One-fifth of nursing assistants who work in nursing homes do so without health insurance, according to a report from the Paraprofessional Healthcare Institute.

A little more than half have employer-sponsored insurance, while one in five rely on public coverage, most often Medicaid. 

That’s despite advancements under the Affordable Care Act, which brought about an 11% coverage increase between 2010 and 2014. Employers provided 5% more policies and Medicare enrollment among the group jumped 18% during those years.

But low pay and on-the-job-demands continue to make hiring difficult, PHI says.

“Rapid growth in the population of older Americans will put even more stress on nursing homes, making it imperative to develop strategies to strengthen and stabilize the workforce,” the institute noted. 

The 2016 Key Facts on nursing assistants reports that they get paid a median hourly rate of $11.87, earn about $19,000 annually and face frequent part-time work.

There are some 612,000 nursing assistants employed by nursing homes. PHI projects that an additional 59,000 positions will be created by 2024.