What industry is both public and private, regulated at both state and federal levels, and is highly unionized but has one of the lowest average wages?

The answer? Home health care.

Because of the industry’s apparent contradictions, home health care workers are often left tangled in a bureaucratic nightmare that leaves them with low wages and limited options.

Home health care workers are generally paid between $8.92 and $11.78 an hour for an average annual income of $18,598. Roughly 50 percent of these workers live in households that receive public assistance, and 89 percent are women, 30 percent are African American, and 16 percent are Latino. They have unpredictable schedules, dangerous work environments, and sometimes erratic employers.

Despite the fact that this is one of the fastest growing industries in the United States, workers have seen a six percent decline in their wages over the last decade, and they remain uncovered by the Fair Labor Standards Act (although the Department of Labor has tried, and failed, to fix that loophole). The result is that home health care workers are not owed overtime or even minimum wage.

How does this happen in an industry where about 600,000—a full 30 percent—of its 2 million workers were union members last year, compared to just 11.1 percent across all industries in the United States?

Unionizing home health care workers is a complicated business. Many states recognize a difference between workers who are employed through a private agency and workers procured by the client directly, with the latter sharing similarities with independent contractors. The breakdown of how many workers are private and how many work without an agency varies from state to state. In California, for example, home health care clients overwhelmingly rely on independent contractors, but clients in New York rely much more on private agencies.

Workers hired by private agencies are allowed to collectively bargain and unionize, but this can be nearly impossible to do in practice in many places. Like a McDonald’s, these businesses are often franchised and employ union-busting strategies that effectively prevent organizing.

Then there are the independently employed home health workers, whose situations vary much more on a state-by-state basis.

In some states, independent home health care workers have been classified as public employees. This is because independent workers are most often hired by those who cannot afford pricier care in nursing homes or from premium private agencies, with clients often relying on Medicaid or other public benefits programs to help pay the bills. Because Medicaid and other benefits are determined by the government, employees hired under these programs similarly have their wages determined by the state. (Private agencies may be paid through government benefits as well, but in these cases, employee wages are determined by the agency agency itself rather than the government.) As for independently hired workers who are not paid through a government program, these individuals don’t qualify under the public employee status and therefore cannot unionize.

Other states, though, instead classify independent workers as independent contractors, saying they are employees not of the government, but of their clients, to whom they provide their services and who have the power to hire and fire them. As such, these workers are unable to collectively bargain for wages. So, even if they joined a union, the union could only assist in dealing with workplace issues like wage theft or on-the-job injuries.

Unsurprisingly, the difference between which states have allowed workers to unionize like public employees and those that have labelled home care workers as independent contractors has a lot to do with which political party is in power.

Blue states like California, Oregon, Vermont, Missouri, and Washington have all given independent home care workers who receive their pay through government programs the right to collectively bargain with the state as public employees. Massachusetts, for example, recently announced that its independent home health care workers would get a $15 per hour wage, while Minnesota raised its pay floor to $11 per hour and gave full-time workers five days per year of paid time off. Over half of all unionized home health care workers come from these seven states, and in them, unions have played a big role in raising workers’ pay and benefits—though privatized workers in these states still continue to suffer.

On the other hand, Michigan Governor Rick Snyder has worked in the opposite direction: in 2012 the Michigan legislature, under his guidance, passed a bill explicitly excluding home health workers from public employee status, effectively collapsing the existing union. Similarly, this past May, Governor Kasich of Ohio issued an executive order that removed the ability of independent home health workers to unionize. These laws are part of a worrisome trend that undermines home health care workers’ rights.

Even when public unions exist and do manage to negotiate for improved wages or benefits, that isn’t always enough to bring about change. New contracts for public employees have to be ratified by both the legislature and the governor, which some conservatives have used to undermine the usefulness of unions. In 2001, for example, the governor of Washington vetoed an improved contract for home care workers after it had already passed the legislature. Actions like this take the fate of workers beyond the control of even effective unions.

Courts, too, have chipped away at workers’ opportunities.

In 2014, the Supreme Court ruled that independent home care workers in Illinois were not really public employees and therefore could not be forced to pay fair share dues. The result was the creation of a “right-to-work” environment that leaves workers covered by any collective bargaining agreements made by their union even if they have not financially supported it—ultimately encouraging a free-rider problem that undermines union funding.

Although the effects of the Supreme Court ruling were limited to Illinois, many home health care unions in other states have preemptively stopped collecting fair share dues, meaning home health care unions across the country now have more limited resources to support their efforts to fight for the rights of members.

Home health care workers have relatively low wages and benefits throughout the country, but those with unions seem to have a notably better deal. Some states have taken steps to improve the situations of at least some of their home health care workers by allowing independently operating workers to collectively bargain with the state. If the rest of the industry can also become unionized, perhaps the abysmal conditions of home health care workers will begin to improve. But for now, the dire reality of workers’ treatment is an ever-pressing reminder that we are not taking care of those who take care of us.