Tony Dejak/AP

Home-care workers are increasingly vital to the future of our healthcare system, but they face obstacles rooted in racism and sexism.

The people who will save American health care likely don’t wear lab coats or perform complicated procedures in operating rooms. They probably don’t have doctorates or years and years of graduate experience. These saviors on average make a tenth or less of what physicians earn each year in salary, and they often perform some of the most thankless tasks of the allied health fields. But as the American population gets older and the health-care system caters more and more to the needs of elderly and disabled people, this growing army of millions of home-care workers will be one of the most valuable elements in keeping the whole system afloat.

Home-care workers are not, however, afforded wages or protections commensurate with their importance, with over a quarter living under the poverty line and more than half reliant on public assistance. That economic vulnerability is especially notable because of just who tends to work in home care: Women of color are the largest demographic group within the home-care workforce. Their vulnerability reflects a long history of exploitation of women of color working in-home jobs, and highlights a growing inequality in the health-care workforce, even as health coverage expands to more and more Americans.

A report from the Paraprofessional Healthcare Institute describes home-care workers as personal aides, independent providers, home health aides, nursing assistants, and even informal networks of family members that provide living assistance, housekeeping chores, medication management, and a host of other services for elderly people and people with disabilities. About 1.4 million of these workers fulfill the kind of formal roles tracked by the Bureau of Labor Statistics—working for firms or insurance companies—while almost a million more are ad hoc “independent providers” who are employed directly by patients or their families. Almost three-quarters of the payment for services provided by home-care workers comes from public-insurance programs Medicaid and Medicare.

The millions of home-care workers operate in one of the fastest-growing fields in the country—one that will add more jobs over the next decade than any other occupation. The American population is aging and the number of elderly people will double over the next 40 years, a spate of growth that will require even more people to enter the home-care workforce.

While the field is rapidly expanding and funded by insurance programs that have been reformed by Obamacare, in many ways it resembles the domestic work that for so long dominated employment options for women of color in the United States. Almost a quarter are immigrants, most did not receive a college degree, over a third are covered by public health insurance themselves, and a quarter have no insurance at all. That point deserves emphasis: A quarter of these people who toil to make the health-insurance system function do not have health insurance themselves. According to a 2008 study, workers across domestic services and home care are subject to exploitation and instability. For many, that exploitation includes assault and abuse, and women of color and recent immigrants often find reporting abuse or seeking legal protection too risky to attempt.

The big problem for home-care workers appears to be the same one that has plagued domestic workers since the days of black in-house “help”: that in-home service work has been subject to a gendering and racialization of labor that has largely carved it out of the labor movement, creating barriers to the kind of protections afforded to unions and industries mostly comprised of men. While organizations led by women of color have a strong history of organizing to advance the interests of in-home workers, domestic workers are still exempt from many provisions of the Fair Labor Standards Act and the National Labor Relations Act. Home-care workers—as members of a more regulated industry where strikes and labor shortages directly endanger lives—are afforded more protections than domestic workers, but still lag far behind others in the health field. While home-care workers are much more likely to have health insurance than domestic workers, their wages often still fall well short of living wages. Home-care workers were only just granted full federal overtime and minimum wage protections in October 2015.

These limited breakthroughs for home-care workers occur even as Obamacare pours billions of dollars into the health-care industry and as salaries for physicians and some other licensed health professionals continue to climb. Assuming the grand project of health reform succeeds in aligning the difficult concepts of affordability and accessibility for most or all Americans, the most expensive and difficult parts of the health system remain care for elderly people and disabled people. That those portions of the system—funded mostly by public insurance—hinge upon the labor of a historically vulnerable workforce is concerning for a reform philosophy based in equity.

The occupation within health care that is growing the quickest still suffers from a legacy of racism and sexism that has pervaded in-home work and the lives of generations of women of color. While home-care work is distinct from domestic labor and requires different training and skills, the marginalization of a population of black, Latino, and immigrant mothers and grandmothers working in private homes indicates a shared history of neglect based on race and gender. As the health economy expands, as service jobs continue to rise, and as the population gets older, the status quo of labor inside many homes in the current century will look surprisingly similar to that of the last.

This story originally appeared on The Atlantic as part of the Next America: Workforce project, a partnership with Pearson.

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