The Age of Treatment | The Nation
A dozen yrs ago, I frequented the Chicago places of work of the National Nurses Organizing Committee on the city’s West Aspect. Noticeable through a massive window was a gigantic parking garage, an annex to a single of the similarly massive hospitals clustered within a dozen blocks. Cook County, Mount Sinai, and a few other healthcare complexes employed tens of 1000’s of employees. Amongst all those in search of to manage them was an African American NNOC staffer.
She informed me she was the daughter of an autoworker in Flint, Mich., who’d been a militant in his union for the duration of the heyday of the battles waged between the United Automobile Personnel and General Motors. In Flint, she grew to become a radical activist, motivated by the ability of the UAW and the ethical electrical power of the civil legal rights motion, and in time manufactured a career as a union organizer of nurses and other health and fitness care staff.
Listening to her story, I was moved by this example of intergenerational doing work-class militancy, from her father’s activism in a manufacturing sector now in brutal disarray to her personal store-flooring organizing in the booming globe of metropolitan wellbeing care. But what I did not have an understanding of was the degree to which these two varieties of work were dialectically related, not just in phrases of the consciousness of the workers but also as a merchandise of the extremely similar political financial state that experienced decimated Chicago’s metal mills and Michigan’s vehicle crops. The outdated industrial unions experienced bargained not just for increased wages but for pensions and health insurance plan. As these unions declined, the non-public welfare states they had completed so considerably to construct turned central to the economies of these Rust Belt towns. With revenue from the federal government, new healthcare facility complexes arose across the Midwest and Northeast, and with them, a new performing course filled the economic and social vacuum left by derelict mills and manufacturing facility towns.
Gabriel Winant charts the rise of this new political economy and doing work class in his fantastic new book, The Following Shift. A analyze of the decline of steel and the increase of a medical-industrial advanced in Pittsburgh, it describes how and why this fantastic social, financial, and moral transformation took place in locations like Western Pennsylvania, exactly where an previous planet of mid-20th-century steel mills, coal mines, and metal-bending shops was shortly changed by a new a single of treatment do the job, reduced wages, racial stratification, and greatly woman work. Presenting fantastic-grained specifics of store-ground industrial relations, the e-book is at after an ethnographic probe into the lives of operating-course households and a comprehensive evaluation of the larger dynamics of the US political financial system, and it gives an expansive new which means to the group review, which has lengthy been a staple of labor history.
At 64 stories, the US Steel Tower dominates downtown Pittsburgh. Concluded in 1971, the modernist skyscraper as soon as represented the power and hubris of the largest company in a single of the nation’s greatest and most profitable industries—a organization that employed far more than 100,000 staff in the metropolitan Pittsburgh location by yourself. But by 2007, US Metal had turn into, like numerous of its rivals, a shadow of its previous self, and a new enterprise, the University of Pittsburgh Professional medical Centre, was the building’s biggest tenant. As the employer of 92,000 wellness treatment staff in the region, the UPMC had invested almost $1 million to area its initials in large illuminated letters on the constructing. Looming about the city from all 3 sides of the tower, the letters symbolized much more than just the medical center’s developing dominance about Pittsburgh’s economy they were being also proof of a profound occupational transformation. The most current regional census recorded 190,000 overall health treatment and social aid staff, compared with just 30,000 continue to employed in the metallic fabrication industries.
Pittsburgh was not on your own in this transformation. Early in his reserve, Winant lists the other postindustrial metropolises wherever overall health care employment is disproportionately significant, constituting a fifth or sixth of the whole workforce. Virtually all of them are Northern towns like Boston, Cleveland, Philadelphia, Pittsburgh, and New York (the boroughs of Brooklyn and the Bronx in specific). And like Pittsburgh, these are towns where robust unions and collectively bargained wellbeing insurance policies designs at the time thrived, and the place the income negotiated by labor from corporate coffers seeded a treatment financial system that took on a daily life of its very own.
As Winant shows, medical center development was not just a question of money, bargaining clout, or political influence. The care overall economy in Pittsburgh and comparable towns expanded not only for the reason that of the achievements of structured labor but also due to the fact of what happened following union users retired: Industrial personnel in these cities relied on the hospitals, nursing homes, and wellbeing treatment providers as they aged and the huge mills shut down.
As deindustrialization took root in Pittsburgh, Winant argues, the communalism and solidarity that the doing the job class had when invested in parishes, neighborhoods, and union locals were being now to be located in health treatment and its allied social companies. This was an epochal transformation, but it was rarely triumphant. The development of this new financial system, and the proletariat that sustained it, was deeply racialized, very dependent on the devaluation of women’s labor, and protective of only a restricted stratum of the in general inhabitants.
To understand the impulses that gave increase to these city welfare states and the dysfunctions they embodied, Winant delivers a penetrating examination of mid-20th-century functioning-class Pittsburgh, equally on and off the job. Today, a good offer of nostalgia colors the photo of blue-collar The us from the conclusion of World War II to the early 1970s. Liberals and labor partisans phone this period the Wonderful Compression, 1 in which unions ended up potent, genuine wages doubled, inequality declined, and the civil legal rights movement remodeled the country conservatives hail the social norms and practices that put the male breadwinner at the head of the house, stored wives at property, certain the loyalty of workers to their employer, and preserved the stabilizing influence of the parish church in near-knit ethnic communities.
Winant’s narrative attracts from and transcends each of these perspectives. Perform in the steel mills did make a feeling of dignity, masculinity, and comradeship, but these were being blended with plenty of danger, insecurity, and petty humiliation to subvert Fortune magazine’s assert that unionism and postwar prosperity had designed the American worker a “middle-class member of a center-course culture.” If you didn’t deliver a dinner pail to get the job done, the rats would normally try to eat your lunch. There was no location to sit, and the heat and smoke could be debilitating. Practically just about every steelworker had a close to-death practical experience at some place.
The USW pushed the corporations to pay their workers adequate to manage a property and increase a household, Winant writes, but the postwar decades were being punctuated by recessions and strikes that slashed acquire-property pay out and created the sort of anxieties that deformed loved ones lifestyle for many years. The historian Daniel J. Clark will make the similar stage in his modern Disruption in Detroit: Even as the automakers set new generation information, layoffs, plant closures, and brief workweeks had been an endemic practical experience, and neither the union nor the Big 3 could do all that a lot about it. Performing-class precarity is not totally new.
Inadequate circumstances in the factories were exacerbated by the relentless management push to boost store-flooring productivity. Metal marketplace capitalists were being conservative in the most profound sense: They feared debt, overcapacity, international level of competition, and union or governing administration attempts to condition steelmaking’s upcoming. To preserve profitability and stay clear of the inflationary rate hikes that weakened the US dollar, supervisors tried out to squeeze their workers by slashing crew measurements, intensifying function, and turning foremen into compliant disciplinary agents. All this culminated in the major strike in US background, a 4-thirty day period perform stoppage in 1959 that Winant calls the “apex of proletarian manhood for a generation of steelworkers,” nevertheless it is now extended overlooked. At the time, the sociologist Daniel Bell termed it anything near to a sham, a “subversion of collective bargaining,” due to the fact he considered both equally management and union management cynically used the prolonged strike to channel and demobilize worker discontent.
As Winant argues, the 1959 strike was much far more than just a way for the rank and file to blow off steam around place of work frustrations. It was as uncooked a contest amongst labor and funds as everything Friedrich Engels or Eugene V. Debs witnessed in the mills of 19th-century Manchester, England, or the Chicago rail yards. The capitalists wanted the unilateral correct to extract much more labor electrical power from virtually 1 million employees devoid of an investment in new technological innovation. The combat inevitably built its way to the halls of Congress and the White Home, the place even Richard Nixon, then the vice president, noticed that operating-course militancy in the Steel Belt was legitimate and probably harmful. As a outcome, the steelworkers won: They stymied the management offensive and even acquired extra cash in just about every paycheck.
But as with so many other strike battles and political fights in the heyday of postwar unionism, the labor movement lacked the electrical power, the political allies, or the eyesight to rework momentary victory into a long lasting triumph. Numerous unions, which include the USW, had been turning into as stolid and complacent as the metal industry’s management. They imagined American capitalism was on an upward trajectory that demanded very little additional than a Keynesian economic tweak and a collective bargaining regime to see that employees bought their reasonable share of the gains. Nonetheless with the rise of overseas competition and the failure of possibly govt or administration to modernize the mills, the 1970s in its place inaugurated a disastrous 10 years for weighty manufacturing and its personnel.
Besides for Pentagon-backed packages, the United States had no Japanese- or German-design and style industrial plan that may well have preserved steel field work opportunities. Neither did the authorities endeavor to discover some other variety of trusted and humane employment for this shrinking industry’s workers. Winant might effectively have explored these choice prospects, which in the 1970s and ’80s had been vigorously advocated by this sort of disparate figures as Ira Magaziner and Robert Reich, who urged an industrial plan during the Clinton administration, and Edward Sadlowski, whose New Left–ish campaign for USW president in the mid-1970s challenged the unimaginative management of his union. But Winant does inform us what really took place: In the absence of concrete alternate options, Pittsburgh-region steelworkers confronted a social catastrophe out of which sprang a incredibly unique path toward revenue, safety, and household welfare.
I[/dropcapn Pittsburgh and elsewhere, reproduction was just as important as production. If social citizenship was forged in the factory, it was distributed to the population via the family, which constituted the “social machinery,” as Winant terms it, that linked the process of daily life to the rhythms of industry. The working of this machinery was imperfect and arduous: If the man came home from the late shift, a spouse or daughter had to have a midnight dinner on the table; during a long layoff, the women stretched the family budget, borrowed from relatives, or went out to work themselves. Women in the mill towns learned what different sirens and whistles meant. “We used to run to grab our clothes off the line when we saw big clouds of smoke coming from the mills!” declared one housewife, who described herself as ”an unpaid clean-up woman for industry.”
But regardless of how grueling and constant the women’s work was, this mythology of the early postwar decades—that men’s work deserved to be paid while women’s was an innate labor of love—remained largely intact. Yet as the city’s industrial economy began to weaken in the 1970s, workers started to look for an institutional mechanism that could sustain this often feminized work in an era of economic chaos, and they found it in the hospitals and social services that were the one segment of the US welfare state that continued to have funding.
Many of these hospitals, built or expanded upon in riverside steel towns, seemed to embody the communitarian values that had flourished in the ethnic neighborhoods that hugged the hills above the mills. Not unexpectedly, hospital visits were disproportionately high in southwestern Pennsylvania. By 1978, the region generated 1,366 inpatient days per 1,000 people, compared with a national average of 1,192. The population was aging, the pollution rife, and the work hazardous, but steelworkers and their families also saw health care as the keystone of a communal welfare state they had helped to build. Hospital visits were “very good experiences,” one working-class spouse recalled. “The nurses were always nice and the doctors were always there to take care of any problems.”
And the money was there as well. Once the Supreme Court ruled in 1949 that collective bargaining over health insurance was a legitimate union goal, the total annual Blue Cross payments to hospitals in Western Pennsylvania more than doubled in just five years. In Homestead, which had lost half its population since 1940, the local hospital was booming. When Medicare came into existence in 1965, it generated a raft of new clients over the age of 65, accounting for more than one-third of the inpatient days there.
The financialization of hospital construction and operation soon followed. With the interest rates on semipublic hospital bonds a couple of percentage points lower than on comparable debt, and with a cash flow guaranteed by the federal government, Pittsburgh’s hospitals became machines for turning Medicare and Blue Cross payments into debt service for private bondholders. Thus, in 1973, a hospital executive in Homestead defended a controversial expansion program by saying, “Investment bankers were willing to buy $27.5 million worth of bonds. That’s good enough for me.” Throughout the 1970s, as the steel mills crumbled, long-term hospital debt doubled.
One of the most remarkable features of this financialized system of health care became apparent in the era of austerity that started after 1979, when Federal Reserve Board chair Paul Volcker pushed interest rates to nearly 20 percent in his merciless attack on chronic inflation. Capital-intensive industries like steel were devastated, with the impact rippling through every segment of Western Pennsylvania’s society and government. That disaster was followed by the Republican assault on the welfare state during Ronald Reagan’s presidency, with sharp cutbacks to food assistance and Aid to Families With Dependent Children, a tightening of unemployment insurance requirements, and the underfunding of job retraining programs.
Yet even as the Reagan Revolution rolled on, the health care segment of the welfare state seemed exempt from austerity. This was partly because mass unemployment generated an avalanche of maladies, from alcoholism and depression to heart attacks, thus doubling the Pittsburgh region’s volume of care from 1982 to 1985.
The peculiar organizational structure of health care, which combined public subsidy and regulation with private profit-making administration, also encouraged the proliferation of hospitals and an increasingly larger sector of nursing homes, clinics, and home health care providers in Pittsburgh. In Allegheny County, Medicare spending did much to dull the Reaganite fiscal knife, with public assistance programs accounting for more than half the revenue of Pittsburgh-area hospitals. Meanwhile, investment in those institutions soared. In terms of growth, their only rivals were jails and prisons, which were also designed to deal with the social dysfunction generated by the aftershock of radical deindustrialization.
The working-class determination to preserve company-funded health insurance played a significant role in the maintenance of these expenditures. By the late 1980s, battles over employers’ efforts to slash their health insurance expenses precipitated 90 percent of all strikes. At Pittston Coal in West Virginia, the fight went on for months, with plant occupations and mass arrests reminiscent of the 1930s. In the Pittsburgh area, the effort of LTV—the conglomerate that had swallowed the Jones and Laughlin Steel Company—to terminate retiree health insurance coverage generated such an uproar that Congress got involved, forcing LTV’s management to backtrack. As the 2017 mobilizations on behalf of Obamacare demonstrated more recently, a defense of health insurance, public or private, can generate a militancy just as potent as that evoked by issues concerning pay.
B[/dropcaput the most consequential role played by working people came from inside the hospitals and nursing homes. These institutions depended on the labor of women, African American women in particular. Black men and their families had always had a far less secure purchase on the social citizenship negotiated by the USW and other unions, so it was Black women who filled the (usually nonunionized) bottom ranks in the health care industry. By the late 1960s, 70 percent of all hospital workers were Black, and 10 percent of all African Americans employed in the Pittsburgh region worked in hospitals—a proportion that would rise in subsequent decades.
Because of the high wages paid in the steel mills, white women had mostly stayed home in the 1950s and ’60s, but hard times now drove thousands of them into the hospitals as nurses, clerical workers, paraprofessionals, and other care workers. As a 1986 management proposal for recruiting home health care aides argued, “The displaced homemaker is tailor-made for [this job] and could be mentioned to have been in training for the situation for decades.”
Winant gives an extremely high-quality evaluation of the time pressures and staffing shortfalls that usually created life in the care financial state nerve-racking, not to point out poorly compensated. What started to consider position in the 1980s was the 1959 metal strike in reverse: Clinic get the job done was considerably more labor-intense than manufacturing facility output, so the communalism of the little-town hospitals under no circumstances stood a likelihood. Support operate, from the retail retail store to the hospital ward, is notoriously tough to Taylorize at the point where by a nurse lays fingers on a affected person or a cashier rings up a sale. So administrators turned disciplinarians of the clock and shift, rationing do the job time although insisting that each individual employee fulfill the requirements of an more and more substantial range of clientele, clients, or clients.
Management’s willpower to squeeze clinic personnel was exacerbated by a authorities revision to Medicare in 1983 that was built to slow health treatment inflation by paying out hospitals a fixed value for any specified prognosis, rather than for just about every health-related process. This created medical center stays shorter and surgical interventions extra frequent, and it put more strain on medical center labor, now 60 percent of all fees. Health care intervention and treatment provision therefore became significantly distinctive endeavors—one cash-intense, the other labor-intense. Consequently the consolidation of Pittsburgh-area hospitals into what would grow to be the UPMC empire and the proliferation of nursing services and residence treatment arrangements throughout the region. Congress had enacted the new mandate with minimal discussion, but its effects ended up huge.
Winant phone calls this Reagan-era innovation the health and fitness treatment equivalent of the Volcker shock: Squeezing consumer demand, it punished overcapacity in the aged industrial facilities. By the early 21st century, UPMC experienced grow to be one particular of the quite a few wellness treatment behemoths that participate in an outsize function in the political economic climate of metropolitan America, as influential in their personal way as the steel and railroad barons of one more era.
T[/dropcaphe Next Shift offers us a useful guide to the sweeping social changes that have shaped a huge segment of the economy and created the dystopian world of contemporary service-sector work. But is its narrative overdetermined? Did the collapse of the steel industry and the USW necessarily lead to such an overpriced and underpaid health care system? Were there points at which the history of the care economy might have turned a different corner?
Two instances come to mind. The first arose in the early 1970s, when it seemed as if hospital workers might follow the same union path as the school teachers, postal clerks, sanitation workers, and municipal employees who also saw racial justice and worker rights as insoluble. Health care workers proved to be drawn to unionism by the same civil rights ethos. Hospital Workers Local 1199, which sought to organize health care workers on the East Coast, lived by the motto “Soul power, union power.”
But hospital executives in Pittsburgh and elsewhere countered this appeal in a variety of ways. Claiming that Local 1199 was more of a disruptive civil rights organization than a union, they appealed to the sanctified philanthropic ideal inherent in health care service: It was one thing not to pick up the garbage, another to neglect sick patients. Those management strategies would fade as health care became increasingly bureaucratized, but by then hospital executives across the nation had found a new strategy: hiring a phalanx of highly sophisticated union-avoidance law firms to snuff out organizing. Union density among health care and social service workers has long been stuck at 7 percent nationwide, which means that whenever the reform of health care does happen, the voices of hospital and nursing home workers will remain largely absent.
A second turning point came in the 1990s, when Bill and Hillary Clinton advanced their plan to reduce the costs and expand the coverage of US health insurance. Their plan was more radical than the one eventually enacted by the Obama administration. It would have forced low-wage service-sector businesses to cover their own employees and thereby pay a much larger share of the nation’s total health care expenses. That would have incentivized the Walmarts, the McDonald’s, and the hospitals to offer more full-time employment. And despite the Clintons’ denials at the time, their plan approached a de facto single-payer system at the state and metropolitan levels. Under this plan, a series of quasi-governmental health insurance purchasing alliances would have virtually monopolized payments to hospitals, nursing homes, and doctors for all employers except the largest.
The steel industry, along with other unionized manufacturing firms, were solidly in the Clinton plan’s camp: They would have saved a huge sum of money if the federal government had cracked down on hospital costs and helped pay for the insurance of their retirees while making the low-benefit freeloaders in the service sector pay their fair share. But as with unionization efforts, this reform was stillborn. The Clintons’ legislative effort was tardy and maladroit; more important, the GOP was intransigent, and the big insurance companies bailed on the plan when they saw themselves being turned into government-regulated utilities.
Had the steel industry and other manufacturers retained their mid-20th-century power, had their unions been as large and as potent, they might well have countered the political hostility of the big hospitals, insurance companies, and retail-sector employers to push some version of the Clinton plan over the finish line. But Big Steel, as well as its unions, no longer occupied the commanding heights of the American economy. When it came to social policy, the terrain of conflict had shifted to the economic world of sales, care, and services. But while the steel industry may have been doomed to wither, there is nothing inherent in service work that consigns the millions laboring in such occupations to precarity and poverty.
The low pay and insecurity of service workers became abundantly clear last year when they won the honorific “essential workers.” Frontline hospital workers—not to mention grocery clerks, nursing home employees, and warehouse workers—briefly achieved the visibility and applause long denied them. Winant wrote The Next Shift before the Covid-19 pandemic added another layer of social trauma to our already misshapen economy. But his book makes clear that only a radical reconfiguration of the way that health care and other services are delivered to the American people can enhance the dignity and well-being of workers in the caregiving economy. American hospitals and their satellite enterprises must be stripped of their profit-making, empire-building propensities. And for that to happen, we will need to embrace the inherent socialization that must govern health care in our time.
