Helping elderly and disabled Americans retain their independence and avoid nursing home care is getting more challenging, thanks to the low-pay and unpredictable working conditions of the home care work force.

Home care workers (also called direct care workers and personal care assistants) are increasingly in demand to help people remain in their homes and out of costly nursing facilities. They perform personal care services, such as help with bathing, dressing, laundry, cleaning and visiting the doctor. Medicaid covers home care for those who would otherwise need to be in a nursing home.

A new study from PHI, a New York-based research and consulting firm, says the home care workforce more than doubled during the past decade, from 840,000 to more than two million last year.

The study says the government expects the number of people 65 and older to nearly double from about 48 million today to 88 million by 2050.

With low wages, unpredictable hours, high turnover and no benefits, the people who perform the backbreaking work it takes to help countless families function are challenged to provide for their own.

The PHI study says one in five home care workers lives below the federal poverty line and half rely on public assistance, compared to about seven percent in the general workforce. What’s more, their wages have remained stagnant during the last decade, increasing less than fifty cents per hour, from $10.66 in 2007 to $11.03 in 2017. With an unsteady work schedule, that amounts on average to $15,100 a year.

Almost all home care workers are women. A quarter were born outside the U.S., about half are people of color and a third say they do not speak English well. Half have no education beyond high school. With little to no training or legal requirements, home care offers opportunities to those who “would otherwise encounter language, educational, or discriminatory barriers,” the study says.

But fewer women are entering the labor force than in previous generations, says the study.

Home care is big business. About two-thirds of home care workers are employed by for-profit agencies, which are paid by Medicaid and pass on a share of the hourly rate to the worker. PHI estimates another 325,000 home care workers are independent providers, paid directly by the consumers who employ them.

Medicare and Medicaid pay for about 65 percent of the home care industry’s annual revenue of $77.6 billion in 2016, the study says. Reimbursements vary by state. In Nevada, Medicaid pays $17 an hour for home care.

By contrast, in Wisconsin, Medicaid pays $42 an hour, the highest rate in the nation, while it pays $9.78 in Nebraska, the lowest reimbursement in the U.S.

While health care is trending toward home care, some 1.5 million Americans require the 24-hour care of a nursing home.

A third of the nursing care provided to nursing home patients comes from nursing assistants, who earn slightly more than home care workers — $12.84 an hour or about $21,200 a year. About fifteen percent live below the poverty line.

Because of the nature of their work, nursing assistants are injured 3.4 times more often than the average worker, says the study.

The Bureau of Labor Statistics has projected nearly 800,000 personal care job openings between 2016 and 2026, more than in any other single occupation.