The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America

The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America, by Gabriel Winant (Cambridge, MA: Harvard University Press, 2021)

Gabriel Winant’s study of the deindustrialization of Pittsburgh and its surrounding mill towns in the latter half of the twentieth century asks: “How did Steel City become a city of nursing assistants?”  (p. 7) The same question might be asked of such New York State cities as Binghamton, Syracuse, Rochester, and Buffalo. These cities also saw their dominant industries and sources of employment atrophy: shoe manufacturing and business machines in Binghamton; machine manufacturing in Syracuse; Eastman Kodak and Xerox most notably in Rochester; and steel, chemicals, and autos in Buffalo. Today all five cities feature economies marked by a mixed private-public health care system linked to their primary research universities. Across rust-belt America industrial work has given way to personal care labor in which most workers live precariously without job security or union recognition. Exit not voice remains their primary means of resistance.

Winant dissects the process as it evolved in the Pittsburgh metropolitan region from the end of World War II to the turn of the twenty-first century. At war’s end steel and its satellite enterprises dominated the local economy. War had secured the place of the United Steelworkers of America in the industry and brought job security in good times through union shop contracts. In Winant’s analysis of postwar labor relations, rather than a labor-capital accord prevailing, corporations and unions waged a cold war. Inflationary pressures during the postwar economic readjustment, the Korean war years, and the Vietnam war era led the union to demand contracts with cost-of-living wage adjustments (COLAs). In reaction employers sought to intensify work and to eliminate contractual rules that impinged on their ability to define job standards or to reassign workers. During the industrial cold war, the union wrested two vital worker benefits from the companies: employer-funded health care and defined-benefit pensions to supplement Social Security. The former established the basis for the private health care system that came to dominate the Pittsburgh economy at the end of the century.

Despite the relative strength of their union and the benefits it won for steelworkers, the everyday life of Pittsburgh area workers, as described by Winant, was anything but stable and prosperous. Recurrent industry recessions, frequent strikes, and injuries and deaths on the job brought unemployment and pain. The world of labor in the Pittsburgh region resembled the workers Harvey Swados depicted in his essays about the myths of the powerful and happy worker rather than John Kenneth Galbraith’s citizens of an affluent society. Winant stresses that life was always far less secure and more penurious for Black workers. Only personal relations formed among and within white ethnic groups and family units made daily life tolerable. Winant is especially sensitive to gender dynamics in the household and the labors borne by working-class wives who remained responsible for nearly the entire burden of social reproduction. Everyday life for working class families caused health problems that made employer-funded health insurance necessary, and local hospitals, especially those in mill towns, essential and trusted community institutions.

The steel industry experienced steady decline and then rapid deterioration as the stagflation of the 1970s and competition from more efficient foreign producers eroded markets for domestic steel. U.S. Steel, Jones & Laughlin, and smaller Pittsburgh area firms had enormous sunk capital that had been invested during the halcyon production days of World War II and the immediate postwar decades while foreign competitors whose production facilities had been destroyed during the war or who were new to steel production invested in the most technologically advanced and productive machinery. As its markets atrophied while its basic wages and employee benefits grew more costly, steel companies stopped hiring, laid off workers with the least seniority, and employed an aging labor force. By the end of the 1980s Jones & Laughlin, victim of a friendly corporate takeover, collapsed into bankruptcy and U.S. Steel shifted investment into oil and other non-metal enterprises, a prelude to the closure of most of the district’s mills. By early in the twentieth-first century the site of the great Homestead Steel Works along the Monongahela River at the foot of the village of Homestead had been transformed into an enormous shopping mall. Only the plant’s small pump house remained as a reminder of what once had been a mammoth steel mill.

In such mill towns as Homestead, Braddock, and McKeesport, the young fled, leaving behind a smaller aging population. In Pittsburgh proper young workers and unemployed steelworkers could find employment in the health sector and various precarious occupations. Where once employment in steel and the metal trades was overwhelmingly male, in health and care services women dominated. As Winant notes, this transformation in the labor market upended customary gender relations within working-class families. Where once men served as primary breadwinners and their wives as housekeepers and the managers of social reproduction, now women often became primary wage earners and social reproduction drew on public resources. Simultaneously, the population of Pittsburgh and especially its mill towns grew less white and more impoverished. White residents who achieved economic affluence fled the inner city and especially the mill towns for a greener, more pleasant life in the expanding suburbs. Left behind was an older, less healthy, Blacker, and more impoverished population.

The altered demography of the district increased the demand for health services. Beginning in the late 1960s Medicare and Medicaid expanded the market for health care exponentially. By the closing decades of the twentieth century health care became a leading source of business profit. Blue Cross, which had originated as non-profit agency to manage in-hospital health care for steel company employees, transformed itself into a for-profit health insurance agency. Smaller regional hospitals were acquired by larger competitors and the University of Pittsburgh Medical Center (UPMC) became the dominant institution in the area’s health services market. As the costs of health care rose inexorably, smaller, more marginal hospitals either closed or merged into the UPMC. Pressure to contain the rising costs of Medicare, Medicaid, and private insurance led UPMC and its competitors to intensify the work loads of their nurses, housekeepers, food service and lab workers. Where once combative labor relations and strikes had wracked the steel industry by the late twentieth and early twenty-first centuries such strife, as Winant notes, marked labor relations in health care.

Winant’s tale of how Pittsburgh evolved from a smoke-filled industrial city to a rust-belt industrial site and to today’s sparkling site of health care services and higher education is a story replicated by a number of former rust belt cities blessed with well-endowed research universities and their associated medical schools. His description of what happened to such mill towns as Homestead and Braddock left behind with their aging infirm or impoverished nonwhite majorities resembles the fate of rust-belt cities without major universities or medical schools. And his analysis of how the Pittsburgh health services market came to be controlled by two providers describes how mega-corporations rose to dominate the national economy.