As we age, become frail, and need personal assistance, we will increasingly require paid aides to help us with routine daily activities, such as bathing, dressing, or cooking. Demand for those aides will increase by 50 percent over just the next decade, to 3 million. But where will they come from?

Aides are poorly paid, have little opportunity for advancement, and often get no benefits. Their on-the-job injury rates are among the highest in the US—higher, for instance, than coal miners.

At least one-quarter are from other countries, a source of workers that may dry up under the Trump Administration’s immigration policies. And as labor markets tighten, many aides will find easier—and better paying—work in other fields.

The painful paradox

Yet, despite the low pay and paltry benefits that plague aides, many families cannot afford to hire them. To save money, they hire on the “gray market,” where they pay cash for care assistants who are unlicensed and unbonded, may be unskilled (not necessarily the same thing), or may face legal issues. Or family caregivers make do on their own, with no paid assistance.

It is a painful paradox. Aides are not paid enough. Yet they are too costly for many families.

And as demand for personal care services rises, it is going to get worse. Today, more than 12 million people need long-term supports and services in the US. That number will double in just a few decades.

Increasingly, less care will be delivered by family members, in part because the Baby Boomers had so few children and in part because society is so mobile. A significant number of adult children live in cities other than their parents, and daughters work or care for their own children.

Low pay, few benefits

That leaves paid aides.

But who will do the work? In 2016, according the Bureau of Labor Statistics, home health aides were paid an average of $10.87 an hour–a wage that has barely changed in a decade after accounting for inflation. Personal care assistants (who have less training) were paid about $10.50. If you hire an aide through an agency, you’ll pay about $22-an-hour. The firm will get half (out of which it must pay its share of Social Security taxes, benefits, and other overhead) and the aide will get half.

While consumers pay some of these costs out-of-pocket, two-thirds of home care revenue comes from either Medicare or Medicaid. As a result, the normal laws of  economics–where a limited supply and growing demand should result in higher compensation–does not apply.

For context, $10.50-an-hour is about what we pay short-order cooks and just two-thirds of what we pay vet techs. In other words, we pay people $5-an-hour more to care for our cats than to care for our mothers.

40 percent on Medicaid

But it is worse than that. According to the advocacy group the Paraprofessional Health Institute (PHI), because home care workers often work part-time or for just part of a year, they earn a median annual income of less than $14,000. One-quarter of their households are below the US poverty level. One in five has no insurance and four of every 10 are on Medicaid.

Keep in mind that the official government statistics reflect only those aides who are employed by home health agencies. PHI also counts 800,000 aides who are hired directly by consumers and paid by Medicaid. But there are many more who work off-the-books, about whom we know very little.

Growing demand for care at home, rather than in facilities, will make this labor shortage even worse.

Hardest jobs to fill

When it comes to efficient delivery of care, it is far better to have people who need assistance living in the same building (think nursing home or assisted living facility) than scattered across a community. It is far easier for an aide to walk across a hallway than to travel 10 miles from one client to another. This is especially true since many aides do not have cars and must rely on public transportation to get to their clients.

Some suggest that technology will replace aides. It is hard to imagine. True, tech may help with monitoring patients, but delivering services, such as bathing, will require a human touch, at least for the foreseeable future.

PHI estimates we will need one million more aides by 2026. According to the job search firm Careercast, home health aides and personal care aides already are two of the top 10 hardest jobs to fill. Nobody should be surprised. Until we figure out how to pay aides a decent wage for the difficult and essential work they do, that problem will persist.