In 2010, Tony Rowe was at a dead-end job pumping gas at a station in Oregon. The former mechanic had once worked on tanks and freight liners in the Army and diesel trucks in civilian life, but he had trouble returning to work in a battered economy after undergoing treatment for alcoholism through the VA.

Then his girlfriend suggested he apply for work with an agency supporting people with disabilities in their homes. The job started under $10 an hour, and he wasn’t sure what he was getting into. But Rowe liked how every day was a little different with the young people — mostly in their late teens and early 20s — he helped support.

“It’s not the same old, same old all the time,” he said. “I found out a lot about myself doing this, so that kinda makes me want to be a better person.”

Rowe, now 40, has stayed on at the job ever since. And in the near future, as manufacturing and other traditional blue-collar fields shrink while health care jobs grow, a lot of workers might have to make the same transition he did.

It won’t be an easy one. Many direct care workers — home health aides, nursing assistants, and direct support professionals like Rowe — struggle to make ends meet. Despite the physical and social skills required, direct care workers are some of the lowest-paid workers in the nation, on par with fast-food workers. Rowe now makes $13.40 an hour — about half as much as he could be making as a mechanic — in a state where the median hourly wage is $18.

In interviews, home care aides told Vox about the drawbacks of a booming field: aching backs, unstable schedules, second jobs, salaries low enough to qualify for Medicaid, and emotional burnout. Health care jobs might be a beacon of the new economy. But that doesn’t mean they’re good news for the workers who do them.

The economy is moving from making things to caring for people

In 1970, 29 percent of workers were employed in the manufacturing industry. An additional 4 percent of workers were in production jobs in other industries, like retail and construction. The majority of those jobs paid well, too — nearly half the people employed in manufacturing or production earned within the top 40 percent of wages in the country. (The largest share of the workers were white men, but workers of color were employed in the sector at disproportionately high rates.)

Nearly all the production workers — 93 percent — never went to college.

Today there’s been a small shift in how many of those workers earn good wages, but the bigger problem is that there are far fewer jobs for them. The manufacturing industry now employs 11 percent of all workers, and only 6 percent of workers are in production.

Meanwhile, an aging population of baby boomers and better treatments for chronic illnesses and disabilities have created a labor boom in the health care sector.

The field, which now employs one in nine working Americans in jobs as varied as doctors, phlebotomists, and medical secretaries, is projected to add 2.3 million jobs between 2014 and 2024, the most out of any group of occupations.

Among estimates for the greatest number of new jobs, health care roles make up a third of the top 20 occupations.

One of the fastest-growing fields is direct care: There are at least 3.6 million direct care workers in the US, not including an estimated 800,000 unreported workers, according to researchers. The Bureau of Labor Statistics projects an increase of more than 1 million new direct care workers — personal care workers, home health aides, and nursing assistants — between 2014 and 2024.

“You can’t make a robot do what I do”

Unlike food service or retail jobs, which round out the top five growing jobs, direct care workers are not in immediate danger of being edged out by automation or internet commerce.

“I think it’s one of the most advantageous fields to be in these days. It’s one that cannot be outsourced,” Nathan Auldridge, a 33-year-old direct support provider in Salem, Virginia, said. He graduated in 2008 with a bachelor’s degree in theater, but theater work was too inconsistent.

Direct care is different: “It’s needed in every single community across the country,” he said. “Now, the pay is shit, but that’s another story. You can’t make a robot do what I do.”

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Auldridge wasn’t exaggerating about the wages. A salary of $20,000 for a personal care aide or home health aide is typical, with 90 percent of workers making under $30,000.

“A lot of people who look from the outside in think we’re just glorified babysitters, but we’re not,” Brittany Hampton, 31, said. She makes around $800 a month in Washington state near Seattle as a home care assistant. “We’re prolonging their lives. We’re allowing them to stay at home, versus a nursing home or rehab center. We are, of course, the cooks, the cleaners. We are companions. We are sometimes the first responders in case of emergencies.”

“We come in, we’re basically counselor, we’re security guard, we’re chef, we’re custodian, we’re chaperone,” said Myles Surland Van Tams, a 32-year-old who works full time in a New York City group home supporting people with developmental disabilities.

Van Tams, Auldridge, and Rowe are outliers in direct care work: They’re men. But the vast majority of home care aides are women, many with family obligations that prevent signing up for odd schedules or doing work for some agencies that provide benefits but require live-in, round-the-clock shifts.

“This week I’m working the 4 to 11 [pm] shift. And next week I’m working the 11 [am] to 7 [pm]. I have to get my mind mentally ready,” Marvette Hodge, 37, of Hopewell, Virginia, said. She makes around $9 an hour in an in-home setting. Hodge’s three children are old enough to look after each other, but when they were younger, she enrolled them in expensive child care she could barely afford while working at Subway.

Caregiving — a low-paid, low-status job — is also most often done by disadvantaged workers. One in 10 working black women are employed in direct care; more than a quarter of direct care workers are black women. In contrast, while white women make up 35 percent of these jobs, only one in 37 working white women is employed in direct care. Latina women, as well as immigrant women, are also disproportionately represented.

The poor are taking care of the poor

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Caregiving takes a toll on the body. But for many, the work doesn’t pay enough to afford health insurance. An estimated 46 percent of home care workers depend on Medicaid for their health coverage. Medicaid is also the largest payer of home and nursing care services, which means the poor are essentially taking care of the poor.

“Because I don’t make enough, I get health insurance through the state,” Hampton said, referring to Washington state’s Medicaid program. Her agency offers health insurance, but her wages of around $800 a month leave little room to purchase it.

The insurance is particularly necessary because direct care workers often get hurt on the job. Nursing aides, in particular, have some of the highest injury rates in the nation, just behind law enforcement and firefighters for days away from work due to illness or injury.

The rate of injuries among home care aides is lower than nursing aides but higher than the average for all jobs, and advocacy groups say direct care injuries are vastly underreported. Aides lift clients in and out of beds and help them get around, with or without proper equipment like Hoyer lifts, and sometimes they use physical restraint to prevent clients from injuring themselves or others.

“You can’t be on any kind of [physical] assistance,” said Sophia Loner, 55, of Gainesville, Georgia. After 20 years in customer service, most recently in the insurance industry, Loner wanted to find more meaningful work and became a home health aide. But she slipped and broke her ankle while walking her dog, and the intense physical requirements of direct care prevent her from returning. “You can’t be a person who can’t balance. You have to be able to lift probably 25 pounds. You have to be able to stabilize a person who can be anywhere from 90 to 200-and-some pounds.”

“They don’t want to pay you, and when you get the job, there’s disrespect on the job”

Rae Gordon, 62, spent more than four decades in home care in Memphis, Tennessee, before she was forced to stop from years of work-related injuries. “The equipment is heavy,” she said. “Most of the job, if you know what you’re going into, physically and mentally you can be prepared. But if you don’t know who you’re going to handle, their condition, what the problem is, then, no, it’s not fair to send you and it’s not fair to the patient, but of course someone has to take care of them, so you do what you can do.

“You’re in the health field, so you’re there, you’re gonna be there,” Gordon said. “And I think that’s why it’s making it so hard now. Because there is no ‘care’ anymore. [Workers] are getting tired. That’s why in the industry there’s such a big gap now, there’s so many vacancies. They don’t want to pay you, and when you get the job, there’s disrespect on the job.”

Even apart from considering the paycheck, she continued to go to work when her body was aching: “I still need to go back tomorrow,” she said she thought, “because who’s going to take care of them?”

The US is about to face a dire shortage of direct care workers

The number of people who won’t have anyone to take care of them is growing.

Experts are predicting a dire shortage of workers in the coming decades. The number of working women, the traditional labor pool for direct care, is not projected to keep up with how rapidly the American population is aging or how complex their health needs are.

When people can’t afford to pay for long-term services and supports for their aging parents and spouses or children with disabilities, family members — usually women — step in. Depending on state requirements and the care receiver’s qualifications, family members can get paid as aides through Medicaid, but not necessarily at a rate to support themselves without a second job.

Nelly Prieto, 55, of Sunnyvale, Washington, has worked for seven years as the primary caregiver for her mother, who has Alzheimer’s. “I never had done home care in my life before, and I never thought I would,” she said. Her brother and daughter also pitch in to ensure that her mother isn’t left alone, but Medicaid only pays for 4.5 hours of care a day, so all three of them have part-time jobs. Prieto drives for a medical transportation company, shuttling clients, many of them in rural areas, to various medical appointments and surgeries.

Anecdotally, at least, the workforce shortage is already here.

“We consult with home care providers and with nursing homes and assisted living facilities,” Robert Espinoza, vice president of policy at the Paraprofessional Healthcare Institute, said. “The No. 1 question we get, easily across the board, is, ‘Can you please help me with recruitment and retention? Because I can’t find enough workers, and I can’t keep them.’”

Why wages are so low — and how advocates hope to raise them

A growing workforce shortage and no increase in pay should be an economic mystery. What about supply and demand? If companies need more workers, shouldn’t they eventually have to pay more and offer better benefits?

But direct care is different for two big reasons: Medicare and Medicaid. Those two government health insurance programs that cover people who are elderly, poor, or both play a huge role in determining how much money there is to be spent on direct care in the US.

“In a classic economic model of a labor shortage, wages, benefits, and other job attributes would simply improve until enough workers were willing to fill the positions, and the shortage would no longer exist,” reads a 2008 report of the future direct care needs of baby boomers. “However, given that Medicaid and Medicare are responsible for about 70 percent of all long-term care dollars spent, there is little room for the market to adjust without the government’s being willing to commit additional funds.”

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There are also other factors at play. Women make up 86 percent of the full-time direct care workforce but are typically out-earned by men doing the same work. There’s some evidence that one of the driving forces behind direct care’s low wages is that women have worked in child and elder care without pay throughout history and thus are stereotyped as innately altruistic. Other research also shows that occupations dominated by white women, men of color, or women of color tend to be devalued in general.

Some direct care workers are hoping to use the job as a stepping stone to other jobs in the medical field that require more education and command higher pay. Marvette Hodge, who makes $9 per hour as an in-home care aide now, is studying to become a medical assistant. Myles Surland Van Tams, who works in a group home for people with disabilities in New York, is slowly working on a bachelor’s degree.

“I love the field that I’m in,” Van Tams said. “At best, I would be able to stay where I’m at right now, and kind of move up there. I could possibly become a nutritionist, assistant manager, maybe a manager of one of the residences.”

But advocates, including labor unions, are working for more systemic solutions. One possible way to increase wages and retention rates is through professionalization and credentialing of the workforce by pushing for local or national government standards and providing training materials and courses to home care agencies. While nursing assistants must be certified by federal standards, there are at least 11 states that require no training of home care assistants.

Nursing assistants are overwhelmingly paid more than people who provide support for people with disabilities, even though the required skills are very similar, said Joe Macbeth, executive director at the National Alliance for Direct Support Professionals, a training and advocacy group: “The [nursing assistant] is required to have a certificate; therefore, they are paid more.”

Advocates also see organized labor as instrumental to improving wages and working conditions for direct care workers. “Unions help change the landscape in how we talk about low-wage work in general. They help challenge the most insidious ideas about low-wage workers,” Robert Espinoza said.

“In the states where we’ve had success, we’ve made a huge impact,” said David Rolf, president of SEIU 775, the Seattle-based branch of the Service Employees International Union, which represents home care workers.

“Typically [professionalization of work] doesn’t happen without the union,” he added. “We created the highest standards here in Washington [state]. You have to get 75 hours of training to qualify for the job, and do a competency-based test. And do 12 hours of continuing ed every year after.”

But most experts agree that increasing funding to Medicaid — and increasing the reimbursement rates for services like in-home care — would have the most significant impact on direct care work.

Agencies can only increase wages and offer fringe benefits like paid time off and sick leave if the government increases Medicaid reimbursement rates.

“[Home care] is an industry created by Medicaid. And so Medicaid is the dominant payer, it’s the dominant regulator. And what Medicaid does, the market will do,” Rolf said. “Any time one entity pays for 68 percent of the services, and there’s no single other large entity that comes close — in fact, a lot of what’s left is individual households paying out of pocket — that’s a huge amount of market power wielded by the government.”

Expanding Medicaid reimbursement in the near future seems unlikely. Republicans in Congress have proposed going in the opposite direction. Their plans to repeal and replace Obamacare call for deep cuts to the program, including capping the amount that states can spend on Medicaid enrollees.

“If the bill limits Medicaid funding, and states are forced to cut their budgets, then home- and community-based services will suffer severely,” Espinoza said. “Older people and people with disabilities, who already struggle to find home care workers because of the growing workforce shortage, will be left with even fewer options.”

View how we generated some of the statistics for this story on Github.