Jandos Rothstein
The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America
By Gabriel Winant
Harvard University Press
In 1983, Arlen Specter, then a freshman senator, homed in on the curious sadism of American economic policy in a hearing on IMF debt bailouts. Why, he asked Treasury Secretary Don Regan, were taxes being used to finance a bailout of private banks that had made predatory loans to state-subsidized steel mills in Brazil, which had in turn flooded the American market with below-cost steel, while American steel mills were closing down en masse?
“This is the reason,” Regan replied. “If you cut out the entire subsidy at this moment, you will throw an additional 300,000 or more Brazilian workers out of a job.”
“Mr. Secretary,” Specter countered incredulously, “we have 300,000 here out of work.”
Specter’s outburst was novel. By the Carter presidency, no one on either side of the aisle cared much about American workers, which is why deindustrialization looks in hindsight like what it was: an economic hate crime perpetrated upon organized labor by the insidious wealth transfer cartel that seems to run everything. As the late historian Judith Stein explored in her nauseating 1998 book Running Steel, Running America, in the 1970s and ’80s, countries like Japan and Korea and Germany and France subsidized their steel mills, kept strict import quotas, and dumped dirt-cheap exports on the U.S. market, seeking to protect the livelihoods of their workers. Hundreds of American steel mills shut down, purging 350,000 steelworkers from the payrolls and comprehensively obliterating dozens of small towns that revolved around its manufacture. Few proved as willing as Mr. Specter to question the single-bullet theory of the misery around which the ruling class had galvanized, whereby American workers were simply too well paid to compete.
The cruelty is more comprehensible in the context of 40 years of neoliberal policy for which periodic ritual humiliations of working-class Americans have become a fixture. Back then, though, a sense of incredulity suffused affairs. Even U.S. Steel CEO David Roderick sounded almost like a downsized mill worker, pleading before the Senate Finance Committee in 1981, “This is not a recession. We are back into the 1930s.”
Roderick spent the era in the role of the shareholder value–maximizing CEO, playing hardball with the United Steelworkers Union of America and buying a massive oil company to offset the brutality of the down cycle. But neither he nor his contemporaries could overcome the resistance of the political establishment to doing anything that gave off a whiff of “protectionism”—even as literally every other country had adopted a comprehensive industrial policy embracing high tariffs, strict import quotas, and subsidized plant modernization. In Pittsburgh, laid-off steelworkers gathered to throw pennies and rotting fish outside affluent churches, Mellon Bank branches, and even Roderick’s house. “I don’t blame them,” he told his son at the time.
Pittsburgh rebranded. Presbyterian University Hospital wooed a high-profile surgeon named Thomas Starzl to town, and by 1985 The New York Times had christened the old steel town the Transplant Capital of America. Half the nation’s organ transplants happened in the Steel City during the 1980s, which would soon nickname its new economic engine “Eds and Meds.” (“When you say medicine, I think transplant; When you say transplant, I think Pittsburgh,” the president of a transplant industry trade group told the newspaper.)
There was just one big problem with this metamorphosis, according to Gabriel Winant’s frustrating new book The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America. Most of those care work jobs don’t pay for shit. Urban certified nursing assistant jobs typically start around $13 an hour, barely more than the $11 hourly wage of the average steelworker in 1980, not adjusted for over 40 years of inflation. Winant thinks America can do better, and so do I, with the caveat that absorbing regurgitated neoliberal phantasms like the ones that occupy his analysis will not get us there.
THE ORGANIZING IDEA of The Next Shift is that these two things—the end of shit jobs that pay well and the rise of shit jobs that pay shit—are inextricably linked. This is very true. Beyond that, though, Winant’s mission is a bit fuzzy. In March, he published a New York Times op-ed calling on President Biden to forsake his vague promises to boost manufacturing jobs in favor of nonspecifically upgrading the wages and working conditions of care workers (which he has also promised). But Winant makes no such prescriptions in the book, probably because doing so would require engaging with the matter of why all those jobs went away, and how it is that the United States came to embrace an ever-widening trade deficit, without which health care could not play such a grotesquely outsized role in our economy. Instead, he casts the chronic precarity of health care workers, in spite of the steady expansion of demand for their labor, as an unintended consequence of the New Deal—which is frankly crazy—and a predictable and inevitable “trilemma” of “the post-industrial state,” as though there is more than one of them.
To review: Each year since 1975, the United States has consumed substantially more on imported goods than it has exported, yielding a trade deficit that has most recently hovered between 3 and 6 percent of GDP, a phenomenon without parallel outside the most severely impoverished and war-torn nations. In 2019, America spent 17.7 percent of its GDP on health care, while Taiwan spent roughly 6 percent—on par with the 1965 United States—and Germany and Japan spent roughly 11.5 and 11 percent, respectively.
Anyone attempting to reverse the problem of the trade deficit will run up against the problem of a health care system that forces large companies to spend an extra approximately $15,000 per employee annually (or right around $7.25 an hour, the current federal minimum wage) on health insurance premiums and out-of-pocket costs, the same system that bankrupts hospital workers for visiting their own emergency rooms. Anyone attempting to curb health care spending will run up against the fact that more than a trillion dollars of that yearly health care spend disappears into the diabolical “public-private” administrative state that murders our days standing in line at the pharmacy counter and haggling with powerless call center employees over collection notices for ancient hospital bills. The so-called post-industrial trilemma was supposed to force policymakers to choose two of three goals: plentiful jobs, good jobs, or a balanced budget. Winant never considers how it is that Americans wound up with zero out of three.
While Winant acknowledges the unique hybrid public-private nature of our health care system as the source of many of its dysfunctions, he generally subscribes to a mendacious narrative wherein the original sin at the core of that dysfunction—and also inflation, domestic abuse, toxic masculinity, the racial wealth gap, and the death of manufacturing itself—was committed by organized labor, when the Congress of Industrial Organizations responded to the intensifying political lunacy of the early 1950s by putting on hold its lobbying for broad social welfare programs and instead negotiating health insurance plans and cost of living–indexed wage hikes on behalf of its members.
Blaming unions for the abandonment of a national health system enables Winant to blame them for something even worse: the corporatization of health care, embodied in villainous union-busting monoliths like the University of Pittsburgh Medical Center, current flagship occupant of the U.S. Steel skyscraper, whose evolution into the engine of the Western Pennsylvania economy he argues is a direct result of “the social formations left behind by manufacturing” having been “disproportionately aged, sick, unemployed, impoverished, and yet relatively well-insured.” Corporate demons feasted on steelworkers’ Cadillac health insurance policies while exploiting legal loopholes never plugged by a self-absorbed industrial labor movement. “Workers’ benefits, a transaction denominated in the economy of the becalmed insider zone, then were spent to import services from the insecure outsider zone—like an unequal international trade relationship in which one currency is far stronger than the other,” Winant writes.
Deindustrialization looks in hindsight like what it was: an economic hate crime perpetrated upon organized labor by the insidious wealth transfer cartel that seems to run everything.
This is a compelling theory, and surely there is some truth to it. But displaced steelworkers with enough seniority to qualify for long-term health insurance benefits were by definition close to qualifying for Medicare as well. (Pittsburgh was by 1990 the second-oldest metropolitan region in the country, behind Broward County, Florida.) And Presbyterian University Hospital, which would rebrand itself UPMC in 1990, built its brand around wooing rich foreigners and other out-of-pocket patients for specialty services. In mill towns particularly, Medicaid and hospital “charity care” expenditures surged during the early 1980s, creating an epidemic of distressed community hospitals that surely tempted the opportunism of Presby’s financially savvy administrators.
Without seeing the payor mix data of regional hospitals in the aftermath of the mill closures, it’s hard to determine the degree to which health care’s expansion in the 1980s and 1990s resulted from hospitals sucking the life out of union-negotiated insurance policies. And to the extent that it did, one wonders if it would not be possible to forgive the narrow self-interest of steel union negotiators, given the multiplicity of debilitating chronic conditions that came with the job. But Winant furnishes no numbers on the regional or occupational incidence or cost of mesothelioma, chronic obstructive pulmonary disease, asthma, or cancer—in fact, he doesn’t really mention them. Nor does he furnish data on disease rooted in substance abuse, though he does make periodic reference to the prevalence of alcoholism among steelworkers both working and downsized.
On the other side of the country, the specific occupational health hazards of steelworkers gave rise to Kaiser Permanente, which is widely regarded as the least evil health care conglomerate in America. Kaiser Steel was pillaged by private equity vultures in 1980, but its managed care consortium lives on, and 160,000 of its 216,000 workers belong to unions, including the USW. Surely unionized steelworkers deserve more credit for Kaiser Permanente than they do the zealously anti-union UPMC, which made the front page of The Wall Street Journal in 2008 after one of its star surgeons, recruited to restore the health system’s heady transplant volume of the 1980s (despite a documented track record of sexually assaulting subordinates), came under fire for replacing the livers of hundreds of patients who arguably didn’t need transplants, often with livers of donors who hadn’t been particularly healthy, often with fatal consequences. The procedures came in handy in feeding the surgeon’s lust for Ferraris and Porsches.
Dr. Winant almost wanders into discussing UPMC’s reputation for unnecessary procedures but quickly turns away, declining to delve into scandals like the liver transplant racket, perhaps because it would contradict his declaration in the introduction that “we would be wrong to see the early twenty-first century as a return to the Gilded Age.” Similarly, Winant leaves out of his narrative the financialization of the American economy, wherein at some point in the 1970s Wall Street big shots with spreadsheets and zero industry knowledge or experience increasingly called the shots about who would and wouldn’t get to survive the End of History. This was an era that emboldened jack-of-all-trades corporate raiders like Jack Welch and Carl Icahn, the latter of whom repeatedly pressured U.S. Steel during the 1980s to get out of steel entirely so it could focus on the higher-margin oil business, where both workers and unions were, not coincidentally, scarce.
Wall Street’s demands were fundamental to the practice of deindustrialization. At the outset, they drafted off the elite viewpoint that the American working class had gotten entirely too accustomed to dignified wages; even the Allegheny County Conference on Community Development cheered the eradication of its economic base in a 1984 report, because it “forced important changes in our economy and the way we do business” and chipped away at the business community perception of Pittsburgh “as an area with high wage costs.”
But the carnage did not stop with unfashionable steel. Even the laissez-faire Reagan administration had sought to nurture obvious growth industries like semiconductors, which would expand 20-fold from 1985 to 2020, as chips predictably proliferated throughout our manufactured goods. The trouble was that the desire of most countries with industrial policies to nurture chip fabrication made the business low-margin, which Wall Street did not want. So they ceded it mostly to Asia, along with the business of manufacturing pretty much anything else you would buy on Amazon.
Winant does not deeply explore the politics of deindustrialization or the forces that engendered it in The Next Shift, treating it as a natural occurrence. In a passage on a survey of unemployed workers conducted by a food bank in Homestead, just outside of Pittsburgh, he muses on the “suddenly worthless” nature of self-reported skill sets like carpentry, plumbing, crane repair, machine operation, auto repair, and electrical work. “Steelworkers’ skills … remained stubbornly rooted in the old economy,” he writes, as though … robots were doing all those things now?
“In the long view,” Winant maintained in his op-ed in the Times, manufacturing “seems not to be a category of labor for which our economy generates consistent demand.” Perhaps not. But even the nursing assistants Winant seems to view as untapped engines of economic emancipation experienced widespread layoffs last year, when nursing home payrolls shrank by 12 percent as residents died off and seniors postponed surgeries. The fact is that our economy has proven stubbornly resistant to generating consistent demand for most categories of labor that involve living wages and reasonable job security.
There are exceptions, of course. Last year, a young addiction treatment specialist from one of the used-up coal towns of Appalachia that once supplied Western Pennsylvania’s steel mills told The Atlantic what a classmate of hers had told a teacher who had made the mistake of asking what they all wanted to be when they grew up:
“A drawer,” one boy said.
“You mean an artist?”
“No, a draw-er”—someone who draws disability checks and doctor-shops for OxyContin prescriptions. The pills could be had for next to nothing through Medicaid and then resold on the black market for $1 a milligram. It was the only future he could imagine for himself.
THE NEXT SHIFT IS HERE to tell us it has always been this bleak. Drawing from the memoirs and union grievances and disciplinary files of steelworkers, hospital workers, their families, and their employers, Winant pieces together a sometimes tedious but voyeuristic account of how Steeltown functioned on a day-to-day basis. He paints a picture of manufacturing work as unspeakably awful and dangerous, its workers as self-delusional meatheads, and their wives as indentured servants who achieved happiness through Stockholm syndrome.
At times, his commentary is unintentionally entertaining. “[T]he night shift, and the consequent lack of control over his body’s rhythms … posed a threat to his performance of normative masculinity,” Winant writes of an entry in one steelworker’s disciplinary file. On the practice of passing on the family row house to one’s offspring: “A house formed the enduring physical carapace of the continuity of working-class life.” On making kids do chores: “Just as women’s domestic work was unquantified, dissolved into the realm of love, children’s work appeared only as part of their upbringing, not understood as an economic contribution.” On a Black steelworker’s wife’s musing during the 1959 strike that “the love of her husband and her children” gave her reason to live: “[H]er shelter against racialized economic disturbance, in other words, was domestic normativity.” On another Black steelworker’s wife who is forced to sled down the hill on a cardboard box to get to her nursing home jobs on time after the mill closes, her husband is laid off, and bus service is curtailed: “Such risky routines illustrate the point made by feminist critic Neferti Tadiar about how care labor turns women’s laboring bodies into ‘media’ for the making of other lives.”
Winant rarely breaks out of this tone of scholarly detachment, but makes an exception to refute the contention of labor historians Jack Metzgar and Jefferson Cowie that the middle-class salaries enjoyed by steelworkers in the 1960s compensated for the physical danger or repressive tedium inherent to working-class domestic life. He scoffs at Metzgar’s declaration in his book about the steel strike of 1959, during which his father was a grievance officer: “If what we lived through in the 1950s was not liberation, then liberation never happens in real human lives.” Bullshit, counters Winant:
Beneath the layers of fetishization of industrial work that have built up over the decades, we can thus discern something else. Working-class men did not only love and draw strength from this work. They also dreaded spending their lives doing it, imagining all that it would require of them and all that it would do to them. This contradiction writ small shaped and damaged thousands of lives; writ large, it damned to profound instability the very structure of social citizenship that was organized around industrial labor.
The “contradiction” responsible for destabilizing the “structure of social citizenship” (whatever that means) is, just so we’re clear, at the heart of most jobs. I loathed waiting tables, how it replaced my interior monologue with desperate prayers to fill my section with black Amex holders and Montrachet-inclined senior partners. I hated missing book clubs and weekend barbecues and new-mom playdates, and most of all I hated working the graduation dinners of debutantes with no student loan debt. While not dangerous or carcinogenic, it was exhausting, and I always say (because it’s easy to say when you’re making enough to feel you have options) that I never would have done it for less than I made, which was enough to pay the babysitter and the rent and only feel stretched when the car or the stroller needed fixing. I made 1970s steelworker money as a waitress, and always felt I had earned it. But having toiled in subsistence journalism for 15 years before I worked in restaurants, I knew how fleeting the absence of desperation could be.
Care workers lack most of those perks. Many young people enter the profession assuming they will rise through the ranks to practical and then registered nurse, but the wages are so poor they are typically forced to work at least two full-time jobs, and thus find themselves alienated from both their own aspirations and most other trappings of the world outside their institutions. Solidarity with co-workers is often the sole source of comfort and pride in their lives, and throughout the pandemic I witnessed many episodes wherein even non-unionized care workers banded together to raise funds for personal protective equipment and other scarce medical supplies, to blow the whistle on the industry’s ubiquitously inhumane practices, to contact the families of residents who had fallen ill when their bosses neglected to do so. Long before COVID-19, though, many nursing home workers viewed their jobs and their co-workers in terms of direct combat and partners in foxholes. And over and over, I’ve heard them express gratitude for the horrors they lived through in 2020 because, finally, someone was paying attention to their plight and that of their patients: the impossible workloads, the residents going weeks without a shower, the open wounds, urine puddled and feces smeared everywhere, lack of basic supplies. These are foundational problems of capitalism and the casual sadism it unleashes.
Winant spares readers most of the gruesome details in The Next Shift, but one of his first published academic papers explores three nursing home workers’ 1975 exposé of conditions in a Pittsburgh nursing home called Kane Hospital, as a showcase for what Achille Mbembe dubs “necropolitics,” i.e., the notion that the preoccupying concern of a state is defining “who matters and who does not, who is disposable and who is not.” Winant encouraged readers to view the nursing home scandals of the 1970s as the inflection point at which the necropolitical project embedded within the New Deal metamorphosed from “a policy regime for sustaining working-class life” into one for “gradually liquidating it.” Behind closed doors, he wrote, care workers were punishing the helpless retired steelworkers for believing in a political project secretly designed to entrench white supremacy by excluding workers like them from the benefits of its policies.
But there was hope: A fledgling socialist group called the New American Movement had a chapter in Pittsburgh, which infiltrated Kane in the name of “praxis,” and exposed the abuses. “Immersed in a political culture with a high level of theoretical sophistication,” they produced a 100-page report detailing the inhumane conditions at the hospital. When local politicians tried to discredit them, they convinced 88 Kane workers to sign a sworn statement corroborating their version of events. Over the next few years, the young radicals secured stricter oversight, higher wages, and bigger budgets for the elder care facility, and then helped quash a campaign to sell it to a for-profit operator. But alas, NAM dissolved into the Democratic Socialists of America, which proceeded to languish in irrelevance for the next 35 years while 70 percent of the nation’s elder care facilities fell into the ownership of sick vulture capitalists.
Winant is an extremely enthusiastic member of the reinvigorated DSA, so perhaps one can excuse him for taking some liberties with the truth in this narrative. But according to Mary Lewin, the lead author of Kane Hospital: A Place to Die and coordinator of the campaign to expose the abuses there, NAM had virtually nothing to do with their efforts. Lewin had been a social worker at the hospital for two years when she recruited her two roommates, one of whom had been active in NAM anti-war protests in college and another who had gone to some meetings, to her cause. The ultimately successful campaign to overhaul and break up the 2,111-bed nursing home involved hundreds of activists and organizers; the typical NAM meeting, Lewing says, “was like fifteen people in a room.”
The original sin of Kane was less ideological than moral: county commissioners were double-billing Medicare and Medicaid and usurping resident mail and $15 a month vending machine stipends. In the end, Kane’s patients were saved not by theoretical sophistication but a robust network of local do-gooder groups operating under the banner Action Coalition of Elders. The Pittsburgh chapter of a national elder rights organization called the Gray Panthers helped publicize the scandal, SEIU 1199 stepped in to organize workers, and the then-fledgling radical Catholic group Thomas Merton Center as well as the Steelworkers Organization of Active Retirees donated funds and passed out pamphlets. Lewin published a letter in The Journal of American History objecting to Winant’s account of the saga, yet she was met with mostly institutional contempt in further efforts to correct the record.
I can’t imagine why Winant would seek to write NAM into an obscure chapter of history that occurred during a period when the founder’s own chapter of the organization could barely make it through a meeting without one member whipping out a little red book to denounce another. I also do not understand why he would blame the New Deal or the labor unions that benefited from it for failing to achieve full economic emancipation when so many Americans who fought for broader economic justice during the Cold War had their lives destroyed or exterminated for trying.
In delving into newspaper archives, steelworker memoirs, and contemporaneous histories to assess the validity of Winant’s assumptions and arguments, I was consistently struck by the robust networks of activism, community service, and mutual aid that bore witness to Pittsburgh’s rapid, shock doctrine–style deindustrialization. Anchored by the steelworkers union and liberal churches, groups like Homestead’s Rainbow Kitchen and the Denominational Ministry Strategy persisted through the various rounds of Reaganite and Clintonite austerity. The United Steelworkers even organized 50,000 nursing home and hospital workers in markets where other unions lacked a foothold; and though they have yet to crack the vile UPMC, it is not for lack of support from the few remaining steelworkers, or the New Deal, or the nuclear family.
It’s because solidarity is tough to forge, and the ruling class is so diabolically effective at incubating distrust and discord among anyone whose unity would pose a threat to them. What is most frustrating about Dr. Winant’s scholarship crediting a fledgling Marxist reading group with a successful campaign to permanently reform a massive institution with 1,800 employees, is how badly it distorts the power dynamics behind genuine political change. In giving us a portrayal of history that comprehensively elides any interrogation of the actions of those who wielded power in the moment, Winant doesn’t ultimately give the reader the sense that he feels any more solidarity with the discarded steelworkers of Pittsburgh than Don Regan had with the steelworkers of Brazil.
