In the summer of 2015, I returned to Pittsburgh to begin a postdoctoral fellowship on the politics of health care, the industry for which the region—following the long decline of steelmaking—had become increasingly well known. Not far from my office, a short walk from the hospital where my mother once worked as a cardiac-unit nurse, that industry's contradictions had begun to flare up.
As I would soon discover, a war had been raging between the region's largest health system, the University of Pittsburgh Medical Center (UPMC), and its largest insurer, Highmark. Several years prior, UPMC had announced it would end its contract with Highmark following Highmark's decision to acquire a hospital system of its own. Now a tenuous consent decree brokered by the state held access to care for thousands of people in the balance. Following some coverage critical of UPMC in the Pittsburgh Post-Gazette, UPMC banned the sale of the newspaper in some hospital gift shops. At the same time, UPMC—whose CEO was infamous for demanding steep increases to his $6.5 million salary—was in the middle of a war on its low-wage workers' efforts to unionize. One strategy the hospital system used in its National Labor Relations Board filings was to maintain that it had no employees and conducted no operations. Care work was thus the economic lifeblood of the region while being heavily reliant on a marginalized, low-wage labor force.
The contradictions of the care economy are at the center of Gabriel Winant's The Next Shift: The Fall of Industry and the Rise of Health Care. The book's six chapters trace the fall of Pittsburgh's steel industry and the emergence of a booming marketplace founded on the commodification of care. This story, absent from most work on the history of American health policy, is vital to understanding both how the United States's uniquely pathological system of health care was locked into place and what the opportunities are for transforming it.
Winant follows the emergence of western Pennsylvania's health care economy back to its roots: the steel mills. By focusing on the daily lives of steelworkers—inside and outside the fortresses of industrial capitalism—Winant complicates recent analyses of the postwar political economy as a “great exception” for working-class power. On the one hand, the New Deal order gave steelworkers an extraordinary level of collective leverage as well as social citizenship. At the same time, steel production remained dangerous and brutalizing work, especially as steady wage hikes and opposition to price increases forced steel companies to cut costs by ramping up the intensity and rate of labor. As Winant puts it, “steelworkers generally feared for their lives, hated their foremen, and needed a drink” (62).
If the process of steel production entailed significant health risks for millworkers and denizens of steel towns, the postwar political economy also yielded financing arrangements that drove greater utilization of health care. Private sector collective bargaining arrangements won by unions weakened support for a universal approach to health provision, while fragmented financing arrangements generated an inflationary dynamic. Among those covered by collective bargaining agreements, consumption increased. This helped to drive up prices, further limiting access for those locked out of this private welfare state. This dynamic, which the creation of Medicare and Medicaid only accelerated (even as they increased coverage), opened significant economic opportunities in the health care sector. As the steel industry retrenched and the ranks of workers covered by the postwar class compromise were diminished, a large aging population with intense care needs was left behind. As a result, health systems could easily attract creditors to finance the expansion of facilities. Health care was thus poised to become the Pittsburgh region's dominant economic sector. By the 1980s, employment in health care and social assistance, after steadily rising for three decades, outstripped employment in steel.
The not-for-profit and privately owned hospitals that became Pittsburgh's new economic engines created a new political economy. With the passage of the Taft-Hartley Act in 1947, hospital workers were excluded from labor protections, hobbling unionization efforts among the low-wage workforce Pittsburgh's new economy relied on. And even when Congress passed amendments to the National Labor Relations Act incorporating these workers in 1974, the industry's structure—which absorbed informal care functions and labor supply from postwar families—imposed severe constraints on their ability to bargain up wages and working conditions. Winant shows how, in 1970, hospital system administrators at the University of Pittsburgh leveraged racial divides within the workforce to suppress union activity, depicting union leadership as Jewish outside agitators. Employers derived other tools of labor discipline from the ideology attached to informal care work, employing the rhetoric of “obligation, duty, and guilt” (223) to hobble worker organizing.
By the 1980s, deindustrialization—aided by cuts to social programs such as Aid to Families with Dependent Children—was tearing apart the social fabric of valley steel towns like the one I grew up in. Hospital systems, however, provided a shock absorber. Care consumption only increased, facilitated by low-wage work and debt-financed investments in new construction. Community hospitals in small steel towns were no longer sustainable under this highly commodified model of care and were soon absorbed into regional health systems, which ultimately shuttered many of these facilities.
Beyond offering an exquisite regional economic history, The Next Shift illustrates how health care became a primary mechanism of social reproduction, allowing the American state to govern the economic and sociological consequences of deindustrialization. Health systems, generously financed by the public, would serve as regional economic stabilizers. At the same time, the provision of health care would itself become a highly lucrative vehicle for managing the symptoms of widening economic inequality.
If the portrait Winant paints of the contemporary American health care regime is bleak, he emphasizes that we should not view the situation as stable. Indeed, the book reads like a catalog of the system's contradictions: regional health systems simultaneously constitute “shock absorbers” responding to unmet social needs while generating extreme inefficiencies in doing so. Health systems react to spiraling costs not by increasing productivity but instead by maintaining an extensive army of low-wage care workers.
It is among these workers—“collectively indispensable, but individually disposable” (261)—that Winant sees the greatest potential for change. There are growing signs of labor militancy in their ranks; over the last decade, the health care industry accounted for the largest share of strikes in the United States. Whatever one makes of these figures, one thing seems certain: if the political economy of American health care is to experience a disruption in the next decades, it will not happen in the absence of mobilization from the low-paid, and often underinsured, workers without whom health systems would not function.
The Next Shift offers powerful lessons for scholars of health policy and politics, complementing other recent work that brings the history of capitalism into the history of medicine (Chapin 2020). Most importantly, Winant shows that when we examine health policy as the product of a relatively autonomous set of political processes, we lose our ability to see how economic transformations, as well as collective responses to those changes, have molded its contours. As a result, political scientists are far better at describing the pathological American health care regime in static terms, or considering which policy solutions might generate a minimum winning coalition, than they are at identifying the conditions for a meaningful disruption of this system. Yet by shifting our attention away from the halls of Congress, as Winant does, and toward sites of class formation—the workplace, the home, and the community—we can better appreciate the regime's internal contradictions and vulnerabilities. Taken together, such analyses might form a map to the sites of an ongoing struggle.
