The Labor of Health Care

Ted McTaggart

The Next Shift:
The Fall of Industry and the Rise of Health Care in Rust Belt America
By Gabriel Winant
Cambridge: Harvard University Press, 2021,
368 pages. $19.95 paperback.

IN THE SPRING of 2007, I accepted a temporary clerical position at a large, not-for-profit teaching hospital in Michigan. Over the past 17 years, through transitions from temp to permanent employee and from clerk to registered nurse, I have observed first-hand the ways that lean management techniques have degraded working conditions as well as patient care.

While the principles of lean management, originally developed at Toyota, moved from manufacturing to penetrate the health care industry only in the early 21st century (see e.g. MIT business professor Steven J. Spear’s 2005 New York Times op-ed piece, “The Health Factory,” advocating for the application of Toyota principles to the health care industry), the corporatization of health care can be traced back many decades further.

In The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America, Gabriel Winant makes an important contribution to the history of corporate health care in America.

Taking Pittsburgh, Pennsylvania as its backdrop, he shows how organized labor, and in particular the United Steel Workers of America (USWA), helped to build a private welfare state including a health system in which private health insurance companies increasingly set the terms for health care.

While also exploring the interplay of race, gender and class over the decades-long decline of the steel industry in Pittsburgh, Winant’s work ends in the 1980s with a bleak vision of an already heavily corporatized health system.

The Steel Mill — An Elemental Force

The steel industry grew in 19th century Pittsburgh due largely to the city’s proximity both to Appalachian coalfields and major waterways for transportation. The early 20th century saw a major increase in demand for steel, bringing with it the growth of Pittsburgh’s working class.

Due in large part to the USWA’s demonstrated strike readiness, many of Pittsburgh’s workers had by the 1950s attained an unprecedented standard of living. At the same time, working class life was rife with contradictions.

In the first chapter, “Down in the Hole,” Winant illustrates the horrors experienced within the steel mills through a number of worker narratives, from rats stealing workers’ sack lunches (it was for this reason that many workers would opt for a metal pail) to death and disfigurement.

“The mill was an elemental force, like a Greek god. . . the mill might take command of your entire life and could cast you aside again easily. It demanded awe and sacrifice and instilled terror and resentment. But in return it yielded a living, and indeed a world, for its people and their city.” (26)

But the world the mill offered to Black workers was a much more restricted one, with practically none in skilled trades and, to the extent they were able to find employment in unskilled or semi-skilled roles within the plant, Black men were particularly vulnerable to layoffs when the steel industry experienced an economic downturn in the 1960s.

Writes Winant, “Seniority in the mill accrued within a worker’s department rather than plant-wide, meaning that the confinement of African Americans to undesirable departments institutionalized the pattern of who was likely to be hired last and laid off first, as well as who would be exposed to the most dangerous and difficult work.” (103)

This marginalization mirrored the conditions faced by the Black community more broadly in the city of Pittsburgh. In the third chapter, “You Are Only Poor if You Have No One to Turn To,” Winant makes an in-depth study of the ways in which segregation and institutional racism shaped the working class of Pittsburgh.

Of particular interest in this chapter is the account of the organizing efforts of the Black working class. These forces included the United Negro Protest Committee (UNPC), Welfare Rights Organization of Alleghany County (WROAC) and Citizens Against Slum Housing (CASH), which fought for equity in housing, social services and employment.

The Black Construction Coalition (BCC), which included members of some of the aforementioned organizations, picketed numerous building sites in 1969 to protest segregation in the building trades, facing police attacks and garnering court injunctions to limit pickets to 20 people.

Black workers’ fight for equity and justice stoked a politics of resentment among many U.S.-born and immigrant white workers, many of whom were co-opted into fights to shut down anti-poverty programs that would benefit their own families as well as those of Black workers.

Commodification of Reproductive Labor

Winant uses narratives of working-class life in Pittsburgh to good effect throughout the book, particularly in the second chapter, “Dirty Laundry.” The stories of Black and white working-class women illustrate not only the domestic realities of families, but the ways in which the steel industry impacted race and gender and how these, in turn, influenced the post-industrial evolution of Pittsburgh’s economy.

The relatively high wages offered by employment in the steel mill led to decreased rates of participation by women in the formal labor market, which in turn bolstered the patriarchal norms of the nuclear family.

Due in large part to the more precarious role of Black men in the steel industry, Black women’s rates of participation in wage labor was relatively higher than white women, but still lagged significantly behind the national average. In 1960 the percentage of married African-American women participating in the labor market was 26% compared to 40.7% nationwide; by way of comparison, percentages for married white women was 19.5% in Pittsburgh compared to 29.7% nationwide. (65)

The relatively high wages earned by men allowed women to focus on uncompensated labor in the domestic sphere, including childrearing and care for elderly and sick family members. As employment in the steel industry dried up and the service industry expanded over the course of the 1960s, this reproductive labor was increasingly commodified.

Writes Winant: “This waged care work was related in very concrete, practical terms to what women did in their own homes: cooking, cleaning, and various forms of care work . . . Black women felt the problem first and had to figure out how to solve it first. Writ large, this meant the increasingly rapid formalization and quantification of reproductive labor, gradually redistributing the responsibility for sustaining life at the collective level.” (74)

The health industry was one of the areas of growth for this commodified reproductive labor. From 1947 until 1974, health care workers had been excluded from the National Labor Relations Act (NLRA) and were thus barred from union organizing. When, in 1969, the workforce at Pittsburgh’s Mercy Hospital attempted to march on the hospital administrator’s office, they were met with locked doors and a police presence.

Bishop Vincent Leonard of the Pittsburgh Diocese, while paying lip service to workers’ right to organize, “insisted that the ‘over-riding’ concern was the Catholic hospital’s ‘obligation’ of community service. Again and again, hospital administrators warned that workers’ self-assertion posed a threat to their altruistic mission . . . As Chancellor Wesley Posvar of the University of Pittsburgh observed, ‘[Workers’] labors, in effect, have been made a part of the charitable services by hospitals.’” (136)

The labor power of the largely Black, largely woman hospital workforce was framed as a charitable donation to the hospital’s patients and administrators. Despite the commodification of reproductive labor, Black women remained in a status akin to domestic servitude; their efforts to assert their rights on the job and demand fair wages were seen as threats to administrators’ efforts to contain health care costs.

The hospital as an institution “mirrored and extended the racial and gendered patterns of household labor, with its employees locked outside the social citizenship that secured their patients.” (136)

Organized Labor & Private Welfare State

While many labor activists and unions of the 1930s and 1940s had advocated for health care as a nationally guaranteed entitlement, union leaderships began to give up hope for achieving this goal soon after the Second World War.

In the chapter “Doctor New Deal,” Winant illustrates the construction by the USWA of a private welfare state for its members. In compensating for the lack of a national health plan, they charted the growth of Blue Cross/Blue Shield and the modern, private insurance driven health industry as a joint project of labor and capital.

Most of the city’s unionized workforce and burgeoning middle class looked upon this new joint project favorably: “The health care system formed an ongoing workable site of compromise, a mechanism for channeling income into the metropolitan economy, filling the coffers of well-positioned corporate actors, shoring up the positions of local officeholders, and reproducing the social arrangements of decaying industrial Pittsburgh.”

Nevertheless, Winant notes, “This generally cozy arrangement did not include everyone. Black working-class Pittsburgh …. could not participate freely in the hospital boom. Many African Americans lacked the health security that their white neighbors enjoyed, and they frequently experienced discrimination and neglect at the hands of the hospitals.” (138)

Uneven access to newly expanded health care resources in turn prompted the advent of Medicare in the 1960s:

“When Congress moved toward Medicare in the late 1950s and early 1960s, it was not only a product of direct lobbying by liberals and organized labor but also an indirect result of organized labor’s economic power in the health care market as a whole.

“While it was true that the deepening commitment of organized labor to health security through privately negotiated industrial relations worked to depoliticize unions, labor’s gains still had an enormous, albeit inadvertent, knock-on effect in the growth of public provision. It drove up prices and politicized those who were now priced out — some of whom, the elderly, enjoyed significant moral standing.

“In a context of rising expectations in access, their exclusion constituted a serious political problem. Thus a rough consensus developed by the late 1950s that some form of federal intervention was necessary, even if the actual development of legislation was much more contentious.” (147)

This chapter contains important information and insight into the evolution of the modern health care industry. It is a complex and convoluted history, rife with contradictory realities. While Winant does an admirable job presenting this material, it makes for a far more challenging read than the rest of the book.

Subsequent chapters explore the transformation of Pittsburgh’s labor landscape in the 1970s and 1980s. With the decline of the steel industry in the 1980s, the private welfare state it created fostered a boom in the health industry.

Politicians promoted building of new facilities such as Pittsburgh Children’s Hospital, and prestigious expansions to Presbyterian-University Hospital (PUH) as boons to the local economy, promising well paying jobs in construction and health care.

This expansion increased the participation of women workers in the formal labor market, though access to high paying jobs remained elusive for most. And while some prestigious institutions were able to reap handsome reimbursements for highly specialized care such as transplants, “marginal institutions dispensed care only to their impoverished local communities” and “now had to ration care for those who needed it and enjoyed only residual welfare state entitlement.” (230)

Rise, Fall & Replacement of Industry

Winant’s work provides an important analysis of the class, race and gender dynamics underlying the rise and decline of two industries — first steel, then health care. His focus on Pittsburgh makes sense in a number of ways, affording a level of detail that a nationwide survey would not have allowed and lending a certain texture to the narratives that make for a much more compelling read.

 At the same time, the reader is left to wonder to what extent the particularities of Pittsburgh obscure a broader understanding of this history on a national scale.

Despite any geographical considerations, and the fact that the changes ushered into the health care industry in the 21st century are addressed only in passing in the introduction and epilogue, it is easy to recognize in Winant’s history the beginnings of where we as health care workers and patients find ourselves today.

November-December 2024, ATC 233