CLEVELAND, Ohio - For the past three years, Taura Tate's mornings have revolved around caring for a woman who suffers from the effects of a stroke and diabetes. She cooks her oatmeal for breakfast, helps with showers and makes sure she takes the right medicine.
Without the help of a home health aide, the woman, who's in her 70s, would be in a nursing home instead of living on her own.
But Tate has her own struggles. Up until a recent promotion, her pay amounted to what she could make at McDonald's. She doesn't get health or retirement benefits and has worked at five agencies in the Cleveland area, some simultaneously, to guarantee she'll have enough clients.
"If they go into the hospital or go on vacation, you don't get paid," she said.
Demand for home health care workers is soaring as baby boomers -- the 78 million Americans born between 1946 and 1964 -- get older and states try to save money by moving people out of more costly nursing homes. But filling more than 1 million new home care positions over the next decade will be a challenge.
Most home health aides are paid about the same as maids and manicurists and don't get sick days or health insurance themselves. Many who are self-employed must pay for their own gas for driving to appointments and cover their own medical bills if they're hurt on the job.
The U.S. Labor Department projects that home health and personal care aides will be among the fastest-growing jobs over the next decade, adding 1.3 million positions and increasing at a rate higher than any other occupation. If those jobs can't be filled, many older Americans are likely to face living with relatives or in nursing homes, which will only cost families and taxpayers more money.
Some aides say they have no choice but to say no when people call looking for help because they can't afford to take on someone else.
"It's hard because I love helping people, but at the same time I've got three kids," said Kimberly Ingram, a home health aide in Lancaster, S.C. "When you add up your miles, your gas money, you don't make nothing."
Her part-time job delivering newspapers pays better when you factor in the time and travel some home care jobs need, she said.
Nearly half of all home care workers live at or below the poverty level, and many receive government benefits such as food stamps, unions and advocacy groups say. The median pay a year ago was $9.70 per hour -- 4 cents less than fast-food workers and short-order cooks, according to the most recent statistics from the Labor Department.
Agencies that supply home health workers blame states and the federal government for failing to increase reimbursement rates for Medicaid and Medicare patients at a time when costs are going up.
Home health services are an easy target for cuts because they're not required by federal law, and legislators in states with big deficits say they have no choice but to cut Medicaid spending, the second-costliest item for states behind education.
Home care agencies say trying to fill jobs will become even more difficult in a few years if the economy improves and job options increase.
"The real staffing challenge is 10 years away," said David Tramontana, president of Home Care by Black Stone in Cincinnati. "If we can't pay them more than they get at McDonald's, we're in big trouble."
The qualifications and training for home care aides varies. A high school diploma isn't usually a requirement, and some states call for only on-the-job training, while others insist on more formal instruction about basic nutrition and personal hygiene at community colleges or elder care programs.
Home care agencies that are reimbursed by Medicare or Medicaid must hire aides who have passed a competency test or received state certification.
Despite the relatively low pay, many aides say they like the flexible hours and find the work rewarding.
Tate, a home care aide since 1999, doubts she could get by if it weren't for her husband, a truck driver who also has health insurance. She could make more money at a nursing home or hospital but relishes the connections she makes in home care.
"I get attached to the people," said Tate, who made $8.50 an hour until she received a promotion and a $2 raise earlier this summer. "How could you not if you're with them every day? Sometimes you're the only person they see."
Retired hospital nurse and home health aide Judith Mezey-Kirby, born a few years ahead of the baby boom, said she worries about who will take care of boomers in the coming years.
Home health care workers need not only better pay, she said, but also better training on how to take care of basic needs. She had good and bad experiences with aides who help her with the laundry and chores that require heavy lifting around her home in Fairview Park, a Cleveland suburb.
"It needs attention bad," said Mezey-Kirby, 73. "You just can't take people off the streets."
Wittens' company considered adding a 401(k) plan for its workers but decided it was too costly. Home aides she hires start at $8.50 per hour and can earn up to $10. Most work 30 to 40 hours a week, and all but a few have other part-time jobs, Witten said.
Jareese Mitchell, a personal care attendant in Manchester, Conn., spends 30 hours a week with two quadriplegics, helping them eat, dress and bathe. He also goes to school and works three nights a week at a clothing store.
"Everybody has a job outside; you pretty much have to," said Mitchell, who until recently was receiving food stamps. He said he might look for different work if the pay doesn't increase.
That's not unusual. The turnover rate among home health aides is estimated to be anywhere from 30 percent to 50 percent, sometimes higher.
The revolving door is especially tough on those who depend on home aides for help throughout the day.
"My mom gets nervous when she has brand-new people. There's always a trust issue," said Beth Cramer, who lives with her 74-year-old mother in the Cleveland suburb of Willowick. An aide comes to the house to help her mother with dressing and cooking while Cramer is at work.
"They're doing the most intimate of intimate things," she said. "Imagine a stranger walking into your house and giving you a bath."
Gail Williams, a personal assistant in Tampa, Fla., said many people have no one else.
"You just can't quit the job because these people need you," she said.
Chris Hradisky, who relies on a personal assistant to help him with meals and clean his apartment in Waukegan, Ill., said he wouldn't be on his own without help.
His aides, he said, are like family. "You build a bond with them."