’s anything I can recommend to any community that’s potentially on the horizon having a control board face them is, don’t. Do everything possible to avoid a control board. Because not only do you lose control with regards to your finances on a day-to-day function, you basically lose the power to make basic policy as well” (quoted in Abbott, 2012).
Further stress was piled on the counties when the Andrew Cuomo administration implemented a property tax cap in 2012, severely limiting the ability of counties to fund county operated nursing homes.
Regulations
With most public services, managers can respond to a reduction in funding with a reduction in spending and still offer a program to the public. However there are some operations that are 24/7 operations where the State has imposed minimum staffing regulations and services that must be complied with regardless of increased costs. One example are county jails. Such is also the case with county owned and operated nursing homes. An important difference for county managers and legislators is that county jails are required by law, but counties are not mandated to have homes.
When Nelson Rockefeller was NYS governor in the 1960s, Medicare covered “a limited period of skilled nursing care” while Medicaid paid for “indefinite institutionalization of the elderly” (Winant, 2018, 102). One of the unintended consequences of New York’s implementation of the Medicaid program was an explosion in private nursing homes, many of them part of a chain of nursing homes operating around the state or nation: by 1969, the US nursing home industry took in $2.5 billion in revenue, with two-thirds of this revenue from government funds (Blackslee, 1970). However, this exponential increase in nursing homes was not accompanied by a reorganization of the State’s administrative agencies to oversee them. The result was diffused oversight among several state agencies and local government and little regulatory oversight(Connery & Benjamin, 1979, p. 157). Indeed, four years after Medicaid was implemented in NYS, there were at most 14 state auditors examining the books of all 2,000 health care facilities (shared health centers, hospitals, laboratories, individual providers, and nursing homes). New York’s Bureau of the Budget (as the Division of the Budget was then called) repeatedly turned down the DoH’s annual requests (1970-1975) for more auditors as NYS in a period when the Governor struggled to balance the State’s budget during the most severe economic recession since the Great Depression (Hynes 1980, 3).
In 1974, the New York State’s Assembly Committee on Temporary Cost of Living began to uncover allegations of fraud and poor care in nursing homes. With investigative reporters writing stories about nursing home fraud, abuse and improper influence in papers from Buffalo to NYC, Governor Carey appointed Morris B. Abram to chair The Moreland Act Commission on Nursing Homes. At the same time, the NYS Attorney General, Louis J. Lefkowitz (D), authorized the creation of the Office of the Special Prosecutor to investigate allegations of criminality (Hynes, 1980, p. 129). The Moreland Commission uncovered widespread fraud that extended well beyond falsifying records to inflate reimbursements. The fraud included expenditures on such items as “vast quantities of liquor,” mink coats, and personal art collections (Hynes, 1980, p. 132). Both NYS and the federal government responded with a barrage of regulations. County homes found themselves in a situation where they now needed to comply with federal, state, and local laws, regulations, codes, standards and principles that arose from Medicaid fraud perpetrated by for-profit nursing home providers (New York Codes, Rules and Regulations). So, for example, NYS’s minimum standards require every nursing home to maintain daily staffing hours equal to 3.5 hours of care per resident per day by a certified nurse aide, licensed practical nurse, or registered nurse (New York State Department of Health, nd).
Another federal regulation has worked against the county nursing home’s ability to generate additional income because the federal government prohibits the use of SSI payments to reimburse county facilities for the cost of assisted living programs (CGR, 2007, p. v; NYSDOH, 2009, p. 18), but the problem is that many of the patients are actually not elderly, but so severly disabled their families cannot take care of them at home.
Medicaid and other State Mandates
While county administrators were facing rising nursing home costs,Albany placed additional pressure on county budgets. New York State requires counties to administer several costly social service and public safety programs (Medicaid, public defender representation, preschool special education, child welfare, probation, and youth detention), but unlike in most states where the state picks up the entire tab, New York imposes local share costs that must be included in the county operating budget. Naturally, as program enrollment increases, the counties must pay for these additional costs. In the time period when many of the county nursing homes were closing, several county executives expressed their frustration, exemplified by Erie County Executive Mark Poloncarz’s comment, “In Erie County we control about ten percent of our overall budget. The rest are related to mandated costs with the various social service programs, the public safety programs, there’s really only a certain amount we can control. Ten to 12 percent at most” (Abbot, 2012). By far, the most costly mandate is Medicaid and is particularly important with respect to nursing homes.
The federal government sets “broad guidelines” for Medicaid, including minimum eligibility benefit requirements. States are required to provide specific benefits for Medicaid enrollees, including nursing facility services. Significantly, Medicaid covers nursing home care for eligible individuals who are 21 or older as long as the care is required. About two-thirds of nursing home residents are covered by Medicaid and 20 percent of Americans over 65. Medicaid accounts for 54 percent of overall national spending on long-term services and supports (National Association of Counties, 2023, pp. 4 & 11).
States are required to contribute no more than 50 percent of Medicaid costs. When in 1966 Governor Rockefeller signed into the law NYS’s implementation of Medicaid, the nonfederal half was split between the state government and local governments: the federal government would pay for 50 percent, the State would pay for 25 percent, and local districts – NYC and the 57 counties outside of NYC – would pay 25 percent (CBC, 2018, p. 2). New York State is one of just 19 states mandating a county contribution (counties in six other states and the District of Columbia can voluntarily contribute), with New York’s local cost share continuing to be the highest in the nation (National Association of Counties, 2023, 10). New York’s approach to Medicaid has exacerbated the political divide between Upstate Republicans (who wanted more funding for long-term care and less generous benefits for Medicaid recipients) and Downstate Democrats (the vast majority of people qualifying for Medicaid lived in NYC). Albany’s approach to the Medicaid cost share became a constant source of friction between Upstate counties and Albany. Thus, from its inception Medicaid represented a costly burden to counties and NYC and more so for counties with a larger (per capita) share of indigent residents. By 1981, the local share exceeded $1 billion (CBC, 2018, p. 2). For seven years, Governor Hugh Carey attempted to have NYS take over the local share and while the NYS Assembly (controlled by Democrats) passed Carey’s proposal, the Republican controlled Senate rejected his proposal each time. In the meantime, county homes received a much needed infusion when in 1981 Congress amended the Medicaid reimbursement program to take account of the disproportionate number of Medicaid recipients cared for in publicly-owned facilities with a new formula called “Medicaid disproportionate share hospital (DSH)” payments, in effect, a Medicaid Intergovernmental Transfer (IGT) for public hospitals and skilled nursing facilities. These monies are transferred from the county’s general fund to the New York State Department of Health (NYSDOH). Albany uses the county funds, along with federal government funds to pay for the services of the county-run health care facilities. The county must provide a 50 percent match up front from the county general fund prior to IGT annual funds assessment (that is, the full 50 percent match required by the federal government from the State).
Congress fixes the total DSH available in the federal budget and the allotment. It has sometimes been lowered depending on congressional priorities (therefore, has changed from year to year). There is often a lag in counties receiving their DSH allocations from Albany so that in some years there are no flows and in other years there can be windfalls (CGR, 2013, p. 78). Another problem is that the IGT payments have not always moved the county home into the black.
But the Medicaid IGT system started to become problematic for counties because around the year 2000 Medicaid IGT payments were no longer keeping up with the increases in county home operating costs (CGR, 2007, p. 55). Counties now faced the unattractive option of having to appropriate funds from the General Fund budget to make up the shortfall in the enterprise fund. So, too, the State’s system for transferring IGT funds was difficult for the more rural counties to manage, with CGR (2013, 87) reporting that “in at least two (county) homes (that closed) county administrators explained that their billing procedures were not sophisticated enough to capture all the reimbursement revenue the homes were due.” Furthermore, by 2004 counties were paying 16 percent of New York’s total Medicaid bill. County Medicaid expenditures continued to rise at an average of 8.6 percent annually, to the tune of $6 billion annually statewide ($4.3 billion in NYC and $1.8 billion in the counties). This led Governor George Pataki to propose a cap on the annual growth of the local share from 2006 to 2008 at 3.5, 3.25, and 3 percent, respectively, with cost growth above these percentages being the State’s responsibility.
The State’s approach and process for Medicaid cost shares became untenable for many counties during the Great Recession of 2008-2009, which left many counties reeling from its effects on their revenue streams, which then triggered a frantic search by county officials to find ways to cut their operating budgets to head off any attempts by Albany to impose a fiscal stability board on their operations. In fact, since 2010 because the operating losses had become so high for many county-run nursing homes, IGT payments were not keeping up (CGR, 2013, p. 79). Furthermore, the Affordable Care Act (ACA) had reduced DSH under the assumption that fewer uninsured individuals would be treated in public hospitals and nursing homes: these situations contributed to uncertainty for the counties with respect to their anticipated reimbursement.
No substantial reforms took place until in 2012 Governor Andrew Cuomo and the Legislature phased out the annual growth rate share to 0 percent by 2015, with all frozen amounts above the 2015 level paid for by the State (CBC, 2018, p. 3). This State takeover has created total savings of $37.9 billion for the counties and NYC (Lisa, 2023). Today, the frozen annual local share of Medicaid is $7 billion (CBC, 2018, p. 3; National Association of Counties, 2023, p. 10), but is expected to rise to its original $7.6 billion with the phasing out the state’s pass through of COVID-19 funds to the counties. Therefore, the Medicaid local share as a percentage of local district gross expenditures averages 8.62 percent. However, this average hides the regressive nature of the State system of Medicaid cost share. So, while the freeze will hold costs flat, it does not correct the regressive local share already in place (CBC, 2018, p. 7). Because Medicaid provides health services primarily to the poor, the less affluent counties “pay a disproportionately large portion of Medicaid costs relative to their population size and wealth” (CBC, 2011).
CGR (2007, p. 59) estimated that in 2006, counties were contributing over $100 million a year in financial support for county nursing homes with just one county not having to subsidize its county nursing home from its operating budget. By 2012, Medicaid rates were falling short by about $42 each day/resident (CGR, 2013, p. 20). Thus, with lower State IGTs, county homes began to eat up more of the counties’ operating budget. The knock-on effect was that counties could no longer afford to pay for other services normally funded from the operating budget and counties’ fund balances (rainy day funds) were shrinking precipitously (CGR, 2007, p. 60). The growing frustration and financial stress associated with lower Medicaid IGTs and various mandates were causing to county budgets was expressed by Stephen J. Acquario, Executive Director of the New York State Association of Counties (NYSAC) in conveying NYSAC’s message to New York State Legislators: “if it is good enough to mandate, it should be good enough to fully fund with state resources.” Acquario’s comments encapsulate the highly contested politics of local self-government in NYS: “We don’t have a say in the creation, just in the execution.” In addition to vigorous lobbying by counties and NYSAC to eliminate the local Medicaid cost share, many counties conveyed their displeasure with NYS’s approach to Medicaid cost share mandate by identifying the county’s contribution in a special category to inform the public on how much of their tax rate is specifically to fund the local costs share.
The Property Tax Cap
Governor Cuomo proposed the tax cap saying property taxes were too high in New York State and he and the State Legislature needed to restrain local government spending to make New York a more attractive state in which to work and do business. County administrators were frustrated by Albany’s view as they perceived high property taxes as the consequence of state mandates. With the management of most of New York’s counties under Republican control, Cuomo had, in effect, taken the wind out of the state Republicans’ sails. The result was that they began to focus even more so on unfunded state mandates, which they blamed on “tax and spend” Downstate politicians dominating State governance. The county nursing home and their unionized workforce (along with their pension benefits) became a target for (mainly) Republican legislators and county managers.
Still reeling from the Great Recession and lobbying Albany for more budgetary relief, Albany’s answer was to impose a property tax cap, which became the proverbial “nail in the coffin” for many counties that had been considering whether to continue to fund/expand/renovate their county homes. The Center for Governmental Research (2013, p. 25) concluded that “the tax cap in some ways represents the final straw for those seeking to find ways to make county nursing homes viable and sustainable in the future.”
The Executive’s Use of the Taskforce: The Berger Commission
New York State has long used the task force to effect (or provide cover for) major policy changes. The Legislature authorized The Commission on Health Care Facilities in the 21st Century (aka the Berger Commission) in 2005, which was then convened by Governor George Pataki. The Berger Commission report, issued in 2006, was accepted by the Governor and became “binding as a matter of law” (NYSDOH, 2009, p. 9). Its two major proposals that directly affected the county homes were as follows:
- proposed the elimination of approximately 18 percent of all non-NYC county beds (1750), compared with about two percent of non-NYC voluntary and proprietary beds or (1250 beds) – a 60% reduction in county homes, despite only 10% of beds being located in State and county facilities (CGR, 2007, p. 49).
- called for more community- and home-based care options
The threat was explicit–Albany had decided county nursing homes were too expensive to operate and a vestige of an old way of thinking about the county’s provision of services to the elderly. If counties wanted to continue to operate nursing homes, they would need to spend their own resources and not come knocking on Albany’s door. The Berger Commission’s proposals were being implemented when the Wall Street meltdown made NYS the epicenter for the Great Recession of 2008-2009 and a scramble to balance NYS’s budget during the recession-driven loss of state revenues.
County Nursing Homes Close
In December of 2014 Orleans County closed their 120-bed nursing home in Albion. Orleans County Chief Administrative Officer Jack Welch explained Medicare and Medicaid rates started being tweaked and were not keeping up with expenses. Mr. Welch pointed out “Medicare rates changed and with the reduction in IGT aid it wasn’t keeping up with current expenses and we couldn’t sustain the nursing home, closing it in 2014.” He emphasized that at the end the county was putting $100,000 into the nursing home and couldn’t be sustained.
Genesee County administration was faced with the same pressure. The county operated a 200-bed nursing home in Batavia that included a 120-bed skilled nursing facility, a 28-bed Memory Care unit, and a 12-bed Rehabilitation Center. While once financed wholly from the Enterprise Fund, the county started making financial contributions to the nursing home in 2005 mostly due to reductions in the Medicaid rate paid to county nursing homes. According to Genesee County Treasurer Scott German, “The state didn’t increase Medicaid rates as our costs increased. We were losing over $100 per day per resident. The state was paying Medicaid rates from 1985 into the 2010 time frame. However private run nursing homes get paid the current Medicaid rate.” In 2010 Genesee County appropriated $560,385 to the nursing home. Genesee County Treasurer German explained the decision to sell the nursing home: “Unfortunately New York’s failure to fund county nursing homes with an appropriate Medicaid rate to actually pay and fund resident care caused many counties across the New York State to actually make direct contributions towards nursing homes. The lack of appropriate Medicaid funding was breaking the bank of most counties and forced most counties to sell their nursing homes.”
Livingston County operated two nursing homes and in 2005 the county closed their two nursing homes and opened one new 266-bed nursing home in Mt. Morris under the concept of a “neighborhood model” Eighty to ninety percent of the residents account for Medicaid revenue for the county. However, the county is receiving a $235 per day Medicaid rate per resident while experiencing a $335 cost per resident according to Livingston County Administrator Ian Coyle. In explaining the county’s situation County Administrator Coyle pointed out, “If you want to have nursing home care you are going to lose money.” Mr. Coyle is able to keep the nursing home going by adding additional local share from their county budget, but admits each year it is a challenging decision to continue allocating additional funds to the nursing home.
Onondaga County sold its county nursing home in 2012 despite opposition from CSEA, the nursing home employees’ bargaining unit. Ryan McMahon, the Onondaga County Legislature Chair argued in favor of its closing noting that State funding had not increased since 1989. “Van Duyn, as it is, is going to run a $115 million deficit over the next nine years. That will bankrupt Onondaga County” (Fecteau, 2012).
In 2009, Westchester County closed its Taylor Care Center, which had been in operation since 1937, and cared for patients ranging in age from 20 to 96 years old (Berger, 2009). The reasons cited were the State cutting off $75 million in Medicaid and other reimbursements, $40 million and $35 million from the Westchester Medical Center’s 2008-09 and 2009-10 budgets, respectively.
Lessons about Crisis Governance, Intergovernmental Relations, and Unintended Consequences
The paths taken
There was a 66.7 percent decrease in county-operated nursing homes from 1997 to 2025 (the last year a county nursing home was sold or closed). (See table 1 for an accounting of all county nursing home closures.) How can we account for this dramatic reduction? We have argued that three factors – State mandates (particularly NYS’s Medicaid cost share formula and the State’s administration of the Medicaid IGTs), the property tax cap, and the State’s implementation of the Berger Commission’s recommendations together account for the death of the county nursing home in New York State created the conditions for weakening the county nursing home.
Counties chose various paths in their attempts to continue to offer services to their indigent elderly and disabled. Erie County, for example, was able to survive the fiscal squeeze because it had merged its county home into a public benefit corporation it established in 2004 that ran the county hospital, an option that just is not available to poor, rural counties. Another large county, Monroe, took a different route by expanding its income revenue capacities into outpatient and other services (CGR, 2013). And a third county—Nassau—had integrated its skilled nursing facility into a public benefit corporation in the 1990s. These were options that simply were not available to rural counties. Indeed, all but one country that exited the nursing home business sold their homes to for-profit providers.
Who decides?
Nevertheless, the decisions of these county officials to close their county homes were often controversial and the vote was contentioius in many counties. So, for example, when the Essex County Board of Supervisors voted to sell Horace Nye (county home) it was split vote of 12 to 6 (2,683 to sell and 1,233 to retain under the weighted-vote rule for financial decision-making) (McKinstry, 2012). Tom Scozzafava, a member of the Board explained why he voted against the sale: “There’s some services that government is morally obligated to provide. I think services for our elderly population is critical, especially in a county as rural as Essex County” (quoted in Mann, 2012). Some residents argued that the public has not been properly informed of the issues (see, for example, Mann, 2012; The Upstater.com, 2015). In some cases residents demanded public referendums, but none were held in any of the counties contemplating selling their county homes. Opponents to the sales pointed out that if the county privatized its home, it would still be responsible for its share of Medicaid costs for residents of the newly-privatized home, but their logic was ignored. And in some counties, such as Niagara, the vote was not only contentious, but was partisan–Republicans voted for the sale and Democrats opposed (Prohaska & Gee, 2006).
County employees and their unions vigorously opposed the sale of county homes. Shawn Barber, a nurse and a county employee who worked at Essex County’s Horace Nye’s County Home for 19 years encapsulated concerns about access to private for-profit homes: “Private picks and chooses who they keep and who they take. And what about the rest of our county residents that’s going to need it someday? And what about our people who are here now that are on Medicaid?” (quoted in Mann, 2012). At the same time, county managers complained about the “escalating benefits” paid to county home staff, including retirement costs passed on from the State to counties and to increased health insurance costs for the staff.[1] Union officials representing the employees who stood to lose their collective bargaining rights spoke at meetings against privatization and in some counties even sued in court to stop the sales; however, the union lost these court cases (see, for example, Coin, 2013; Perham, 2012; Prohaska & Gee, 2006).
County officials continued to blame Albany. So, for example, Gary Swackhammer, a Steuben County legislator complained, “It’s not us. It’s not us. It’s the state government you should be talking to. They said ‘You build it. We’ll pay you more.’ They lied to us … You’re talking to the wrong people” (Perham, 2012).
Do county homes provide better care?
Turning to the question of value and quality of privatized nursing homes, 16 out of the 18 county homes were sold to private for-profit nursing home operators (many of them chains). Yet “a large body of research” indicates that for-profit nursing homes are “associated with lower-quality long-term care compared with nonprofit ownership of homes” (Braun et al., 2021). There is also evidence from NYS: CGR (2013, pp. 58-60) found that for-profit homes in the State “consistently have the highest rates of hospitalization for both short-stay and long-stay residents.” One study also found that county homes provide about 40 minutes of additional direct nursing care per resident day as compared to for-profit providers and 23 more than in non-profit homes (CGR, 2013, p. 67). Nursing homes sold by Delaware, Onondaga, Orleans, and Otsego counties to for-profit nursing home chains have been cited for fraud, neglect, and/or abuse–two of them (Onondaga and Orleans) are being sued by the NYS Attorney General at the time of this writing (2024) for diverting Medicaid funds for their own financial gain, inadequate staffing, and neglect. Furthermore, both the owner and manager of the for-profit nursing home that purchased the Otsego county home pled guilty to one of eight counts against them in a plea agreement. The for-profit nursing home sold by Delaware County closed rather than remedy deficiencies cited by the Centers for Medicare and Medicaid Services (Borrelli, 2018; Richardson, 2012; Roszkowski, 2023; Towhey, 2023).
In another twist to this evolving story, private equity firms are snapping up nursing homes: increasing from $5 billion in 2000 to more than $100 billion in 2018, with about five percent of all nursing homes now owned by private equity firms (White House, 2022). It is difficult to obtain information on the extent to which private equity firms have purchased former county homes, but we do know of at least one instance in NYS. In 2013, Ulster County sold its 280-bed Golden Hill Nursing Home for $11.3 million to a private equity firm, which also received tax breaks for Ulster County’s IDA. In 2019, that group of investors resold the home to another private equity firm for $37.6 million (Ward, 2019). While it is not known the extent to which private equity firms own any other formerly-owned county nursing homes, this should be of concern because evidence is mounting that just as the for-profit nursing home is associated with lower-quality care, the private equity (PE) firm goes even further than non-PE for-profit nursing homes in squeezing profits from the care of the elderly and severely disabled. Braun et al., 2021 analyzed 9,864 US nursing homes, including 9,632 residents in 302 nursing homes acquired by private equity firms and 249,771 residents in 9,562 other for-profit nursing homes without private equity ownership. Private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations and higher Medicare costs. Another study found that private equity nursing homes have increased excess mortality, increased prescription of antipsychotic drugs, decreased hours of frontline nursing staff, and increased taxpayer spending (Gupta et. al, 2023). And private equity firms performed poorly during the COVID-19 pandemic, where infection rates and death rates were well above statewide averages (Americans for Financial Reform Education Fund, 2020).
Integovernmental relations and “home rule”
NYSAC Executive Director Acquario reflected on what he saw happening over these years in New York State:
“I witnessed the elimination of the public nursing home…It was a core function of the local government to care for those in need and give people a retirement home to age with dignity. This model became fiscally unsustainable for many counties as the state gradually increased the costs of a wide variety of state mandated programs in the 1990’s and early 2000’s…It was unfortunate and the State Department of Health knew what it was doing in the 1990’s and 2000’s when it was enacting regulation and policy. The state did not want counties to operate these homes.” – NYSAC Executive Director Acquario
While the 1960s saw counties asserting their independence vis à vis state authority, this case study suggests the extent to which this independence can be deceptive. As this study of the death of NYS’s county nursing homes has demonstrated, many counties – especially those with smaller populations and without deep pockets – have limited autonomy when Albany makes fiscal decisions that undermine the ability of counties to deliver long cherished services to their needy residents.
In a comprehensive study of private ownership of U.S. healthcare facilities, Gaffney et al. (2023) concluded that the “American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health.” Wittingly or unwittingly, the State of New York has contributed to this concerning trend by its unwillingness to provide the necessary financial support to prevent the death of county nursing homes. In 2012, at the height of the “big squeeze” on local governments (see Parshall, chapter 9), Westchester County Executive Rob Astorino commented, “We’re getting down to the bare necessities now. It’s going to be eventually, five to ten years from now, counties will be the social services arm of New York State. That’s it” (quoted in Abbot, 2012). Astorino’s comments likely captured the frustration of many county executives and supervisors, although naturally as a Republican county executive dealing with a Democratic governor, Astorino could feel less inhibited in his assessment of the State-county fiscal relationship. (Astorino was the Republican nominee for governor in 2014 and was defeated by incumbent Andrew Cuomo).
The hopes of county leaders that had to make the consequential decision to sell their nursing homes was captured by Genesee County Treasurer Scott German when he said, “As painful as it was to sell our nursing home, financially I am glad we are no longer in the nursing home business as we just couldn’t afford it. I just hope the residents are still receiving the great care the county gave them.”[3]
Nevertheless, many county leaders did not want to leave the care of their citizens in the realm of “hope”: 16 counties swam against the stampede of county leaders closing and privatizing their county homes. Undoubtedly, some of these counties risked fiscal ruin, but refused to allow the State to make decisions about how local governments should provide for their indigent elderly and disabled residents. As the tumultuous years since the Great Recession illustrate, and this specific case study of county nursing homes suggests, New York’s counties can self-govern and even resist State demands, but doing so can sometimes require nerves of steel (and, perhaps, a little bit of luck that the funding formulas may change to their advantage). In the case of New York’s county homes, that “luck” came in the form of COVID-19 State and federal funding and New York’s comprehensive nursing home reforms enacted in the FY 2022 budget requiring more accountability aimed at the private for-profit skilled nursing facilities by requiring new regulations such as a minimum percentage of the budget allocated to direct staff care. Increased accountability and more focus on ensuring more funds are spent on staffing (versus administrative salaries) should create a more level playing field for New York’s county homes.[4] But this “fix” – whether it is temporary or long-term is anyone’s guess–comes too late for the many counties that have sold or shuttered their county homes. At home care, while preferable, is not an option for all New Yorkers. Those New Yorkers living, especially in rural counties, and who need to be cared for in skilled nursing facilities, will find that their options have been drastically curtailed because the majority of New York State counties no longer operate county homes.
Table 1. County Nursing Homes as of November 2025
Updated November 21, 2025
| COUNTY | FACILITY | YEAR (sold/closed) | Admin | Percent Pop ≥65 (2020) |
| Albany | Shaker Place Rehabilitation and Nursing Center | County | 17.7 | |
| Alleghany | Had not owned nursing home in recent years (CGR, 2013) | 19.6 | ||
| Broome | Willow Point Rehabilitation and Nursing Cente | County | 19.8 | |
| Cattaraugus (two nursing homes_ | The Pines Healthcare and Nursing Center The Pines Healthcare and Nursing Center | County | 20.2 | |
| Cayuga | Cayuga County Nursing Home merged into Mercy Health & Rehabilitation Center in Auburn. The Cayuga County Home was vacant, sold to the Auburn Community Hospital in 2020 | 2013 | Nonprofit | 20.3 |
| Chautauqua | Sold its 216-bed Chautauqua County Home (located in Dunkirk) to Vetstra Care for $16 million. Operates as Chautauqua Nursing and Rehabilitation Center | 2014 | For profit | 20.9 |
| Chemung | Chemung County Health Center Nursing Facility | County | 19.7 | |
| Chenango | Preston Manor | County | 21.7 | |
| Clinton | Sold Clinton County Nursing Home (went up for sale in 2002, NYS approved sale in 2025) | Clinton County Nursing Home sold to private owners 2025 | For Profit | 18.2 |
| Columbia | Sold Pinehaven Nursing and Rehabilitation Center 120-bed facility for $6.5 million to Premier Health Care Management of Long Island | 2015 | For Profit | 24.7 |
| Cortland | Had not owned nursing home in recent years (CGR, 2013) | 18.2 | ||
| Delaware | Sold Countryside Nursing Home 199-bed facility 6 for $2.5 million. The for profit company closed the home in 2012 instead of developing a plan to address 66 deficiencies cited by the Centers for Medicare and Medicaid Services (Richardson, 2012). | 2006 | For Profit | 25.0 |
| Dutchess | Dutchess County Infirmary | 1998 | Closed | 18.5 |
| Erie | Erie County Medical Center Corporation became a public benefit corporation in 2004. Terrace View Long-Term Care Facility opened in 2013 replacing the Erie County Home, built in 1926 in Alden) – “hospital-based nursing home.” | 2004 | Public Benefit Corporation* | 18.6 |
| Essex | Sold 100-bed Horace Nye Nursing Home to Speciality Care of the Bronx for $4.05 million. | 2012 | For Profit | 23.8 |
| Franklin | 80-bed county nursing home merged with Alice Hyde assisted-living facility. | 2013 | Nonprofit | 18.8 |
| Fulton | Sold their 176-bed facility for $3.5M to a Bronx-based chain. | 2012 | For Profit | 21.0 |
| Genesee | Sold their 160-bed facility for $15.2 million to a Long Island-based company. Now operating as “Premier Genesee Center for Nursing and Rehabilitation.” | 2015 | For Profit | 19.9 |
| Greene | Had not owned nursing home in recent years (CGR, 2013) | 22.3 | ||
| Herkimer | Had not owned nursing home in recent years (CGR, 2013) | 21.6 | ||
| Jefferson | Had not owned nursing home in recent years (CGR, 2013) | 14.8 | ||
| Lewis | Lewis County General Hospital-Nursing Home Unit | County | 19.8 | |
| Livingston | Livingston County Center for Nursing and Rehabilitation | County | 19.5 | |
| Madison | Had not owned nursing home in recent years (CGR, 2013) | 19.0 | ||
| Monroe | Monroe Community Hospital | County | 18.5 | |
| Montgomery | Sold 120-bed facility for $.86 million. Renamed River Ridge Living Center | 2007 | For Profit | 20.1 |
| Nassau | A. Holly Patterson Extended Care Facility (part of Nassau Health Care Corporation) | 1997 | Public Benefit Corporation* | 18.4 |
| Niagara | Mount View Health Facility 172-beds sold for $2.4 million. Facility closed at the end of 2007. -Targeted by Berger Commission for excessive nursing home beds. | 2006 | For Profit | 20.1 |
| Onedia | Had not owned nursing home in recent years (CGR, 2013) | 19.3 | ||
| Onondaga | Sold 513-bed Van Duyn Nursing Home for $5 million to Upstate Services Group (nursing home chain). However, the county paid $2 million to Upstate Services to start the for profit operation with cash on hand and 1.3 million to demolish the former sanatorium at the complex. Onondaga County must also continue to contribute to pension contributions, retiree health care, and other expenses related to the transfer (Coin, 2013) | 2012 | For Profit | 18.1 |
| Ontario | Sold its 98-bed County Home for $1 million. Now operating as Ontario Center for Rehabilitation and Health Care | 2014 | For Profit | 21.5 |
| Orange | The Valley View Center for Nursing Care and Rehabilitation | County | 14.3 | |
| Orleans | Orleans County sold its 120-bed Village of Orleans Health and Rehabilitation Center for $7.8 million to Comprehensive Healthcare Management Services. | 2014 | For Profit | 18.7 |
| Oswego | Sold the Andrew Michaud county home, an 89-bed facility for $.8 M. County officials rejected higher offers from for-profit corporations in favor of a local non-profit nursing home operator | 2005 | Nonprofit | 17.4 |
| Otsego | Sold Otsego Manor for $18.5 million, name changed to Focus Rehabilitation and Nursing Center | 2014 | For Profit | 21.8 |
| Putnam | Had not owned nursing home in recent years (CGR, 2013) | 18.2 | ||
| Rensselaer | Van Rensselaer Manor | County | 17.7 | |
| Rockland | Summit Park Hospital and Nursing Care Center sold to for profit Sympaticare in 2014, but in 2015 Rockland County withdrew and closed the facility at an estimated cost of $6-8 million. | 2015 | Closed | 15.7 |
| Saint Lawrence | Had not owned nursing home in recent years (CGR, 2013) | 18.2 | ||
| Saratoga | Sold 257-bed Maplewood Manor Zenith Health Care for $14.1 million. Sold in 2019 to another owner. Closed in 2020 after being placed on the federal watchlist for patient failures under both owners. | 2015 | For Profit | 19.0 |
| Schenectady | Glendale Home | County | 17.9 | |
| Schoharie | Had not owned nursing home in recent years (CGR, 2013) | 22.2 | ||
| Schuyler | Had not owned nursing home in recent years (CGR, 2013) | 22.7 | ||
| Seneca | Had not owned nursing home in recent years (CGR, 2013) | 19.9 | ||
| Steuben | Sold 105-bed facility to Centers for Speciality Care Group for $11 million. | 2012 | For Profit | 20.3 |
| Suffolk | Had not owned nursing home in recent years (CGR, 2013) | 17.7 | ||
| Sullivan | Sullivan County Adult Care Center (Sunset Local Development Corporation) | County | 18.7 | |
| Tioga | Had not owned nursing home in recent years (CGR, 2013) | 20.3 | ||
| Tompkins | Had not owned nursing home in recent years (CGR, 2013) | 15.2 | ||
| Ulster | Sold 280-bed Golden Hill Nursing Home for $11.3 million sold to a private equity firm. Resold to another private equity firm in 2019 for $37.6 million. | 2013 | For Profit | 20.4 |
| Warren | Sold Westmount Health Facility | 2014 | For Profit | 23.2 |
| Washington | Sold Pleasant Valley Infirmary for $2.44 million to Bronx-based chain, Centers for Speciality Care | 2012 | For Profit | 20.3 |
| Wayne | Wayne County Nursing Home | County | 19.6 | |
| Westchester | Taylor Care Center (operated by the Westchester County Health Corporation)-Targeted by Berger Commission for excessive nursing home beds | 2009 | Closed | 17.4 |
| Wyoming | Wyoming County Community Hospital SNF | County | 19.0 | |
| Yates | Had not owned nursing home in recent years (CGR, 2013) | 21.9 |
*Public benefit corporations (aka “public authorities”) are monitored by the New York State Authorities Budget Office. Three counties outside of NYC – Erie, Nassau, and Westchester – established public benefit corporations–reconfiguring the county home as complexes with trauma centers, psychiatric wards, hospitals, rehabilitation, and long-term nursing facilities – in one health center. In converting their county homes/hospitals to public benefit corporations, county legislatures have been removed from a direct decision-making capacity. Each of the three public benefit corporations providing care are classified as a “State Authority,” which under state law is a public authority or public benefit corporation with one or more of its members appointed by the governor or who serve as members by virtue of holding a civil office of the state, other than an interstate or international authority or public benefit corporation, including subsidiaries of such public authority or public benefit corporation (New York State, 2023).
Table compiled by the author from many sources.
Table Sources:
CGR. (2013). The Future of County Nursing Homes in New York State. https://www.cgr.org/NY-county-nursing-homes/docs/FutureofNursingHomes_NYS.pdf
Coin, G. (2013, December 1). Van Duyn Nursing Home Gets New Life as Onondaga County Cedes Control to Private Firm. Syracuse.com. https://www.syracuse.com/news/2013/12/van_duyn_nursing_home_gets_new_life_as_onondaga_county_cedes_control_to_private.html
Richardson, D. (2012, October 2). Countryside on Track for Closure. The Daily Star. https://www.thedailystar.com/news/local_news/countryside-on-track-for-closure/article_e7883f5e-9f1c-540d-a224-a1e45c2a4afb.html
New York State Department of Health. (2023a). NYS Health Profiles: Nursing Homes by Region/County. Retrieved from https://profiles.health.ny.gov/nursing_home/county_or_region/county:009. (searchable database)
Other sources about individual nursing homes, ownership/closings pieces together from local newspapers, etc. See comprehenisve list in References.
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About the Authors:
Laurie Buonanno, PhD, MBA is Professor of Political Science and Public Administration in the Department of Economics & Finance at SUNY Buffalo State University. Contact: buonanl@buffalostate.edu
Frank Ciaccia, MA, spent most of his career working in the public sector. Having served for both Monroe and Genesee counties, his extensive experience in the field includes program and project management, policy drafting and implementation, public management, public budgeting, and collective bargaining negotiation. Many of the positions held throughout his career have dealt with decisions directly impacting the communities he has served including his most recent position of Assistant County Manager of Genesee County. Ciaccia is a graduate of Buffalo State and holds a MA in Urban Administration from SUNY Brockport. Frank serves as a mediator for NYS’s Public Employment Relations Board (PERB).
Lisa Parshall, PhD is Distinguished Professor of Political Science at Daemen University. She is also a fellow at the Rockefeller Institute of Government, SUNY. Contact: lparshal@daemen.edu
Suggested citation:
Buonanno, L., & Ciaccia, F. (2024). “The life and death of New York’s County Homes.” Governing New York State Through Crises Project. https://governingnewyork.com/essays/the-life-and-death-of-new-yorks-county-homes/
Governing New York State Through Crises 