As America gets older, the need for caregivers is rising. Much of this care is being provided by relatives or friends, most of whom are doing it for no pay. The cost goes beyond financial, however. A survey found nearly a quarter of the caregivers interviewed reported they, too, were in only fair or poor health.

These caregivers are an underappreciated part of the health care system. Baby Boomers are living longer and largely choosing to stay at home. If not for caregivers, they would be in hospitals and long-term care facilities, straining an already stressed system.

But what about the caregivers?

The Centers for Disease Control and Prevention survey found more than 1 in 5 of the 250,000 people interviewed are unpaid caregivers, and another 17% expect to be caring for someone in the next two years. More than 60% of the caregivers are women, and nearly half are under age 45.

The CDC said being a caregiver impacts a person’s ability to work at a paying job and, if they are employed, it limits their pay level and chances at advancement.

Many of the caregivers said it’s their responsibility as a family member, or that it gave them emotional satisfaction, a sense of purpose or new skill sets. Many, though, acknowledged it is demanding and is taking a toll on their own health.

And fewer family caregivers may be available in the coming years because of smaller family sizes, more women in the workforce and the greater dispersal of families who used to live closer to each other.

The CDC said caregiving is a public health issue of increasing importance, and urged government leaders to find more ways to support those who lovingly give of themselves to support loved ones.