Consider the job description of a personal care aide or home health aide: ability to withstand emotionally draining and physically demanding tasks, and inconsistent or part-time hours. And the pay: average hourly wages of less than $10 and median annual earnings of $17,000. These are the nation’s fastest-growing jobs—the U.S. Bureau of Labor Statistics projects a 70% growth rate between 2010 and 2020—yet it’s no wonder that supply is expected to fall far short of demand, fueled by aging baby boomers who want to avoid living in nursing facilities.

“Our labor policy hasn’t kept up with our health care policy, which is to take care of people in the community,” says Steve Edelstein, national policy director for the Paraprofessional Healthcare Institute (PHI), which represents personal care aides, who assist people with tasks of daily living; home health aides, who can also perform simple medical tasks; and nursing aides, who typically work in nursing homes.

Unlike those in other occupations in which growing demand leads to higher pay, home health workers still struggle to earn a living wage. Reimbursement from Medicaid for home health services is low, as is pay from clients—often on fixed incomes—who foot the bill themselves. “Medicaid in many states pays between $10.50 and $16 an hour for home services,” says Bill Dombi, vice president for law at the National Association for Home Care & Hospice. “At that fixed rate, a home health agency can’t cover a $10-an-hour wage without taking a loss.” One approach to elevating wages is to increase training requirements for workers. Currently, home health aides and nursing aides must meet a minimum federal standard of 75 hours of training—which isn’t enough to prepare them for the demands of the job, according to PHI and the Institute of Medicine, which recommends 120 hours. “In many states, the person who takes care of your dog has more training than the person who takes care of your grandma,” says Thomas Konrad, senior scientist at the Institute on Aging at the University of North Carolina, who is participating in a demonstration program funded by the federal Affordable Care Act (ACA) to recruit and train more personal care aides. By turning unskilled workers into credentialed employees, the hope is that payers and employers will be willing to pay more for their services.

A major provision of the ACA—expanding Medicaid eligibility—might indirectly help agencies recruit or retain direct-care workers. If more of these caregivers qualify for Medicaid, that may increase their willingness to stay employed with agencies that don’t offer health insurance. Yet at the same time, the ACA’s mandate that employers provide health insurance to full-time employees or pay a penalty could cause many home health agencies to cut their employees’ hours to part time.

Solutions to the shortage of home health workers can’t wait much longer. “The baby boomers will force us to deal with questions of long-term care that we have been avoiding for years,” says Clare Stacey, associate professor of sociology at Kent State University and author of The Caring Self: The Work Experiences of Home Care Aides. “Suddenly we’ll have an entire generation that can’t afford high-quality home care, doesn’t qualify for Medicaid and doesn’t want to go to a nursing home. There is a crisis coming.”