The Health Care Crucible (Review)
The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America by Gabriel Winant. Harvard University Press, 368 pages.
BEFORE THE DECISIVE SHIFTS of the late 1970s and early 1980s reconstituted the economies of the Global North, politics turned on the management of labor and capital. But since the end of the post-war boom—and with it the era of full employment—our social order has to an increasing degree revolved around the question of how to manage those populations now denied access to the American dream. As unemployment has repeatedly spiked since the 1970s while the meager leftovers of the New Deal state have been slowly dismantled, so those populations who have clung on to society’s precarious fringes have proved to be an intractable problem.
If such concerns could once be ignored by those in the liberal establishment, even while discontent simmered at the margins, then the election of Donald Trump, with his repeated promises to bring industry back to Rust Belt towns, brought them once more to national attention. Even as Trump’s promises proved hollow, political pundits have continued to prod the open wounds, each one armed with their own diagnoses and each clasped tight to a patronizing image of the working class—invariably white and male, and almost always the holder of reactionary opinions. This is the Hillbilly Elegy story, often told by those who struggled and strived to drag themselves out of the stagnating pond of Rust Belt America, then perpetuated by liberal and conservative pundits ad nauseam. What we’re far less likely to hear is what became of those who never made it out.
When industries left the United States, whether because of offshoring, automation, capital flight, or a combination of all three, they took with them the jobs that had long sustained large swaths of the industrial working class. Capital is inherently mobile, always on the move, looking for new and more productive avenues for investment; it cannot (nor would it want to) take the workers with it. The problem with people is that they are rooted in particular places, embedded in specific communities. The ties that bind are strong, forming the country’s dense social fabric. Or they were, once. In many communities, deindustrialization left a social fabric that was wearing thin and a population that was, in the words of historian Gabriel Winant, “poorer, sicker, and older.”
Paul Brooks was forty-eight when he lost his job as a truck driver hauling steel from the mills near his home in Vanport, Pennsylvania. After the steel mill that he worked for closed in 1982, he spent the next twelve years in and out of work, sometimes driving a truck for a local bakery and later picking up steel from the area’s few remaining mills. His wife, Dorothy, took work as a sales clerk to help cover the living expenses for herself, Paul, and their ten children. By the mid 1990s, a broken shoulder left Dorothy unable to work, and the family were living on social security checks and the small pension Paul received from the Teamsters’ Union. Then doctors found a lump on Paul’s larynx. In 1996, the couple were struggling with mounting medical debt and rising living expenses, their finances stretched to breaking point. A pending round of state-level cuts to Medicaid felt to the couple like a “form of euthanasia.” “I’m scared,” Dorothy told the Pittsburgh Post-Gazette, “God forbid I should get some type of illness.”
Such stories, recounted in Winant’s new book The Next Shift, are not uncommon in America’s Rust Belt. As manufacturing fled areas like Brooks’s home near Pittsburgh, the lives of those who relied on it started to disintegrate. The aspects of the welfare state that remained plugged some gaps, but little else. In The Next Shift, which deftly charts the twin processes of deindustrialization and the rise of the health care sector in Pittsburgh, Winant sets out to present a broader narrative than the one often given in discussions of America’s long downturn from the 1970s to today. The factories of industrial America didn’t just make steel or cars or the vast mountains of consumer products that fueled postwar growth; they also made whole social worlds. Work doesn’t end when the hard-hatted laborer clocks off for the day. It relies on the labor of whole communities, of families and friends, and the informal and formal networks of care and support that they sustain. In turn, such social labor makes and remakes those very same communities.