Medicaid spent $126 billion on personal care aides from 2018 through September 2024. Every surgeon in America, billing every office visit, generated $76 billion over the same period. The gap between those two numbers is $49.7 billion.

That comparison is not a rounding error. Personal care services (billed under T1019 and T1020) outspent all evaluation and management office visits combined by 65%. Medicaid has quietly become the country's largest home care program, and the billing data makes that unmistakably clear.

One Code Carries Most of the Weight

T1019, which covers personal care in 15-minute increments, accounted for $118,067,674,252 of the $126 billion total across 1,066,809,132 claims. The per-diem companion code, T1020, added another $8 billion. Together, they generated more Medicaid spending than the entire category of physician office visits, which logged 1,488,783,424 claims but only $76,360,421,513 in reimbursements.

The volume comparison is striking on its own: E&M office visits produced 40% more claims than personal care codes, yet cost $49.7 billion less. Personal care aides are billing less frequently per claim but accumulating far more total dollars. For Medicaid budgets, that means the cost center most people associate with doctors' appointments is now secondary to home-based attendant care.

T1019's share of total Medicaid provider spending rose from 8.92% in 2018 to 11.49% in 2023, while annual spending on the code grew from $9,688,109,818 to $22,836,001,936. That's a 136% increase in six years, during a period when overall Medicaid spending grew substantially but not at the same pace. Every dollar Medicaid spends on personal care is a dollar not available for other services, and that share is still growing.

New York Is Running a Different Program Than Everyone Else

The national total obscures a geographic concentration that has no parallel in other Medicaid spending categories. New York alone accounted for 61% of all T1019 and T1020 spending nationally, totaling $79,219,868,313 across 516,772,211 claims. The top five states (New York, Massachusetts, Missouri, New Jersey, and Virginia) accounted for 78.89% of all personal care spending combined.

New Hampshire's position in that table deserves attention. Despite ranking second in per-enrollee spending at $7,417.10, it accounts for only 1.23% of national spending because its Medicaid enrollment is small. New York's $10,579.69 per enrollee is more than 31 times Texas's $337.02. Both states operate under the same federal Medicaid statute.

That gap reflects something structural, not incidental. Texas and Florida, two of the largest states by Medicaid enrollment, each spent less than $2 billion on personal care over the entire period. New York spent $79 billion. For Medicaid enrollees in Texas, the practical availability of personal care aide services is a fundamentally different proposition than it is in New York, and the billing data quantifies exactly how different.

The Trajectory Points One Direction

From 2018 to 2023, T1019 spending grew every single year without exception. The 2020 and 2021 figures ($15,954,076,254 and $17,345,628,536 respectively) show the growth continued even as overall Medicaid spending shifted during the pandemic period. By 2023, personal care was approaching $23 billion annually from a single billing code.

If that trajectory holds, T1019 alone will likely exceed $25 billion in annual spending before the end of the decade. The program that most people think of as covering doctor visits and hospital stays is, by the numbers, primarily financing home-based attendant care, concentrated in a handful of states, and growing faster than the rest of the Medicaid provider budget.

Given that New York alone accounts for 61% of all personal care spending at $79,219,868,313, and its per-enrollee spending of $10,579.69 is more than 31 times higher than Texas's $337.02, the question analysts haven't fully answered is whether that gap represents a policy choice about who deserves home care, a difference in how states define eligibility, or something in the billing infrastructure itself.