For Workers, Hospitals Have Become the New Steel Mills — Minus the Strong Unions
Health care workplaces have replaced steel mills and auto plants as the nation’s big employers. But while industrial workers once had mighty unions, hospital workers have struggled by comparison to win representation and good contracts.
- Interview by
- Daniel Denvir
How did it come to be that health care is the largest sector of employment in the United States? And why is health care work so much more precarious and less heavily unionized than the dominant industries of eras past?
Gabriel Winant takes up these questions in his book The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America. The book contends that when deindustrialization hit and the New Deal order began to crumble under the neoliberal onslaught, a new system centered around health care emerged along the bygone system’s fault lines. In particular a burgeoning private health care system, funded by both government and collective bargaining agreements, not only survived the crisis but continued to grow, fueling the consolidation of insurance and hospital companies as the cost of care skyrocketed.
Winant’s book is a study of the emergence of the service sector and a new working class out of the wreckage of deindustrialization, told through the story of the rise and fall of unionized steel in Pittsburgh and its replacement by a massive hospital industry. In this new industrial landscape, health care workers — who are disproportionately women of color — were unable to exercise the same sort of power that their white male steelworker predecessors once had.
Winant sat down with Daniel Denvir, host of the Jacobin podcast the Dig, to discuss his book and America’s new labor terrain. You can listen to the conversation here. The following is an excerpt, edited for clarity.
Steelworkers Unions and the New Deal Family Model
I want to start by talking about how the inclusions and exclusions of the New Deal order were structured, because that history is really critical to understanding this low-wage health care system — staffed disproportionately by women and people of color — that emerged from the wreckage of the New Deal order.
You write that the majority of postwar strikes during the strike wave of 1946 took place in either Pennsylvania, or in Illinois, Michigan, New York, or Ohio, the geographical core of the New Deal’s mass base. Why was the New Deal’s geographical base so narrow, and what did the labor movement and New Deal order look like after they both emerged from these waves of sustained reaction?
The New Deal coalition was famously very heterogeneous. It consisted of various segments of capital, of the Southern Democrats as well as Northern Democrats, and of workers across industries and sectors. But the book is arguing that the ideological core of what we think of as the social democratic element of the New Deal project — the expansion of the welfare state, the building of the labor movement — was really found in mass production industry in particular. When I say mass production, that means auto, steel, coal, electrical production like making radios, or garments in New York City, that kind of thing.
Mass production industry was actually quite geographically concentrated in those states that you just named in the Northeastern, Upper Midwest, and Appalachian regions. The Congress of Industrial Organizations (CIO) emerged out of the Appalachian coalfields, the New York garment shops, and then increasingly auto and steel in the Upper Midwest and Great Lakes. There had been this rapid emergence of the labor movement there around these concentrated sites of production. And just to give you an image of that, the River Rouge plant, which was Ford’s largest plant built in the 1920s just outside of Detroit, employed 120,000 workers making model autos at its peak. You basically had wood, coal, iron, and raw rubber coming in one side and finished automobiles coming out the other side of the plant.
It was that concentration of people and their shared social experiences — the neighborhoods they lived in together, the churches and synagogues they went to together, the stores they went to together, the fraternal organizations many of them were in together — that really formed the basis of the new unionism of the 1930s, and formed the basis of the ideological world of the social democratic side of the New Deal. The solidarity those workers developed was possible because of their concentration together and the similar lifeways that they had.
The flipside of that was that while they were very numerous in those places and politically able, often, to control local government and state government, and to make a very important contribution to a national coalition, they were not a national majority and they were not spread evenly across the country. We don’t need to go through all the twists and turns of the political history from the late 1930s through the late 1940s, but as various crises unfolded the social and ideological elements that held that coalition together — and that bound the larger Democratic coalition to that working-class formation — began to stretch and change.
In particular, the layer of ideological radicals who had articulated the common interests of mass production workers with one another across lines of race and skill and ethnicity — and had articulated their place in a larger social democratic project — were politically basically wiped out by the onset of the Cold War. And that left you with this large social and political bloc that was solidified in its position, but no longer was the driving or leading edge of a transformative agenda.
What I try to argue is that the labor movement had been the New Deal’s engine, its motor. It’s the source of a lot of its radicalism, in particular due to the labor movement’s own internal radical layer of activists. But by the late 1940s and early 1950s, those activists were increasingly unable to play the role they had once played as a vanguard formation of a broad, emancipatory movement that all sorts of people imagined themselves as linked to or part of — whether they were mass production workers or not.
In the 1930s, the CIO meant something for millions of Americans, most particularly in the auto industry or steel industry, but also for a broad swath of people beyond that — because it was the leading organized force that was fighting for Social Security, for a national health plan that was never won, for the end of child labor, and against racism and Jim Crow. When the CIO had begun organizing in steel towns and auto towns, workers would just show up at the CIO local office and say, “I’m here to join the CIO.” They wouldn’t even necessarily know about the United Auto Workers local or the United Steelworkers local that they would ultimately be members of. They wanted to join the CIO.
By the 1950s, what you had was a regularized, institutionalized, increasingly bureaucratized system of collective bargaining in which organized labor was still able to represent the interests of its own members very powerfully through real shows of industrial militancy, like periodic strikes. We should not think of the 1950s and 1960s as a period when class conflict stopped. Rather, class conflict became managed and parochialized, so that organized labor became one of the many interest groups that were allied together within the Democratic Party. It no longer had a transformative edge, and it no longer was the leading formation in a potentially destabilizing social movement.
You write, “As time went on, the institutional apparatus of economic security, the welfare state and the labor movement continued to effect some downward redistribution of wealth. But this apparatus also simultaneously secured the shape of the broader social hierarchy.” What emerged was the semi-privatized welfare state, secured through unions’ collective bargaining agreements. And people without access to that unionized work were excluded in a variety of ways.
How were these lines drawn between the inside and outside of the system of what you call “social citizenship”? Did the security of those on the inside depend on the insecurity of those who are locked outside?
Social citizenship is the idea that beyond political citizenship — the right to vote, to sit on a jury, and so on — is this category of what we would call social rights, things like retirement, health care, time off, disability, and so on. And this is what the welfare state secures. But the outcome of the New Deal and its struggles and limitations was that the top tier of social citizenship was administered privately. It was privatized, in particular, through collectively bargained employment.
A steelworker gets access to a pension through his job, to health care through his job, to vacation and insurance against unemployment and disability and injury through his job. The forms of these benefits that you might have access to if you don’t have a job in the secure industrial sector of the economy — if you’re not in a collectively bargained industrial workplace and if you have to rely on the public sector for them — are actually significantly worse typically. So the public-private nature of the welfare state is also stratified for the working class, and people who have access to better benefits typically do through the private sector.
And that in turn is a racialized and gendered phenomenon, because steelworkers, for example, are virtually universally men. And moreover, they’re not all white, but inside a steel mill or inside an auto plant you will find an internal racial hierarchy. The best jobs are held by white men, and the worst jobs are typically held by black men.
A further point that I make is that a lot of these social benefits — the things that you gain access to through social citizenship — are not just cash. In various ways they consist of or at least imply services. Social benefits often require someone to enact them for you. In a variety of ways, the privatized social welfare system is set up to encourage and assume a certain family structure. Many of the benefits that social citizenship confers more or less assume an unwaged worker at home — a wife — who will take the various things that, for example, unemployment insurance offers or that a pension offers and turn that stream of income into food, housing, laundry, etc.
If we extend this thought to health insurance in particular, we can see this extremely clearly, because what is health insurance actually? What does it buy you? It buys you time in the hospital. That’s the core thing that it pays for, especially in this early period, in the 1950s. And when it buys you time in the hospital, what it’s really buying you more than anything else is hospital labor. Hospitals — especially then, although still now to some degree — are very labor intensive, and when you are paying a hospital bill or when an insurer is paying a hospital bill on your behalf, the largest part of that bill consists of paying the people who are changing your sheets, feeding you, washing your body, taking care of you in various ways.
And so we can start to see social citizenship as not just a stratification, in which some people have it better than others, but actually a system of relations within the working class that divides the working class. It’s not just implicit; it actually mobilizes some of the people who have worse quality social citizenship — like hospital workers who were not covered by labor law, who were not entitled to form a union under the Wagner Act, who were not covered by the minimum wage until the 1960s, who are overwhelmingly women and much, much more likely to be people of color — to serve a purpose for those who are on the inside of the social citizenship system.
You write, “The heteropatriarchal nuclear family was mass production capitalism’s instrument for obtaining and reproducing a stable workforce.” But the home was also experienced, of course, as a refuge from the workplace and from the market and a place for both love and intimacy.
How did those two seemingly contradictory purposes of the domestic sphere to “produce both life and labor power” coexist? And what role did the family play, as you write, “in privatizing political problems as social problems”?
Socialist feminism has provided this insight in some form since the 1970s, if not longer. The insight is that in some way the Fordist factory seems to require a particular family form. The male-headed nuclear family arose in coordination or correspondence with the transformations of employment in the twentieth century and got codified into law in various ways. For example, as Alice Kessler-Harris shows in her book In Pursuit of Equity, the Social Security system very strongly encouraged women to be housewives, making that make financially more sense than to work the low-wage jobs that were available to women. Women would accrue more Social Security benefits by means of the housewife formula than they would likely accrue in a job as a waitress or a secretary or the other jobs that were available to most women. This is one of the many examples of how the welfare state herds working-class people into this particular family form.
Why is it that the structure of the capitalist welfare state social formation prefers and seeks to produce this family organization? There have been huge debates, and we don’t need to get into them here, about what exactly is the value relationship between housework and capital accumulation. Should we understand housework as directly producing value or not? I encourage folks to read and think about that, but my book doesn’t try to resolve that. Rather, the point is that the labor force upon which industrial production depends has to get produced and reproduced in the family. This is particularly true for industrial mass production like steel and auto. For long-term planning purposes, managers need a stabilized workforce. And for this, they need the labor force to be consistent and reliable and to show up in more or less the same form that they can anticipate every day. This is part of why they were willing ultimately to accept collective bargaining.
What that means is that the family has a particular role to play. The family has to produce steelworkers. It has to raise male children who are in one way or another ready for this role. It has to refresh them each night.
And it’s a more complex undertaking than you might think. Steel mills run twenty-hour hours a day. You can’t turn them off because they’re too hot and it takes too long to heat them back up again, so you just run them constantly. They run in three eight-hour shifts, which means that every steelworker at various points is going to be doing an 8:00 a.m. to 4:00 p.m. shift, a 4:00 p.m. to 12:00 a.m. shift, and sometimes a 12:00 a.m. to 8:00 a.m. shift. If he’s doing a 4:00 p.m. to 12:00 a.m. shift, and the family has four or five kids — these are typically pretty big families, especially in the earlier Cold War period — the wife has to make dinner for the kids at 5:00 or 6:00 p.m. and then stay up and make him dinner again at midnight when he gets home.
Moreover, when he gets home, he is going to be filthy, because he works in a steel mill. His clothes are going to be caked in industrial grease, and there will be grease under his fingernails, in his hair, on his eyelids. She has to help him get clean. He’s going to be tired, frustrated, worn out, maybe humiliated from the shit he went through with his foreman that day, and he’s maybe going to want to have one or two drinks, a very common ritual. So she has to do what we could think of as emotional work to deal with that. She needs to keep him from waking up the kids. He’s then going to sleep through the next day because he was up late working at the steel mill, and so she has to keep the kids from making any noise that would wake him up during the next day.
Just from these little examples I’m giving you, you can see how the family has this economic function supplying a steady supply of labor power, but it’s people who make it up. It’s not just a series of input factors — it’s people living their lives, with human experiences and needs and desires and conflict. And basically it’s a wife and mother’s job to square that right, to figure out how to keep it all going. It’s a very difficult job, emotionally and physically. I read diaries and letters and all kinds of things from steelworkers’ wives saying things like, “I typically do the laundry at two in the morning because that’s when I know no one will need me for anything else.” And it’s also impossible: they can never make it fully line up. They can’t ever be the family that postwar Cold War America imagined that they should be able to be.
Cracks in the New Deal Order and the Rise of Private Health Care
You write, “By the end of the 1950s, the union secured increases that made its members the very symbol of the postwar promise to the US working class.” We think of the postwar era as the golden age for white working-class men, either nostalgically or skeptically, depending on the analysis being made. But in reality the work and their lives could be pretty brutal. How did this myth about the lives of unionized steelworkers develop, and how does it fall short of reality?
The myth emerges from a true track record of high levels of economic growth from the end of the 1940s through the early 1970s, and the ways that cashed out in rising wages and then secondary things like homeownership and pensions and health benefits and so on. That became physically manifest in the growth of suburbs, in the acquisition of consumer appliances, and in the baby boom. It’s not baseless. Something happened.
But it’s really important to be careful about how we understand what happened and to see the internal contradictions and transitory qualities of it. If you were a steelworker right after World War II, you experienced a cyclical recession that was likely to put you on temporary layoff for a couple of months in ’46, ’49, ’52, ’54, ’56, ’57, ’58, ’59, ’60, and ’61. So when you look closely, this image of the heroic breadwinner with total stability starts to decompose.
There’s a report that I talk about in the book, a Bureau of Labor Standards Statistics report on what would be a comfortable — the phrase was “modest but adequate” — standard of living for a working-class family in Pittsburgh in around 1960. The family it describes is a family of four, two parents and two children. They are tenants, not homeowners. They’re able to buy a couple items each year, probably new clothes for their kids. It’s not what you think of as this postwar suburban ideal. And even this family life is out of the reach for most steelworkers, if you really look at the wages they were making and factor in either being on strike or being on temporary layoff. They fall short of this “modest but adequate standard,” which doesn’t even include home ownership or a new car or things like that that we really associate with the myth.
Then I think we have to also understand what’s happening inside the factory. By the end of the Korean War, American steel manufacturing had become extremely overbuilt in its capacity, partly subsidized by the state, by military Keynesianism. They had drastically expanded capacity, and not done so using new technology that had been developed in Europe, the so-called basic oxygen furnace, which would have been more productive. And there’s complicated reasons for why that played out that way. But in 1955, let’s say, there was not a ton of competitive pressure on an industry like American steel. European and East Asian steel production were still in ruins from the war.
And domestically the industry was organized oligopolistically. There were about a dozen big steel firms that bargained together, one contract with the union, with US Steel in the leadership position. After the contract was settled, US Steel would figure out what adjustments it had to make to its pricing per ton of steel to pay for the wage concessions it had made to the union, and then all the other steel companies would basically follow its lead. So they could just pass on the costs of collective bargaining to steel consumers, who were generally in the construction and auto industries.
In the postwar period, much of America’s infrastructure relied on steel. For this reason, there was increasing concern about the relationship between steel prices and general inflation, and increasing political pressure on the steel industry to constrain its price increases. Every steel strike through the whole postwar period basically gets settled in the Oval Office by the president, because the president doesn’t want a long steel strike, as that would be bad for the economy. But the president also doesn’t want to piss off the steelworkers’ union because they’re powerful. And he also doesn’t want inflation because that’s bad for him in another way. So whoever the president is, he’s always trying to find some middle ground where they can work all of this out.
So the steel mills don’t have the new technology that would hold down their costs per hour in putting out steel there. And they are under political pressure not to pass on their costs to customers too much in the form of price increases. In the late 1950s, the steel companies start figuring out that the best thing to do is to, hour by hour, grind out a little more productivity from the workforce. They’re very explicit about this. And this generates an ongoing — in some ways low-level, but from the perspective of workers very intense — class war on the shop floor. This is common in a lot of industries in this period, where you’re just in this ongoing trench war with management.
You write, “Over the postwar decades, employment and manufacturing underwent a long secular decline. And across the entire deindustrializing world, a wave of welfare state expansion followed in the immediate aftermath, as governments responded to these demands and sought to manage the appearance of new forms of poverty amid the postwar plenty.” In the US context, we know about black urban riots and uprisings, about President Johnson’s War on Poverty and Great Society initiative, which included the establishment of Medicaid and Medicare. How did the mass expansion of the private health care system secured through collective bargaining fit into all of that?
By the late 1940s and early 1950s, the same groups of industrial workers and their families who were concentrated in certain neighborhoods and communities are also becoming insured through shared health plans. If you’re an insurer, it becomes easier to offer good rates for big groups of people who are predictable in similar ways in terms of their exposure to risk.
I don’t want to sound too trippy when I say this, but these huge pools of industrial workers sort of distort the fabric of time. As these giant groups of workers and their families become insured together, they generate a common risk profile, and their risk profile becomes the site not just of an insurance market, but also a health care provision system. The health care system is going to have to respond to the risks to which steelworkers in Pittsburgh are going to be exposed as they move through their lives collectively in this temporal bloc.
In 1949, the court system rules that an employer must negotiate with a recognized union over so-called fringe benefits — health care and retirement — and the steelworkers negotiate their first health plan. Then over the course of the ’52 and ’56 and ’59 contracts, that plan becomes very good. There are strikes in a few of those contract cycles. They win a lot of gains on the health care side. By 1959 steelworkers make no contribution to their premiums.
So in response to this, the health care system in Pittsburgh, which largely consists of Catholic hospitals, changes. And a lot of this is happening in the private sector, but we have to see it as a welfare state phenomenon in that it’s being shaped and partitioned and cordoned and directed by social and political class struggle through the state, which then is acting back on the private sector.
Prior to this period, hospitals were basically places where the poor went to die. But in response to the steelworkers contract, the quality of care goes up. The degree of attention that working-class people are able to get, if they’re in this secure fraction, increases.
And as that happens it acts back on the formal public welfare state, because now working-class people who are not part of that secure fraction see their neighbors or people they know actually getting good quality health care that never used to be available to anyone in the working class. But not only is that not available to you if you’re not employed or married to someone employed at the steel mill, but prices are rising for you. As hospitals are upgrading, as doctors and hospitals together are providing more complex and technically intensive kinds of care, health care costs are increasing. And if you’re not in the secure faction of the working class, if you don’t have access to that steelworker health plan, that means that prices are rising for you.
So then, who is it that I’m describing? Who’s not part of it? On the one hand, obviously, it’s the poor. It’s people who are lower in the labor market hierarchy than steelworkers. It’s anyone who is not part of the collectively bargained, secured part of the working class. That’s a very heavily racialized phenomenon. And it’s also affecting the elderly, which is part of what generates the political pressure to pass what would become Medicare and Medicaid.
What’s important about those programs is that they don’t displace in any way the core public-private bargain that’s driving the growth of the health care system. They don’t interfere with it. They don’t position the government in any way as a supplier of services. They have the government step in instead of a buyer of services on behalf of people who can’t get insurance for themselves through their jobs.
And this arrangement doesn’t pose a problem for the private insurance companies because it’s insuring people who the private insurance companies aren’t insuring in the first place, and it poses no threat at all to the private provision of care.
And critically, the same invisibilization of care work that enabled women’s labor in the home to reproduce the working class without being recognized as work has the same effect on those working in hospitals. That facilitated the legal exclusion of waged health care workers from the protection of labor law.
Under the original Wagner Act, the position of health care workers was ambiguous. It was not resolved, and it didn’t seem like a super pressing issue because health care was just not that big of an industry. And that got struggled over for about a decade in a handful of union fights and some number of legislative battles.
Quite notably, there was an effort by the CIO to organize largely black nurses at West Penn Hospital in Pittsburgh in the 1940s. That prompted a lawsuit by every hospital in the region together, basically seeking an injunction against them, which said these people are not employees. That is not the legal relationship that a hospital is in with its workers. It’s not an employment relationship.
The question is settled in 1947 by the Taft-Hartley Act, which explicitly says hospital workers are not covered by American labor law. They’re also not covered by the Fair Labor Standards Act, which establishes wages and hours. This has long been a form of work that is assigned to marginal people in the labor market, mostly women and people of color, with relatively little labor market power. It’s related culturally to wives’ domestic labor, and has similar maternal overtones. Add to that the religious inflection of caregiving at the time. I don’t think those cultural associations on their own explain the exclusion, but I think they are the cultural level of a deeper phenomenon which has a legal dimension and an economic dimension.
Black Workers and the Fight for Welfare
You write that the rise of the modern health care system “appears in close parallel to the rise of mass incarceration.” Do those two processes just run in parallel or were they more intertwined?
I think this comparison is very fruitful, but we have to be cautious as we use it. Because while the health care system has extremely cruel dimensions, we’re not for its abolition. It’s not exclusively a mechanism of domination and oppression.
There’s plenty of good stuff that happens in hospitals.
Right. And I think actually that’s important to say, because it’s only if we understand that and say that, that we then become able to parse out the ways that the health care system is helping make people who they are and reproducing them in ways that stabilize the larger social order. That is, at the most abstract level, how it’s similar to the prison system. The growing health care system is producing social roles, stabilizing social roles, and holding people in those roles, and in that way contributing to a larger social stability effect, which is also what the prison system does.
At a less abstract level, they manage bodies out of place. Both patients and prisoners are people who no longer have a productive purpose in the capital accumulation process, which is what we mean when we describe them as surplus population. And so if there’s an institution that can put together, as Ruth Wilson Gilmore would say, surplus capital and surplus state capacity to manage the surplus population, then it’s going to prosper by doing that. So they’re similar in that way as well.
What’s different about them is that health care is a social right. It’s something that we want to get. And the people who are able to get it are in a better position than the people who are not able to get it. It’s unequally distributed.
As you mentioned earlier, black workers have the worst jobs in the steel industry. And that also meant that they were “laid off earlier and at higher rates.” But at the very same time that the industry was falling apart, the black freedom struggle was directly confronting racist labor market exclusion in both steel and unionized construction.
You write, “As in construction, the black workers’ victory was slow to arrive, was haltingly implemented and coincided precisely with the decline of the industry. They struggled persistently, but they struggled for inclusion within the structure of the postwar liberal order seeking black men’s admission to a blue collar breadwinner status that was itself entering crisis. Black workers’ movements were thus confined by the same material limits as the liberal state itself, requiring a healthy industrial economy generating jobs whose distribution could be contested.”
This was really poignant. Does it point to the general tragedy of the 1960s struggle to universalize the New Deal order at the very moment that that order was collapsing?
If your image of racial and class exclusion from postwar affluence and security is an image of people who have not yet been allowed to catch up and to join, then it makes sense to imagine a racial-liberal quasi–social democratic program that is going to open the doors. It’s a problem that the doors are not open for people, and the goal is to integrate the economic security of the 1960s.
The black steelworker struggle was a very heroic effort, and I have no feeling for it except admiration. Black workers fought against the terrible conditions that black steelworkers were made to work in. In particular, they had to work in the blast furnaces and the coke ovens, which are the worst places to work in a steel mill. It’s hell on earth. The temperature is just extremely high all of the time. This noxious gas is floating around all of the time. You can’t get it out of your mouth and nose after you leave work. It’s going to give you cancer. I’m not exaggerating. It was incredibly toxic and poisonous. It’s horrible work. You’re likely to be vomiting blood all the time.
So theirs was an important struggle to try to escape that occupational segregation and the seniority lines that preserved it. But as you said, it rested on an assumption — which was a reasonable assumption from the perspective of people at the time — that steel work was going to continue. It was what the city had been built for. There was a huge amount of capital laying on the ground — for twenty or thirty miles of riverbank, there’s nothing but factory. Presumably someone is going to continue to operate it. It makes sense to think that the best way to get some security is to help people get included in it and on fair terms.
By comparison, you write about the welfare rights movement, that the “spaces of community constructed by black women through hard times became seed beds of a form of resistance that defied the assumptions of the liberal order entirely, developing a feminist analysis and seeking to detach survival from production.” What sort of critique were organized black women making of the New Deal state, and to what extent did they point to another possible order beyond it?
I think this is a really important question. Even if it’s difficult to imagine a world where the welfare rights movement sweeps the nation and takes over the apparatus of political power, the struggle that black activist women in that movement led did imagine an alternative that genuinely went beyond what a lot of mainstream liberalism was able to imagine.
As this early creeping deindustrialization was playing out, the toll of economic insecurity was passed on to the systems of social reproduction in various ways. People would claim access to social citizenship and benefits from the welfare state where they could, but they were also thrown back onto each other and compelled to use their shared resources. This was true for white and black people in different ways, but it was especially true for African-American families and African-American women, because deindustrialization and rising economic insecurity hit them harder and earlier and more intensely. They had to figure out among themselves more powerfully and quickly how to survive. And there were various resources in black history that enabled and made imaginable forms of social cooperation.
Black neighborhoods were quite densely knit networks of what we could think of as basically mutual aid. That might just take even the form of one person gets laid off and then they go and live with their brother who hasn’t gotten laid off, or the brother’s wife brings food over once a week to help out. In addition, cooperation around childcare was extremely important. Cooperation around making rent was extremely important. And this predates any formalized movement activity around these kinds of things.
There’s a really classic book about an industrial town in Michigan called All Our Kin by Carol Stack that I really recommend on this point. What Stack shows is how the very same social behaviors that were pathologized by Daniel Patrick Moynihan in his infamous report on the black family were adaptive to this environment of economic inequality. What Moynihan condemns as matriarchal were really the ways that black women would lead and organize social networks of mutual aid. He wants them to behave like New Deal liberals sorted into male-headed nuclear families, and he thinks we need to create the job opportunities for that to happen. But Stack shows, and I try to show historically in the book, the ways that these women’s networks are really important to survival.
And that is the social basis of what then becomes a more ideological and political phenomenon in the mid-to-late 1960s in the welfare rights movement, which is a national phenomenon but has an important Pittsburgh chapter. The welfare rights movement engaged in all kinds of struggles around the dignity and security of so-called welfare mothers. It tried to establish that they should not be in poverty just because they didn’t have access to the kinds of preferred employment that New Deal liberalism structured social citizenship through, and moreover that poverty should not be punishment for their children.
While they certainly didn’t win that struggle writ large, I do think that their movement raises the key question of: What would it have looked like to transition out of the labor-capital bargain that was at the core of New Deal liberalism? To imagine delinking wages and productivity in a fundamental way, and to assert that the denial of access to industrial work by no means has to be synonymous with denial of dignity and security and economic well-being?
Health Care’s Rising Costs and the Transformation of Care Work
I want to delve into your core argument how this semi-privatized health care system became more dysfunctional and expensive as deindustrialization battered the working class, all while remaining as politically resilient as ever, or even becoming more politically resilient. Why was such a dysfunctional system so adaptive amid such incredible stress? And how did that all depend on shifting costs to workers?
The different points of connection that the health care system has to the patient, to the state, and to capital make it able to function in an ongoing state of negotiation over who is going to bear the costs of social inequality, and in particular the way social inequality became enacted and manifest through deindustrialization.
You had this system of typically nonprofit hospitals in places like Pittsburgh and in some bigger cities. There’d be some public hospitals also, but public hospitals were always a small minority, and for-profit hospitals were, for much of the twentieth century, a nearly nonexistent phenomenon and really confined to the South. So you have these institutions that have to bear some responsibility to their public, and the way that they relate to the public is a market relationship, but it’s not only a market relationship. And their markets are growing from the mid-to-late 1960s through the 1970s because you have these aging populations that are also quite well insured. Medicare is helping with that, and Medicaid to some extent. And already by the early 1970s, it’s becoming clear that their hospitals want to grow.
In 1971 Allegheny County, where Pittsburgh sits, creates a mechanism that allows hospitals to borrow on municipal bond markets. That’s a tax subsidized, very safe form of debt. So hospitals can get access to capital markets. Very quickly they go from financing their expansion through philanthropy, through retained revenue, to overwhelmingly financing it through debt. So now you’ve hooked up to the capital market this patient demand in the form of these big insured markets — the steelworkers, steelworker retirees, other Medicare beneficiaries. And so the hospitals have every reason to grow and incur more costs because costs, from the perspective of a hospital administrator, are revenue. The system runs on reimbursement. And so in this period, racking up your costs is a way of racking up your revenue. That seems very perverse, but that’s how it works. So there’s more and more growth.
This population of people who have good insurance is aging, and is carrying into old age the accumulated health burdens of a life in the steel mill or life in the steel valley, where there is a tremendous amount of ambient industrial pollution, and also the emotional and psychological dimensions of that health profile. The extension of their social rights into the health care system and into their old age allows them to use the living hell out of the health care system. What’s called health utilization — the rate and extent to which steelworkers use the health care system — just absolutely balloons over the course of the 1970s.
You write that low wages and bad conditions “produced a nationwide uprising of black healthcare workers in the late 1960s, led by the dynamic New York based Local 1199. This movement arrived in Pittsburgh in November 1969, and their slogan was Union Power, Soul Power.”
How did racialized and gendered class power shape hospitals’ exploitation of black workers during this period when hospital growth just began to explode? And then what sort of racialized and gendered working-class consciousness animated Local 1199 to fight back?
We talked about the legal exclusion of health care workers from the New Deal regime and the cultural and economic dimensions of that. As health care workplaces are growing, they’re attracting, in particular, more and more black women into them. Black women largely transition out of domestic service into hospitals.
Over the course of the 1960s, you write that domestic employment fell from 32 percent of African-American women’s employment to 13 percent.
Right. And health care replaces domestic labor as the most important component of black women’s employment. Hospital work is understood as better than domestic service in a lot of ways, but there’s also a continuity there which is, again, encoded in the law, as well as having cultural and economic dimensions.
But the civil rights movement makes those exclusions increasingly politically intolerable, and makes health care workers increasingly likely to resist and fight back. And in the context of growth, it becomes more possible to envision how you do that. It started in New York, where 1199 had first emerged in the 1930s as the pharmacists’ union, and over the course of the 1940s and especially 1950s had won some key victories. In the late 1960s, on the momentum of the civil rights movement, 1199 tried to go national. There’s a very famous strike in Charleston, South Carolina, which the union loses, but they lose it in a heroic way that gains them a lot of attention and credibility. Coretta Scott King is very involved and becomes the union’s national figurehead, and they launch these campaigns in a bunch of other cities: Baltimore, Philadelphia, Buffalo, Cleveland. They succeeded in a number of places, laying the groundwork for what would become a nationwide health care union that eventually became part of SEIU, which it still is today.
In Pittsburgh, at the end of 1969, they roll into town and they try to carry out the same strategy they carried out in other places, and it doesn’t work. The strategy was to overwhelm the conservatism and resistance of hospital administration by means of just pure militancy. The idea was that you can’t go through the NLRB because you’re not covered by labor law, but you can potentially force an employer to recognize you anyway if you’re determined enough, if you hold together through direct action of different kinds. That’s what they tried to do.
They succeeded at winning recognition at a big nursing home, the Jewish home and hospital in the Squirrel Hill neighborhood. But they did not succeed in any of the big general hospitals. One reason is that the racial composition of the workforce was a little different than it was in Philadelphia or Baltimore or New York. Pittsburgh didn’t really have a second Great Migration from the South, because the steel industry stagnated relatively early compared to, say, the auto industry.
And so its black population was smaller proportionally.
Exactly. So that means that while black workers are still disproportionately represented in the health care industry, the workforce is not as racially homogenous. If you’re going to carry out a strategy like just jamming union recognition through by means of direct action, it helps to have a relatively homogeneous black workforce. If that’s your strategy, and your slogan is “Union Power, Soul Power,” none of the white workers are going to participate. So their ceiling was already lower in Pittsburgh.
And because of the legal situation and the social context of health care work, management was able to resort to all of these tools that would be illegal in another context. They invite in a rival union to compete and muddy the waters, which would be illegal in another context. And they race-bait and even Jew-bait, because 1199 had Jewish leadership.
Looking back on it, it’s just clear that health care workers were are too legally, culturally, economically, and politically marginal to carry out something like this. The system was going to be able to hold them at bay while it continued its growth cycle over the course of the 1970s.
Ultimately, the whole health care system is premised on the invisibility of a huge section of the workforce. And I don’t mean that in a general cultural way. I mean that literally they were not legally considered workers for a huge portion of the time in which the system was being built. Even in 1974, when federal labor law was amended, it was amended in such a way as to only allow them to unionize under severely burdened conditions — to make it harder, very explicitly, because we can’t have them interfering with the business of the hospital, because the business of the hospital, although it’s private, is still a public concern. There’s always that weird public-private thing at the heart of this.
The reality of health care labor is structurally, economically, and legally denied in how the system is institutionally organized and how its labor relations are conducted. What that means is that as it grows, the boosters who see health care as a potential basis for a postindustrial recovery or a new economy can pretend that the bottom layers of the workforce aren’t really there or don’t really matter. They don’t particularly have to be accounted for.