Home care is the fastest-growing job in America. It still can't hold anyone.

The country has decided, by policy and by preference, that older adults and people with disabilities should be cared for at home rather than in an institution.▸ That decision costs money and it costs labor, and the two sides don't add up. The money is growing. The workforce is growing too — faster than almost any other job in America. And still, more than half a million people are stuck on a list waiting for care that isn't there.

Medicaid home and community-based services (HCBS) — personal care, home health aide visits, and related supports that let people stay out of a nursing home — cost $312.9 billion in 2023.▸ Medicaid itself pays 68 cents of every one of those dollars; the rest comes from out-of-pocket payments and other public and private payers.

That $312.9 billion mostly becomes paychecks for a workforce of personal care aides and home health aides.▸ Those paychecks are thin. The median hourly wage for a home care worker was $16.77 in 2024, up from $13.07 in 2014 in inflation-adjusted terms — a $3.70 raise over ten years, per PHI's analysis of BLS wage data. That works out to a median annual income of just $22,429. Fifteen percent of home care workers live below the federal poverty line, 41 percent live below twice that line, and 59 percent rely on some form of public assistance — Medicaid, food and nutrition assistance, or cash aid — to get by, according to the same PHI analysis of 2023 American Community Survey data.

Demand for home care is rising with the population it serves, and the workforce has more than doubled to meet it — from 1,353,340 workers in 2014 to 3,160,500 in 2024.▸ Projecting forward, the U.S. Bureau of Labor Statistics expects the home care workforce to add 681,400 new jobs from 2024 to 2034 — more growth than any other single occupation tracked by BLS, ahead of software developers (+267,700), per PHI's analysis of BLS Employment Projections data.

Growth is only half the story — churn is the other half.▸ Counting new jobs, replacements, and people who simply leave the labor force, BLS projects 6.1 million total home care job openings between 2024 and 2034, the second-most of any U.S. occupation, trailing only fast food and counter workers. Why so many openings for a workforce that's already growing? Because it doesn't hold onto people: of direct care workers (personal care aides, home health aides, and nursing assistants) who held such a job one year, only 81% remain in a direct care occupation the next, while 8% leave the labor force entirely and 3% become unemployed, according to PHI's analysis of 2020–2023 Current Population Survey data. States know it: a KFF survey of state Medicaid agencies found nearly every state reported a 2024 shortage of direct support professionals and personal care attendants (48 states each), and nursing staff and home health aides (47 states each) — and 48 states responded by raising Medicaid payment rates anyway.

The wages didn't catch up, and the shortage shows up on the other end of the system: people who qualify for HCBS but can't get it.▸ Nationally, 607,000 people were on Medicaid HCBS waiting or interest lists in 2025 — up 14% from 2024 — according to KFF's annual tally. Three-quarters of them are people with intellectual or developmental disabilities.

The list undercounts the problem rather than overstating it: six states — Florida, Iowa, Oklahoma, Oregon, South Carolina, and Texas — don't screen applicants for eligibility before wait-listing them, and together account for over 325,000 of the national total, while other states manage shortages through provider capacity limits that never show up on a list at all.

Dollar figures for HCBS spending cover calendar year 2023, the latest year in CMS's National Health Expenditure Accounts; payer-split dollar amounts are the reported percentage breakdown applied to the $312.9B total. Waiting-list figures by population are likewise the reported percentage breakdown applied to the 607,000 national total and are rounded to the nearest thousand — both source breakdowns sum to slightly more than their stated totals due to independent rounding.