A dozen years ago, I visited the Chicago offices of the National Nurses Organizing Committee on the city’s West Side. Visible through a large window was a gigantic parking garage, an annex to one of the equally huge hospitals clustered within a dozen blocks. Cook County, Mount Sinai, and three other medical complexes employed tens of thousands of workers. Among those seeking to organize them was an African American NNOC staffer.

She told me she was the daughter of an autoworker in Flint, Mich., who’d been a militant in his union during the heyday of the battles waged between the United Auto Workers and General Motors. In Flint, she became a radical activist, inspired by the power of the UAW and the moral energy of the civil rights movement, and in time made a career as a union organizer of nurses and other health care workers.

Hearing her story, I was moved by this example of intergenerational working-class militancy, from her father’s activism in a manufacturing sector now in brutal disarray to her own shop-floor organizing in the booming world of metropolitan health care. But what I did not understand was the degree to which these two kinds of employment were dialectically connected, not just in terms of the consciousness of the workers but also as a product of the very same political economy that had decimated Chicago’s steel mills and Michigan’s auto plants. The old industrial unions had bargained not just for higher wages but for pensions and health insurance. As these unions declined, the private welfare states they had done so much to construct became central to the economies of these Rust Belt cities. With money from the federal government, new hospital complexes arose across the Midwest and Northeast, and with them, a new working class filled the economic and social vacuum left by derelict mills and factory towns.

Gabriel Winant charts the rise of this new political economy and working class in his terrific new book, The Next Shift. A study of the decline of steel and the rise of a medical-industrial complex in Pittsburgh, it explains how and why this great social, economic, and moral transformation took place in regions like Western Pennsylvania, where an old world of mid-20th-century steel mills, coal mines, and metal-bending shops was soon replaced by a new one of care work, low wages, racial stratification, and heavily female employment. Offering fine-grained details of shop-floor industrial relations, the book is at once an ethnographic probe into the lives of working-class families and a comprehensive analysis of the larger dynamics of the US political economy, and it gives an expansive new meaning to the community study, which has long been a staple of labor history.

At 64 stories, the US Steel Tower dominates downtown Pittsburgh. Completed in 1971, the modernist skyscraper once represented the power and hubris of the largest corporation in one of the nation’s largest and most profitable industries—a company that employed more than 100,000 workers in the metropolitan Pittsburgh region alone. But by 2007, US Steel had become, like many of its rivals, a shadow of its former self, and a new enterprise, the University of Pittsburgh Medical Center, was the building’s largest tenant. As the employer of 92,000 health care workers in the region, the UPMC had spent nearly $1 million to place its initials in giant illuminated letters on the building. Looming over the city from all three sides of the tower, the letters symbolized more than just the medical center’s growing dominance over Pittsburgh’s economy; they were also evidence of a profound occupational transformation. The most recent regional census recorded 190,000 health care and social assistance workers, compared with just 30,000 still employed in the metal fabrication industries.

Pittsburgh was not alone in this transformation. Early in his book, Winant lists the other postindustrial metropolises where health care employment is disproportionately high, constituting a fifth or sixth of the entire workforce. Almost all of them are Northern cities like Boston, Cleveland, Philadelphia, Pittsburgh, and New York (the boroughs of Brooklyn and the Bronx in particular). And like Pittsburgh, these are cities where strong unions and collectively bargained health insurance plans once thrived, and where the money negotiated by labor from corporate coffers seeded a care economy that took on a life of its own.

As Winant shows, hospital growth was not just a question of money, bargaining clout, or political influence. The care economy in Pittsburgh and similar cities expanded not only because of the achievements of organized labor but also because of what happened after union members retired: Industrial workers in these cities relied on the hospitals, nursing homes, and health care services as they aged and the giant mills shut down.

As deindustrialization took root in Pittsburgh, Winant argues, the communalism and solidarity that the working class had once invested in parishes, neighborhoods, and union locals were now to be found in health care and its allied social services. This was an epochal transformation, but it was hardly triumphant. The construction of this new economy, and the proletariat that sustained it, was deeply racialized, highly dependent on the devaluation of women’s labor, and protective of only a limited stratum of the overall population.

To understand the impulses that gave rise to these urban welfare states and the dysfunctions they embodied, Winant offers a penetrating examination of mid-20th-century working-class Pittsburgh, both on and off the job. Today, a great deal of nostalgia colors the picture of blue-collar America from the end of World War II to the early 1970s. Liberals and labor partisans call this era the Great Compression, one in which unions were powerful, real wages doubled, inequality declined, and the civil rights movement transformed the nation; conservatives hail the social norms and practices that put the male breadwinner at the head of the household, kept wives at home, assured the loyalty of workers to their employer, and maintained the stabilizing influence of the parish church in close-knit ethnic communities.

Winant’s narrative draws from and transcends both of these perspectives. Work in the steel mills did generate a sense of dignity, masculinity, and comradeship, but these were combined with enough danger, insecurity, and petty humiliation to subvert Fortune magazine’s claim that unionism and postwar prosperity had made the American worker a “middle-class member of a middle-class society.” If you didn’t bring a dinner pail to work, the rats would often eat your lunch. There was no place to sit, and the heat and smoke could be debilitating. Almost every steelworker had a near-death experience at some point.

The USW pushed the companies to pay their workers enough to afford a house and raise a family, Winant writes, but the postwar decades were punctuated by recessions and strikes that slashed take-home pay and generated the kind of anxieties that deformed family life for years. The historian Daniel J. Clark makes the same point in his recent Disruption in Detroit: Even as the automakers set new production records, layoffs, plant closures, and short workweeks were an endemic experience, and neither the union nor the Big Three could do all that much about it. Working-class precarity is not entirely new.

Poor conditions in the factories were exacerbated by the relentless management drive to increase shop-floor productivity. Steel industry capitalists were conservative in the most profound sense: They feared debt, overcapacity, foreign competition, and union or government efforts to shape steelmaking’s future. To maintain profitability and avoid the inflationary price hikes that weakened the US dollar, managers tried to squeeze their employees by slashing crew sizes, intensifying work, and turning foremen into compliant disciplinary agents. All this culminated in the largest strike in US history, a four-month work stoppage in 1959 that Winant calls the “apex of proletarian manhood for a generation of steelworkers,” though it is now long forgotten. At the time, the sociologist Daniel Bell called it something close to a sham, a “subversion of collective bargaining,” because he thought both management and union leadership cynically used the long strike to channel and demobilize worker discontent.

As Winant argues, the 1959 strike was far more than just a way for the rank and file to blow off steam over workplace frustrations. It was as raw a contest between labor and capital as anything Friedrich Engels or Eugene V. Debs witnessed in the mills of 19th-century Manchester, England, or the Chicago rail yards. The capitalists wanted the unilateral right to extract more labor power from nearly 1 million workers without an investment in new technology. The fight eventually made its way to the halls of Congress and the White House, where even Richard Nixon, then the vice president, saw that working-class militancy in the Steel Belt was genuine and potentially dangerous. As a result, the steelworkers won: They stymied the management offensive and even got more money in every paycheck.

But as with so many other strike battles and political fights in the heyday of postwar unionism, the labor movement lacked the power, the political allies, or the vision to transform momentary victory into a lasting triumph. Many unions, including the USW, were becoming as stolid and complacent as the steel industry’s management. They thought American capitalism was on an upward trajectory that required little more than a Keynesian economic tweak and a collective bargaining routine to see that workers got their fair share of the profits. Yet with the rise of foreign competition and the failure of either government or management to modernize the mills, the 1970s instead inaugurated a disastrous decade for heavy manufacturing and its workers.

Except for Pentagon-backed programs, the United States had no Japanese- or German-style industrial policy that might have preserved steel industry jobs. Neither did the government attempt to find some other kind of dependable and humane employment for this shrinking industry’s workers. Winant might well have explored such alternative possibilities, which in the 1970s and ’80s were vigorously advocated by such disparate figures as Ira Magaziner and Robert Reich, who urged an industrial policy during the Clinton administration, and Edward Sadlowski, whose New Left–ish campaign for USW president in the mid-1970s challenged the unimaginative leadership of his union. But Winant does tell us what actually happened: In the absence of concrete alternatives, Pittsburgh-area steelworkers confronted a social disaster out of which sprang a very different path toward income, security, and family welfare.

I[/dropcapn Pittsburgh and elsewhere, reproduction was just as important as production. If social citizenship was forged in the factory, it was distributed to the population via the family, which constituted the “social machinery,” as Winant terms it, that linked the process of daily life to the rhythms of industry. The working of this machinery was imperfect and arduous: If the man came home from the late shift, a spouse or daughter had to have a midnight dinner on the table; during a long layoff, the women stretched the family budget, borrowed from relatives, or went out to work themselves. Women in the mill towns learned what different sirens and whistles meant. “We used to run to grab our clothes off the line when we saw big clouds of smoke coming from the mills!” declared one housewife, who described herself as ”an unpaid clean-up woman for industry.”

But regardless of how grueling and constant the women’s work was, this mythology of the early postwar decades—that men’s work deserved to be paid while women’s was an innate labor of love—remained largely intact. Yet as the city’s industrial economy began to weaken in the 1970s, workers started to look for an institutional mechanism that could sustain this often feminized work in an era of economic chaos, and they found it in the hospitals and social services that were the one segment of the US welfare state that continued to have funding.

Many of these hospitals, built or expanded upon in riverside steel towns, seemed to embody the communitarian values that had flourished in the ethnic neighborhoods that hugged the hills above the mills. Not unexpectedly, hospital visits were disproportionately high in southwestern Pennsylvania. By 1978, the region generated 1,366 inpatient days per 1,000 people, compared with a national average of 1,192. The population was aging, the pollution rife, and the work hazardous, but steelworkers and their families also saw health care as the keystone of a communal welfare state they had helped to build. Hospital visits were “very good experiences,” one working-class spouse recalled. “The nurses were always nice and the doctors were always there to take care of any problems.”

And the money was there as well. Once the Supreme Court ruled in 1949 that collective bargaining over health insurance was a legitimate union goal, the total annual Blue Cross payments to hospitals in Western Pennsylvania more than doubled in just five years. In Homestead, which had lost half its population since 1940, the local hospital was booming. When Medicare came into existence in 1965, it generated a raft of new clients over the age of 65, accounting for more than one-third of the inpatient days there.

The financialization of hospital construction and operation soon followed. With the interest rates on semipublic hospital bonds a couple of percentage points lower than on comparable debt, and with a cash flow guaranteed by the federal government, Pittsburgh’s hospitals became machines for turning Medicare and Blue Cross payments into debt service for private bondholders. Thus, in 1973, a hospital executive in Homestead defended a controversial expansion program by saying, “Investment bankers were willing to buy $27.5 million worth of bonds. That’s good enough for me.” Throughout the 1970s, as the steel mills crumbled, long-term hospital debt doubled.

One of the most remarkable features of this financialized system of health care became apparent in the era of austerity that started after 1979, when Federal Reserve Board chair Paul Volcker pushed interest rates to nearly 20 percent in his merciless attack on chronic inflation. Capital-intensive industries like steel were devastated, with the impact rippling through every segment of Western Pennsylvania’s society and government. That disaster was followed by the Republican assault on the welfare state during Ronald Reagan’s presidency, with sharp cutbacks to food assistance and Aid to Families With Dependent Children, a tightening of unemployment insurance requirements, and the underfunding of job retraining programs.

Yet even as the Reagan Revolution rolled on, the health care segment of the welfare state seemed exempt from austerity. This was partly because mass unemployment generated an avalanche of maladies, from alcoholism and depression to heart attacks, thus doubling the Pittsburgh region’s volume of care from 1982 to 1985.

The peculiar organizational structure of health care, which combined public subsidy and regulation with private profit-making administration, also encouraged the proliferation of hospitals and an increasingly larger sector of nursing homes, clinics, and home health care providers in Pittsburgh. In Allegheny County, Medicare spending did much to dull the Reaganite fiscal knife, with public assistance programs accounting for more than half the revenue of Pittsburgh-area hospitals. Meanwhile, investment in those institutions soared. In terms of growth, their only rivals were jails and prisons, which were also designed to deal with the social dysfunction generated by the aftershock of radical deindustrialization.

The working-class determination to preserve company-funded health insurance played a significant role in the maintenance of these expenditures. By the late 1980s, battles over employers’ efforts to slash their health insurance expenses precipitated 90 percent of all strikes. At Pittston Coal in West Virginia, the fight went on for months, with plant occupations and mass arrests reminiscent of the 1930s. In the Pittsburgh area, the effort of LTV—the conglomerate that had swallowed the Jones and Laughlin Steel Company—to terminate retiree health insurance coverage generated such an uproar that Congress got involved, forcing LTV’s management to backtrack. As the 2017 mobilizations on behalf of Obamacare demonstrated more recently, a defense of health insurance, public or private, can generate a militancy just as potent as that evoked by issues concerning pay.

B[/dropcaput the most consequential role played by working people came from inside the hospitals and nursing homes. These institutions depended on the labor of women, African American women in particular. Black men and their families had always had a far less secure purchase on the social citizenship negotiated by the USW and other unions, so it was Black women who filled the (usually nonunionized) bottom ranks in the health care industry. By the late 1960s, 70 percent of all hospital workers were Black, and 10 percent of all African Americans employed in the Pittsburgh region worked in hospitals—a proportion that would rise in subsequent decades.

Because of the high wages paid in the steel mills, white women had mostly stayed home in the 1950s and ’60s, but hard times now drove thousands of them into the hospitals as nurses, clerical workers, paraprofessionals, and other care workers. As a 1986 management proposal for recruiting home health care aides argued, “The displaced homemaker is tailor-made for [this job] and could be said to have been in training for the position for years.”

Winant offers an exceptionally fine analysis of the time pressures and staffing shortfalls that often made life in the care economy stressful, not to mention poorly paid. What began to take place in the 1980s was the 1959 steel strike in reverse: Hospital work was far more labor-intensive than factory production, so the communalism of the small-town hospitals never stood a chance. Service work, from the retail store to the hospital ward, is notoriously difficult to Taylorize at the point where a nurse lays hands on a patient or a cashier rings up a sale. So managers became disciplinarians of the clock and shift, rationing work time while insisting that each employee satisfy the needs of an increasingly large number of clients, customers, or patients.

Management’s determination to squeeze hospital workers was exacerbated by a government revision to Medicare in 1983 that was designed to slow health care inflation by paying hospitals a fixed price for any given diagnosis, rather than for each medical procedure. This made hospital stays shorter and surgical interventions more frequent, and it put more pressure on hospital labor, now 60 percent of all expenses. Medical intervention and care provision thus became increasingly distinct endeavors—one capital-intensive, the other labor-intensive. Hence the consolidation of Pittsburgh-area hospitals into what would become the UPMC empire and the proliferation of nursing facilities and home care arrangements throughout the region. Congress had enacted the new mandate with little debate, but its consequences were huge.

Winant calls this Reagan-era innovation the health care equivalent of the Volcker shock: Squeezing consumer demand, it punished overcapacity in the old industrial centers. By the early 21st century, UPMC had become one of the several health care behemoths that play an outsize role in the political economy of metropolitan America, as influential in their own way as the steel and railroad barons of another era.

T[/dropcaphe Next Shift offers us a useful guide to the sweeping social changes that have shaped a huge segment of the economy and created the dystopian world of contemporary service-sector work. But is its narrative overdetermined? Did the collapse of the steel industry and the USW necessarily lead to such an overpriced and underpaid health care system? Were there points at which the history of the care economy might have turned a different corner?

Two instances come to mind. The first arose in the early 1970s, when it seemed as if hospital workers might follow the same union path as the school teachers, postal clerks, sanitation workers, and municipal employees who also saw racial justice and worker rights as insoluble. Health care workers proved to be drawn to unionism by the same civil rights ethos. Hospital Workers Local 1199, which sought to organize health care workers on the East Coast, lived by the motto “Soul power, union power.”

But hospital executives in Pittsburgh and elsewhere countered this appeal in a variety of ways. Claiming that Local 1199 was more of a disruptive civil rights organization than a union, they appealed to the sanctified philanthropic ideal inherent in health care service: It was one thing not to pick up the garbage, another to neglect sick patients. Those management strategies would fade as health care became increasingly bureaucratized, but by then hospital executives across the nation had found a new strategy: hiring a phalanx of highly sophisticated union-avoidance law firms to snuff out organizing. Union density among health care and social service workers has long been stuck at 7 percent nationwide, which means that whenever the reform of health care does happen, the voices of hospital and nursing home workers will remain largely absent.

A second turning point came in the 1990s, when Bill and Hillary Clinton advanced their plan to reduce the costs and expand the coverage of US health insurance. Their plan was more radical than the one eventually enacted by the Obama administration. It would have forced low-wage service-sector businesses to cover their own employees and thereby pay a much larger share of the nation’s total health care expenses. That would have incentivized the Walmarts, the McDonald’s, and the hospitals to offer more full-time employment. And despite the Clintons’ denials at the time, their plan approached a de facto single-payer system at the state and metropolitan levels. Under this plan, a series of quasi-governmental health insurance purchasing alliances would have virtually monopolized payments to hospitals, nursing homes, and doctors for all employers except the largest.

The steel industry, along with other unionized manufacturing firms, were solidly in the Clinton plan’s camp: They would have saved a huge sum of money if the federal government had cracked down on hospital costs and helped pay for the insurance of their retirees while making the low-benefit freeloaders in the service sector pay their fair share. But as with unionization efforts, this reform was stillborn. The Clintons’ legislative effort was tardy and maladroit; more important, the GOP was intransigent, and the big insurance companies bailed on the plan when they saw themselves being turned into government-regulated utilities.

Had the steel industry and other manufacturers retained their mid-20th-century power, had their unions been as large and as potent, they might well have countered the political hostility of the big hospitals, insurance companies, and retail-sector employers to push some version of the Clinton plan over the finish line. But Big Steel, as well as its unions, no longer occupied the commanding heights of the American economy. When it came to social policy, the terrain of conflict had shifted to the economic world of sales, care, and services. But while the steel industry may have been doomed to wither, there is nothing inherent in service work that consigns the millions laboring in such occupations to precarity and poverty.

The low pay and insecurity of service workers became abundantly clear last year when they won the honorific “essential workers.” Frontline hospital workers—not to mention grocery clerks, nursing home employees, and warehouse workers—briefly achieved the visibility and applause long denied them. Winant wrote The Next Shift before the Covid-19 pandemic added another layer of social trauma to our already misshapen economy. But his book makes clear that only a radical reconfiguration of the way that health care and other services are delivered to the American people can enhance the dignity and well-being of workers in the caregiving economy. American hospitals and their satellite enterprises must be stripped of their profit-making, empire-building propensities. And for that to happen, we will need to embrace the inherent socialization that must govern health care in our time.