What do you think?
Rate this book
The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America
Winner of the Frederick Jackson Turner Award
Winner of the Isaac and Tamara Deutscher Memorial Prize
Winner of the C. L. R. James Award
A New York Times Book Review Editors’ Choice
A ProMarket Best Political Economy Book of the Year
“The Next Shift is an original work of serious scholarship, but it’s also vivid and readable…Eye-opening.”
―Jennifer Szalai, New York Times
“A deeply upsetting book…Winant ably blends social and political history with conventional labor history to construct a remarkably comprehensive narrative with clear contemporary implications.”
―Scott W. Stern, New Republic
“Terrific…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.”
―Nelson Lichtenstein, The Nation
Pittsburgh was once synonymous with steel, but today most of its mills are gone. Like so many places across the United States, a city that was a center of blue-collar manufacturing is now dominated by health care, which employs more Americans than any other industry. Gabriel Winant takes us inside the Rust Belt to show how America’s cities have weathered new economic realities.
As steelworkers and their families grew older, they required more health care. Even as the industrial economy contracted sharply, the care economy thrived. But unlike their blue-collar predecessors, home health aides and hospital staff work unpredictable hours for low pay. Today health care workers―mostly women and people of color―are on the front lines of our most pressing crises, yet we have been slow to appreciate that they are the face of our twenty-first-century workforce. The Next Shift offers unique insights into how we got here and what could happen next.
Winner of the Isaac and Tamara Deutscher Memorial Prize
Winner of the C. L. R. James Award
A New York Times Book Review Editors’ Choice
A ProMarket Best Political Economy Book of the Year
“The Next Shift is an original work of serious scholarship, but it’s also vivid and readable…Eye-opening.”
―Jennifer Szalai, New York Times
“A deeply upsetting book…Winant ably blends social and political history with conventional labor history to construct a remarkably comprehensive narrative with clear contemporary implications.”
―Scott W. Stern, New Republic
“Terrific…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.”
―Nelson Lichtenstein, The Nation
Pittsburgh was once synonymous with steel, but today most of its mills are gone. Like so many places across the United States, a city that was a center of blue-collar manufacturing is now dominated by health care, which employs more Americans than any other industry. Gabriel Winant takes us inside the Rust Belt to show how America’s cities have weathered new economic realities.
As steelworkers and their families grew older, they required more health care. Even as the industrial economy contracted sharply, the care economy thrived. But unlike their blue-collar predecessors, home health aides and hospital staff work unpredictable hours for low pay. Today health care workers―mostly women and people of color―are on the front lines of our most pressing crises, yet we have been slow to appreciate that they are the face of our twenty-first-century workforce. The Next Shift offers unique insights into how we got here and what could happen next.
368 pages, Paperback
First published March 23, 2021
Ratings & Reviews
Friends & Following
Create a free account to discover what your friends think of this book!
Community Reviews
Displaying 1 - 30 of 84 reviews
December 14, 2020
Will write things elsewhere but: read it if you have even a passing interest in that thing we often call without much awareness of what we mean, "the working class."
November 29, 2022
One of my top books of the year, and for sure my favorite in political economy. A shining example of how to write about huge economic shifts while staying close to the ground, in the factory, in the home, on the street, in the hospital, and so on.
I write about and work in health care, and this book really made a lot of things click for me. Health care focused authors all seem to agree that something shifted with fiscal crises in the 70s, but have no explanation for why or even consensus around what those shifts even were. Lots of economists and Marxists have accounts for what happened, but this is the book that, for me, finally connected the long downturn and stagflation to the experience of the hospital. It also has the most convincing explanations for the contradictions of this moment (which in its most basic form is: if we experienced a major slump and fiscal crisis, why did funding for health care tend to rise just as manufacturing began to decline?)
I write about and work in health care, and this book really made a lot of things click for me. Health care focused authors all seem to agree that something shifted with fiscal crises in the 70s, but have no explanation for why or even consensus around what those shifts even were. Lots of economists and Marxists have accounts for what happened, but this is the book that, for me, finally connected the long downturn and stagflation to the experience of the hospital. It also has the most convincing explanations for the contradictions of this moment (which in its most basic form is: if we experienced a major slump and fiscal crisis, why did funding for health care tend to rise just as manufacturing began to decline?)
August 3, 2021
This is a great book. Winant's ability to trace Pittsburgh's history from the 50's to the 90's, and connect the relationship of labor between different industries is brilliant. This is really the crux of what makes the book so good. Winant consistently does an excellent job of analyzing the relationships between labor, politics + policy at a national and local level, housing, race, gender, economics, and really everything.
I also found Winant's writing not overly heavy handed or deterministic, which he admits in the introduction. Although I think his analysis somewhat speaks for itself, he doesn't use excessive language or tone to strike specific policies as "good" or "bad." Evidence is mostly written as it occurs. That said his prose/writing itself wasn't overly impressive. His writing comes off a bit formulaic, which is probably right for this type of book. I also appreciated the many many anecdotes to support his story.
With all of that said, I do think the book feels incomplete. A great amount of care was taken to tell Pittsburgh's history from the post war era through to the early 90's, but the remaining years are blazed through in about 20/30 pages. The book is still certainly worth reading and to some extent I can interpret that the post Clinton years don't change the story he's telling, but I would have enjoyed their inclusion anyway. The direction of UPMC/BCBS/Highmark/etc domination is signaled but how that manifested and continues to do so today would have been pretty interesting.
Another few "gripes," one related to the prior sentence, the proliferation of dominant and oligarchic hospital/insurance networks are emerging/already present (mostly already present) across the country. I recall some mention of how the story of Pittsburgh was chosen as sort of an explainer for other cities, but that proliferation of oligarchies is our current day reality, and I would have loved more analysis on what to do with it outside of a few pages in the Epilogue.
This directly flows into my final gripe, where I really would have liked a lot more on "what to do." I guess this was really more of a history book than a prescriptive policy solution, which is fine, but I always find it underwhelming and a bit frustrating when you read a book that spends a lot of time telling you about problems, with a response solution that could be summed up into like 2 sentences. "Create a new working class solidarity with an emphasis on healthcare workers. Also, get single payer/nationalized healthcare."
Obviously, I agree with the above solutions, but Winant spends a lot of time getting into the detail and weeds of industrialization, neighborhoods, healthcare policy, hospital acqusition, Medicare payment models, etc and you would like to see at least one chapter detailing how to improve/develop those moving forward. Then again, I guess this goes back to the earlier thing I praised him for where I said he explicitly wasn't heavy handed. Whatever, I still wanted one chapter of his personal ideas.
Anyway, I rambled and did an enormous review that is entirely too long. Read this book. It's wonderful even if there's a few more things I wish he wrote about.
I also found Winant's writing not overly heavy handed or deterministic, which he admits in the introduction. Although I think his analysis somewhat speaks for itself, he doesn't use excessive language or tone to strike specific policies as "good" or "bad." Evidence is mostly written as it occurs. That said his prose/writing itself wasn't overly impressive. His writing comes off a bit formulaic, which is probably right for this type of book. I also appreciated the many many anecdotes to support his story.
With all of that said, I do think the book feels incomplete. A great amount of care was taken to tell Pittsburgh's history from the post war era through to the early 90's, but the remaining years are blazed through in about 20/30 pages. The book is still certainly worth reading and to some extent I can interpret that the post Clinton years don't change the story he's telling, but I would have enjoyed their inclusion anyway. The direction of UPMC/BCBS/Highmark/etc domination is signaled but how that manifested and continues to do so today would have been pretty interesting.
Another few "gripes," one related to the prior sentence, the proliferation of dominant and oligarchic hospital/insurance networks are emerging/already present (mostly already present) across the country. I recall some mention of how the story of Pittsburgh was chosen as sort of an explainer for other cities, but that proliferation of oligarchies is our current day reality, and I would have loved more analysis on what to do with it outside of a few pages in the Epilogue.
This directly flows into my final gripe, where I really would have liked a lot more on "what to do." I guess this was really more of a history book than a prescriptive policy solution, which is fine, but I always find it underwhelming and a bit frustrating when you read a book that spends a lot of time telling you about problems, with a response solution that could be summed up into like 2 sentences. "Create a new working class solidarity with an emphasis on healthcare workers. Also, get single payer/nationalized healthcare."
Obviously, I agree with the above solutions, but Winant spends a lot of time getting into the detail and weeds of industrialization, neighborhoods, healthcare policy, hospital acqusition, Medicare payment models, etc and you would like to see at least one chapter detailing how to improve/develop those moving forward. Then again, I guess this goes back to the earlier thing I praised him for where I said he explicitly wasn't heavy handed. Whatever, I still wanted one chapter of his personal ideas.
Anyway, I rambled and did an enormous review that is entirely too long. Read this book. It's wonderful even if there's a few more things I wish he wrote about.
June 28, 2021
There is a significant part of the health care work force that is low paid, poorly treated, and precarious in its status and stability as a source of work upon which workers can build their lives. If you examine this work force in more detail, it will also be clear that its marginal precarious status is associated with the ethnic and gender identities of its workers. That comes across clearly in Gabriel Winant’s recent book on the rise of health care as a critical industry in post-industrial Pittsburgh.
My difficulty with this is that I already knew this. The evolution of US health care into a major economic sector that leads the world in pricing but is also associated with major health care disparities in the population is a well known story. The economic details of this evolution are well known and copiously documented, most recently by Dranove and Burns earlier this year. The rise of temporary and highly precarious parts of the national workforce is also a well covered phenomena that goes well beyond healthcare in its coverage. This new “temp” economy is hugely difficult to consider whether you are a worker or a consumer of temp services.
So what does Professor Winant’s book add to this? He provides a particular story that has not received as much attention as it should have received. The claim is that the service-based portion of the health care industry that rose to prominence in Pittsburgh developed as a response to deindustrialization in the area from the late 1950s through to the 1970s and 1980s. The strong position of minority females in this sector stems from the prior position of these workers in the regional economy, especially their greater need to work rather than stay home, their weaker community structures, and their greater experience as domestics, before that part of the service sector was attenuated by broader business downturns. This is what contributed to making low pay health care service work into an archetypical employment area of the post-industrial economy.
Ok, this is an interesting story. What’s the problem? To start with, this story does not really show up for consideration until about halfway through the book. A large portion of the book in an interview and case study based examination of family life during the heyday of the era in Pittsburgh of steel industry prosperity and its subsequent decline. This is important to the major arguments, in that black families were for several reasons more vulnerable to the economic consequences of business downturns that were the white ethnic steelworker families and their communities. So far so good, but the consolidation of local healthcare markets did not really take off until the 1990s.
The analysis of steelworker communities and their decline could also contribute to studies of what happened to white working class communities where their work went away - related to the Case and Deaton research (which receives some mention by Winant) - although this is not well developed in the book. The rich story of Pittsburgh history is good, but health care consolidation has produced concentrated local markets throughout the US. It would be interesting to know how well the racial/ethic history so important here was important in other areas or whether precarious health care labor markets have developed for other reasons as well.
My difficulty with this is that I already knew this. The evolution of US health care into a major economic sector that leads the world in pricing but is also associated with major health care disparities in the population is a well known story. The economic details of this evolution are well known and copiously documented, most recently by Dranove and Burns earlier this year. The rise of temporary and highly precarious parts of the national workforce is also a well covered phenomena that goes well beyond healthcare in its coverage. This new “temp” economy is hugely difficult to consider whether you are a worker or a consumer of temp services.
So what does Professor Winant’s book add to this? He provides a particular story that has not received as much attention as it should have received. The claim is that the service-based portion of the health care industry that rose to prominence in Pittsburgh developed as a response to deindustrialization in the area from the late 1950s through to the 1970s and 1980s. The strong position of minority females in this sector stems from the prior position of these workers in the regional economy, especially their greater need to work rather than stay home, their weaker community structures, and their greater experience as domestics, before that part of the service sector was attenuated by broader business downturns. This is what contributed to making low pay health care service work into an archetypical employment area of the post-industrial economy.
Ok, this is an interesting story. What’s the problem? To start with, this story does not really show up for consideration until about halfway through the book. A large portion of the book in an interview and case study based examination of family life during the heyday of the era in Pittsburgh of steel industry prosperity and its subsequent decline. This is important to the major arguments, in that black families were for several reasons more vulnerable to the economic consequences of business downturns that were the white ethnic steelworker families and their communities. So far so good, but the consolidation of local healthcare markets did not really take off until the 1990s.
The analysis of steelworker communities and their decline could also contribute to studies of what happened to white working class communities where their work went away - related to the Case and Deaton research (which receives some mention by Winant) - although this is not well developed in the book. The rich story of Pittsburgh history is good, but health care consolidation has produced concentrated local markets throughout the US. It would be interesting to know how well the racial/ethic history so important here was important in other areas or whether precarious health care labor markets have developed for other reasons as well.
April 20, 2023
As a Pittsburgher born into a former steel-industry family, it was amazing getting to witness the ways in which the patterns Winant identified mapped directly onto my family’s history. From displacement from the former manufacturing industry/industries into low-waged “unskilled” labor that inscribed itself on my family’s bodies, the material conditions that I call my life were directly determined by the subjects discussed in this analysis. I am thankful for this text and the language it has given me — as a leftist and as a Pittsburgher — to describe the history that my family and I have lived.
A powerful example of effective and articulate leftist writing that demonstrates exactly how social systems develop and entrench themselves in our daily existence; a powerful and resonant demonstration of how policy maps itself onto the lived experiences of an entire region.
A powerful example of effective and articulate leftist writing that demonstrates exactly how social systems develop and entrench themselves in our daily existence; a powerful and resonant demonstration of how policy maps itself onto the lived experiences of an entire region.
October 21, 2026
so well crafted, researched and written. has to be read with winant's lecture for his deutscher prize, this is what historical materialist class analysis looks like. immediately made me want to know how one could extend his analysis of pittsburgh's deindustrialisation to other, european, contexts, where health care was initially nationalised but is now similarly (but not to the same extent, of course) commodified as in the US (and what that means for working-class formation).
June 27, 2025
2.5 stars. Probably the most interesting book about the decline of steel in Pittsburgh that I've ever read, though it's still mostly pretty dry.
This is the first of a couple of books I picked up recently about Rust Belt cities in the US. I'm reading them in an attempt to get behind the media portrayal and understand just why people in these communities feel so let down by the political establishment. There was so much hoo-ha about the Rust Belt surging Trump into power for a second time that I felt compelled to get an inkling as to why they felt that way.
There are some interesting parts of 'The Next Shift', particularly in the chapters about the machinations of the steel industry in 1950s Pittsburgh and, later, the absolute abuse and weaponisation of the healthcare industry by the political class.
But this is a classic case of me being nowhere near as interested in the minutae of those machinations as Winant is. For my money, he uses an awful lot of words - not to mention dull, litigious meandering - to basically say that working class and black people have always been fucked over by those with more power than them. Nothing eye-opening there, then.
I guess the books does what it sets out to do, i.e. chart and explore the decline of steel in Pittsburgh and the modern reliance on healthcare. And it does become clear that nobody in any administration has served these people well. But it's not particularly insightful as to why, on a practical level, people in Pittsburgh overwhelmingly voted for Trump in 2024, other than the classic feeling of being left-behind.
As I'm sure the people of Pittsburgh are finding out - and will continue to find out - Trump doesn't care about them.
This is the first of a couple of books I picked up recently about Rust Belt cities in the US. I'm reading them in an attempt to get behind the media portrayal and understand just why people in these communities feel so let down by the political establishment. There was so much hoo-ha about the Rust Belt surging Trump into power for a second time that I felt compelled to get an inkling as to why they felt that way.
There are some interesting parts of 'The Next Shift', particularly in the chapters about the machinations of the steel industry in 1950s Pittsburgh and, later, the absolute abuse and weaponisation of the healthcare industry by the political class.
But this is a classic case of me being nowhere near as interested in the minutae of those machinations as Winant is. For my money, he uses an awful lot of words - not to mention dull, litigious meandering - to basically say that working class and black people have always been fucked over by those with more power than them. Nothing eye-opening there, then.
I guess the books does what it sets out to do, i.e. chart and explore the decline of steel in Pittsburgh and the modern reliance on healthcare. And it does become clear that nobody in any administration has served these people well. But it's not particularly insightful as to why, on a practical level, people in Pittsburgh overwhelmingly voted for Trump in 2024, other than the classic feeling of being left-behind.
As I'm sure the people of Pittsburgh are finding out - and will continue to find out - Trump doesn't care about them.
December 18, 2021
I took a while to read this one, and stopped for a long time in the middle because it was so dense. That being said, it’s really well researched and makes incisive points about labor and inequality in tracing the decline of the steel industry and the rise of the healthcare industry in Pittsburgh/it’s suburbs. Having spent a time and Pittsburgh and also two years working on healthcare market research, I’d say this book is spot on. I learned a lot too.
January 23, 2023
"The paradox of health politics is that the organizational fragmentation of the industry has allowed health care provision to stand in as a social response to rising inequality. While ever-rising health care costs appear within public debate almost exclusively as a fiscal problem, health care inflation represented, ironically, a political solution to the ravages of deindustrialization—helping to explain why systemic dysfunction has proven so politically difficult to resolve. As the fragmentary health care system presented one of the only sites with the institutional capacity to expand and respond to such social problems at scale—because it linked public resources with private profits—health policy processed economic dislocation into an epidemiology." (260)
"Two sets of compulsions thus created the new working class in health care. The first, the gendering of care work and the constitution of women as caring subjects, ran on a longer time line, operating throughout the course of the lifetime. Working-class women were produced as caring subjects in their schools, their churches, their neighborhoods, and especially their families. In the world of the single-wage household, this care served its purpose in relation to the rhythms of the industrial economy: women cooked for tired steelworkers, disciplined children into the industrial routine, cleaned up the soot from their houses, and scrimped and saved during layoffs and strikes; women tended to their people when they got old or sick. With the decline of the steel industry, however, the gendering of care work intersected with another equally powerful compulsion: economic need. While the long, slow decline of steel employment had taken a steady toll on Black working-class families for decades—creating a well-established pattern of labor force participation for Black women— things had gotten dire enough to push large numbers of displaced white women into work only in the final spasm of the steel industry." (216)
"While hospitals saw dramatic employment growth through the early 1990s, this pattern shifted with the emergence of market oligopoly. Hospital employment peaked in 1993, the inflection point in the corporate consolidation process. But even as hospital work leveled off, health care labor markets in general kept up their expansion, spreading out into other types of institutions; ambulatory facilities, nursing homes, physicians’ offices, and home care agencies all continued rapid employment growth. After another decade, health care work overall accounted for 14 percent of the regional labor force, making it easily the largest industry in the labor market, approaching the direct imprint of the steel industry in its heyday." (252)
"Hospitals, seeking to contain costs in their labor-intensive industry, faced a compulsion to maximize workers’ productivity by limiting their numbers, in the expectation that they would deliver sufficient output regardless. This expectation rested on the inherited care ethic, the cultural substrate left over from the dissolving decommodified system. Management enjoyed leverage in the fact that workers themselves would not allow the vital elements of care work to go undone." (253)
"What do we mean when we as a society call these workers “essential”? We evidently do not mean that they are owed substantive recognition or power, money or status, for their efforts. We mean, rather, that whether they like it or not, they owe us something—possibly everything. Those invested in the current unequal social order may come to regret acknowledging how much depends on these workers, demanding so much from them while offering them so little." (264)
"Two sets of compulsions thus created the new working class in health care. The first, the gendering of care work and the constitution of women as caring subjects, ran on a longer time line, operating throughout the course of the lifetime. Working-class women were produced as caring subjects in their schools, their churches, their neighborhoods, and especially their families. In the world of the single-wage household, this care served its purpose in relation to the rhythms of the industrial economy: women cooked for tired steelworkers, disciplined children into the industrial routine, cleaned up the soot from their houses, and scrimped and saved during layoffs and strikes; women tended to their people when they got old or sick. With the decline of the steel industry, however, the gendering of care work intersected with another equally powerful compulsion: economic need. While the long, slow decline of steel employment had taken a steady toll on Black working-class families for decades—creating a well-established pattern of labor force participation for Black women— things had gotten dire enough to push large numbers of displaced white women into work only in the final spasm of the steel industry." (216)
"While hospitals saw dramatic employment growth through the early 1990s, this pattern shifted with the emergence of market oligopoly. Hospital employment peaked in 1993, the inflection point in the corporate consolidation process. But even as hospital work leveled off, health care labor markets in general kept up their expansion, spreading out into other types of institutions; ambulatory facilities, nursing homes, physicians’ offices, and home care agencies all continued rapid employment growth. After another decade, health care work overall accounted for 14 percent of the regional labor force, making it easily the largest industry in the labor market, approaching the direct imprint of the steel industry in its heyday." (252)
"Hospitals, seeking to contain costs in their labor-intensive industry, faced a compulsion to maximize workers’ productivity by limiting their numbers, in the expectation that they would deliver sufficient output regardless. This expectation rested on the inherited care ethic, the cultural substrate left over from the dissolving decommodified system. Management enjoyed leverage in the fact that workers themselves would not allow the vital elements of care work to go undone." (253)
"What do we mean when we as a society call these workers “essential”? We evidently do not mean that they are owed substantive recognition or power, money or status, for their efforts. We mean, rather, that whether they like it or not, they owe us something—possibly everything. Those invested in the current unequal social order may come to regret acknowledging how much depends on these workers, demanding so much from them while offering them so little." (264)
September 30, 2025
Aquest llibre és una història de la classe treballadora de Pittsburgh des dels 50s fins als 90s estudiant el simultani procés de declivi de la indústria de l'acer (que va passar de representar la feina de la meitat de la població treballadora a pràcticament desaparèixer) i el sorgiment de la indústria dels cuidats/salut. Aquesta transformació s'explica a través dels canvis en la composició de classe i en les maneres de viure-la en termes de classe i gènere. Ja només per com estudia la transformació dels processos de reproducció social de la classe treballadora el llibre val la pena. El que potser no m'ha agradat és que l'estudi concret exhaustiu d'un cas tan particular com l'estudiat acaba eclipsant tot intent de derivar-ne tendències històriques que vagin més enllà del provincialisme de l'experiència de la classe treballadora de Pittsburgh. És interessant com en termes legals les treballadores hospitalàries no eren considerades en la legislació laboral. Totes les tasques de cures en salut que fins fa no tant quedàven reservades a l'àmbit privat de la família o el treball de metges individuals privats esdevé tot una nova indústria i tot un nou àmbit de control estatal de les vides del proletariat. Una cita i ja estic:
"The process of working class decomposition was, at the same time, a process of working class recomposition. Most significantly, the division between these processes was gendered. The market in men's labor contracted sharply, and the market in women's labor expanded. These dynamics were also racialized."
bisousss
"The process of working class decomposition was, at the same time, a process of working class recomposition. Most significantly, the division between these processes was gendered. The market in men's labor contracted sharply, and the market in women's labor expanded. These dynamics were also racialized."
bisousss
June 18, 2024
The descriptions of the day to day lives of the steelworkers were rly well done and very interesting. I wish he had applied a similar level of description to the modern day schedule/life of healthcare workers— there’s a lot of necessary focus on the history of the shift from steelwork to healthcare & the policies and movements that surrounded this, but it would have been a good way to conclude the book.
October 20, 2023
Excellent. A must read for any yinzer. The careful attention paid to the historical and social contexts of the Rust Belt cities, but Pittsburgh in particular, leading to the decline of the industrial and rise of health care. Eye-opening, and yet, mostly puts into words or solidifies things I think many working-class folk have felt. Important reading for how we move on from here.
December 13, 2024
Winant provides a compelling story of how the crumbling steel industry in pittsburgh led to the booming healthcare industry however he could’ve given further details onto how specifically this collapse happened + more contextualization
December 21, 2025
we do just kind of repeat history all the time don’t we? in failing to recognize the importance and opportunities we have in certain moments either for ourselves or for others to enact change, will we ever find a way to rise above the systems designed to keep us down?
in other words, I liked it and once again reminded myself of why I love to study history
in other words, I liked it and once again reminded myself of why I love to study history
July 10, 2023
This dispels many of the myths and destroys the lies about the accepted narrative around the so called thriving Post War America. Yes it was thriving, but for who?...and who was doing all the horrible jobs and hard work to allow that minority to thrive?...
So many example of horrendous working conditions, working poor, trapped in a hideous drudge of work, washing, cooking and cleaning. So much for the new age of consumption, tell that to those workers in Pittsburgh who had to put cardboard in their shoes.
There was some really well-researched detail and interesting history in here, with excellent parts, but only up to a point. This soon got bogged down and by about two thirds through this became almost agonisingly tedious and a real battle to get through, which is a shame, as it had its qualities. And the way it ended felt a bit bizarre too.
So many example of horrendous working conditions, working poor, trapped in a hideous drudge of work, washing, cooking and cleaning. So much for the new age of consumption, tell that to those workers in Pittsburgh who had to put cardboard in their shoes.
There was some really well-researched detail and interesting history in here, with excellent parts, but only up to a point. This soon got bogged down and by about two thirds through this became almost agonisingly tedious and a real battle to get through, which is a shame, as it had its qualities. And the way it ended felt a bit bizarre too.
September 11, 2021
Although I've lived in Pittsburgh most of my adult life, I never felt I truly got a handle on the history of the steel industry and subsequent decline. This book, with it focus on working class families interspersed with historical analysis, filled that void. Some might think it a little too academic, but I found it mostly accessible. I particularly enjoyed the breakdown of how the healthcare industry and in particular hospitals in Pittsburgh formed as a result of the Steel Industry and Union health coverage and their response to that decline.
January 20, 2023
Feels like it meanders a bit, but ends up being an incisive account of why deindustrialization manifested itself in the particularly perverse version of health care we have in the US. Lots of details to chew on. Understanding our current situation as following from healthcare being the only part of the new deal welfare state able to respond to deindustrialization while still being subject to the pathologies of market pressures/austerity was revelatory.
September 13, 2021
This is essential reading for any person who has ever been a resident of the city of Pittsburgh. Connecting the industrial past of steel mills with the post-industrial landscape of healthcare monopolization within the city, the author Gabriel Winant does a superb job of weaving academic prose with personal testimonials to paint a picture of a complex rust belt labor market that is demarcated on racial and gendered lines. Using Pittsburgh as a case study of a city - majority white and informed by Catholic and Protestant values of work and family life - Winant shows just how ingrained the underlying ethos of post-war and neoliberal political policies, as well as entrenched racial and class divisions, have created a whole new professional class of workers that are facing even more dire problems of equity in the workplace due to the collapse of collective bargaining. While the conclusions of this book will not make anyone feel positive about the future, this book carves out a path through the 20th century history of Pittsburgh to show people how we even got here in the first place. Required reading.
March 5, 2022
Really phenomenal in the connections it draws - connecting the decline of manufacturing directly to the rise of the healthcare industry, unwaged and domestic care labor to the grinding and torturous conditions faced by the majority of those who work in healthcare, how and why market forces began acting in the industry, the role of the state in driving that market discipline, its costs on human bodies, and so much more.
Read
October 31, 2025Great read. A book that should be written ten times over up and down the UK. Marxism as a method used to understand how societies produce and reproduce themselves under the changing dictates of capital. Pleasingly concise and unacademic too.
May 9, 2021
Obvious new classic.
August 12, 2023
Probably one of the best books I’ve ever read
Read
January 16, 2025Book club discussion notes -
Discussion sources pulled from
Sources:
From
https://en.wikipedia.org/wiki/Reuther...
From
https://newrepublic.com/article/16186...
Book Overview:
Introduction:
Pg. 17 - Unions became more and more confined to a parochial economic project, advancing the narrow interests of their own memberships
Pg. 23 - Taft-Hartley act excludes hospitals…"no profit is involved in this work"
Section I:
Down in the Hole - Steelmaking Pittsburgh in the 1950s
Pg. 44 - Inflationary cycle of unions - causing "the mirage of blue collar - working class stability"
Pg. 49 - Increasing productivity = smaller crew sizes because no investment was made in efficiency gains…
Pg. 55 - Maintaining and reproducing authority (salaried from wage earners).
Pg. 61 - Remaining human throughout the toll of the steel work
Pg. 73 - Working class man did not only love and draw strength from this work. They also dreaded spending their lives doing it…
Section II:
Dirty Laundry - Labor and Love in the Working-Class Home
Pg. 76 - Working class was supposed to have gained a proper domestic life
Pg. 79 - Women's work not only produced and sustained living labor but also continuously forced into alignment the conflicting pressures of work and daily life… Human personality is not born but must be made through the socialization process that in the first instance families are necessary.
Pg. 90 - Homeownership… was another way of trying to resolve the contradictory obligations and rewards of family into a coherent and continuous material reality.
Pg. 104 - Distinction between working class and middle class - parent/child relationship
Section III:
“You Are Only Poor if You Have No One to Turn To” - Race, Geography, and Cooperation
Pg. 112 - Collective anchoring of churches, fraternal organizations to working class people
Pg. 115 - Layout of segregated areas of Allegheny County
More generally - Black vs. white working class families experiences weathering the coming deindustrialization
Pg. 140 - Traditionally high-wage, high-skill, union jobs in construction would represent a leap from the world of last hired, first-fired dirty work that defined even many unionized Black jobs. The industry’s record, moreover, was indefensible.
Section IV:
Doctor New Deal - Social Rights and the Making of the HealthCare Market
Pg. 153 - [For white people] hospitals symbolized their inclusion in the social contract
Pg. 154 - By delivering care through public support for demand in a fragmented and privatized system, the institutional architecture of the postwar health care system locked in an inflationary dynamic. …
Pg. 155 - Public intervention into the market w/ Medicare and Medicaid…
Pg. 156 - health care system… a mechanism for channeling income into different buckets
Pg. 157 - Hill-Burton Act (1946) - federal funding for new hospital construction, particularly in rural areas
Pg. 158 - BC Western Pennsylvania - every steelworker in the country, union preserved "community rating" in which insurer charged all subscribers the same rate, regardless of health.
Pg. 167 - Medicare & Medicaid - public-private welfare state
Pg. 182 - High utilization of health care as a substitute for familial types of support and care both materially and emotionally
Section V:
Enduring Disaster - The Recycling of the Working Class
Pg. 216 - Acceleration of mass incarceration following collapsing labor market
Pg. 223 -
Ron McMunn, a Homestead steelworker, was laid off in 1983. “I worked
all them years at the plant and I have nothing now. I feel all tied up. I feel like
I’ve been all balled up tight for so long now,” he lamented. “I lost my wife
and my family. I used to get very angry. All the time I was filled up with
hatred.” Harry Rhodes, a millwright, hanged himself May 17, 1985, a week
after he relented to early retirement. “I can’t go on without working,” read
his suicide note. Georgeanne Koehler, a psychiatric aide at St. Francis
Hospital, remembered “a lot more people thinking about suicide, I would
say. So you spent a lot of time making sure that they knew that somebody
loved them, whether or not they worked.”53
Pg. 241 -
• DISCUSSION POINT
Ø The trilemma - increased debt, reduction in wages, or lower unemployment
Section VI:
“The Task of Survival” - The Commodification of Care and the Transformation of Labor
Pg. 243 - Shift of Medicare reimbursement from cost-plus to Prospective Payment System
transition of the hospital from a labor-intensive, durational
model of care to a capital-intensive, interventionist model of treatment. This
transition induced a shakeout, with far-reaching effects across the health care
system. Smaller and poorer hospitals faded while larger, richer ones grew,
leading to a process of industry consolidation. The old communitarian health
care system was not so much dissolved as enclosed by emergent corporate
giants in the field.
Pg. 253 -
Reform changed whom hospitals treated, how, and for how long. Lengths
of stay shortened, diminishing preoperative and recuperative days. Before
the reform, recalled Maryann Johnson, a registered nurse, “People weren’t
sent out of the hospital after a day or two.” Stays frequently exceeded a
week, even for minor procedures. “The nurses took care of you, prepped you.
… We didn’t do outpatient surgery back then.” After the reform, however, the
actual mix of patients in a hospital at any given time shifted toward needing
more acute care. Inpatient populations became sicker and older. This, in turn,
triggered adjustment in the daily round of what hospital workers actually
Did
Pg. 261 -
Warehousing of elderly population in nursing homes
Topics:
Ø Micro vs Macro
○ DISCUSSION POINT - What is the next shift? Global impact of shift towards a service economy?
○ Micro -
§ granular exploration of the ways this transformation affected individual neighborhoods
§ The social worlds that steelmaking and steelworkers made were gendered and racialized, reproduced along social hierarchies, and unevenly laid across space and time.
□ "A person leaving a steel mill and walking uphill from the Mon Valley floor in 1960 would, within five or ten minutes, enter and exit the Black steelworker neighborhood. After another twenty minutes, the white steelworker neighborhood would come and go, still displaying some internal ethnic gradations: Slovaks and Poles here on the hillside, the Italians there, the Irish a bit higher, and managers over the ridgeline. With the spasmodic decline of the steel industry, insecurity worsened for many working-class people but did so more severely for African Americans. A wave of layoffs, as it ground its way through the steel mill seniority list and through hierarchies of race and skill, would creep up the hillside like a rising tide."
□ Fumes and filth meant considerable cleaning labor for women—rubbing overalls with lard to remove industrial grease or scrubbing the basin of a washing machine to excise dust and silt. One steelworker’s wife described herself as “an unpaid clean-up woman for industry.” Fathers, sons, and brothers often worked different shifts, necessitating women being “in and out of the kitchen all day long,” as one steelworker’s daughter recalled. Surveys revealed housewives working more than 50 hours a week. And, in an industry where pain and slow violence were the norm—and where to “drink, fight, drag heels, or sleep constituted a form of resistance,” as Winant notes—many men had trouble turning this off at home; mental and physical abuse were not uncommon.
Ø Domesticity, the family unit,
§ Winant builds off this work to explore how the social crisis of deindustrialization led to a shattering of social reproduction and the reconfiguration of daily survival strategies. Those who had family and friends to turn to obtained loans, food, daycare, and for the lucky, a job prospect. Those who did not found aid in their neighborhood or at community institutions. At the level of the neighborhood, deindustrialization reconstituted familial structures and community relationships.
□ As a result of automation and capital flight, the steel jobs gradually began to disappear in the 1960s. From 1960 to 1970, the number of metal manufacturing workers in the region fell from 162,514 to 128,142, part of a broader, massive decline in blue-collar industrial jobs across the country. This decline hit Black workers hardest. Layoffs often affected them at more than three times the rate of their white counterparts. Relatives, churches, and ethnic community centers had long shared money, food, and assistance, pooling their resources to care for families suffering as a result of a strike, an injury, or a death. But these ties and institutions began to strain under the weight of so much need.
□ As community networks frayed and mutual aid resources started crumbling, former steel families were increasingly forced to turn to the health care system for care—and, eventually, for jobs. Steelworkers had won robust health insurance decades before; Medicare had “seemed to open a faucet of limitless funds” for hospitals and insurers, and facilitated greater access for elderly people. This was of enormous importance in the Pittsburgh area, as more and more people were becoming sick. The economic downturn and decline of manufacturing jobs brought devastating health impacts; rates of heart attacks, schizophrenia, alcoholism, depression, and suicide rose sharply, far outpacing the national average.
○ DISCUSSION POINT - Is there a generally agreed upon way to construct a bridge from one economic pillar to another such that the people of a given place don't have the rug pulled out from underneath?
§ Decline in steel led to the rise in healthcare need but not by some grand vision
§ The idea of regional pride for a given economy making tangible goods that serve as the backbone of the country - Pittsburgh - steel, Detroit - auto… How do we understand that status? Today we have Silicon Valley - which isn't a tangible good
□ Few jobs have been as fetishized, as mythologized, and as misunderstood as that of the steelworker. It’s certainly true that the steel mills of western Pennsylvania provided steady, relatively stable employment for generations throughout the twentieth century. By the 1940s, these jobs were heavily unionized. Years of strikes and solidarity led to average hourly wages of $3.36 by the early 1960s (equivalent to $28.53 in 2020 dollars). But these jobs were also brutal and dirty and dangerous. They slowly wrecked men’s bodies, and often injured them much more quickly. In one mill in McKeesport, Winant notes, 500 injuries were routinely reported per month in a facility with just over 4,000 employees. Coke ovens, blast furnaces, and open hearths exuded a punishing heat, with some workers inhaling so much burning dust that they vomited blood. “Working-class men did not only love and draw strength from this work,” Winant writes. “They also dreaded spending their lives doing it, imagining all that it would require of them and all that it would do to them.”
□ To grow up in Pittsburgh in the 1990s and 2000s—as I did—was to experience something paradoxical: slow-motion whiplash. In my early childhood, everyone seemed to agree that the city was dying around us—another victim of deindustrialization and globalization and a general brain drain, the factories gone forever and talented young people fleeing for greener pastures. A city that had once provided the steel to win world wars and been home to more Fortune 500 companies than any other except New York and Chicago had, by the early 1990s, lost almost half its people (down from a peak in about 1950) and nearly all of the industry that had employed generations and made the resplendently bearded robber barons—like Carnegie, Frick, Heinz, Mellon, and Westinghouse, whose names adorn virtually all of the city’s institutions—so damn rich. Pittsburgh exemplified “Rust Belt decline.”
At the start of the 1950s, few people in the region worked in health care, while nearly 20 percent of jobs were in the metals industry, especially steel; today, few people in or around Pittsburgh work in steel or other industrial jobs, but health care jobs account for nearly 20 percent of the area’s workforce.
○ Macro -
§ private-public welfare state, collective bargaining, and the impacts and reforms of Medicare and Medicaid
§ If industrial work was steadily available and robust unions represented workers, millions of industrial employers, including their families, absorbed the new social rights. But this system was on a timer, and even at its peak, it was uneven and differentiated by race, gender, and space.
§ Like mass incarceration, health care was a way for capital and the state to respond to the crises and surpluses of the late twentieth century. When deindustrialization shattered communities, traditional support structures fell apart. Young couples and single men left to look for work elsewhere. Many left their elders in nursing homes primarily staffed by low-paid women of color. While the decline of industry hit Black men the hardest, it opened opportunities for Black women. Care work was gendered and racialized, associated with domesticity and servanthood. This understanding of care labor devalued the work despite its social, political, and cultural importance. Existing hierarchies of race and gender, imposed by the postwar welfare state and the political economy of industrial production, were reproduced in the newly emerging care economy.
§ DISCUSSION POINT -Care work was gendered and racialized, associated with domesticity and servanthood. This understanding of care labor devalued the work despite its social, political, and cultural importance.
□ Is this the current perception?
§ DISUCSSION POINT
□ The big question for our times that Winant poses is whether this emergent working-class majority can become a potent political force. If the Covid-19 pandemic has taught us anything, it is that low-wage, service sector workers have an immense reservoir of power and public support. And with the Biden administration moving towards the most pro-labor policy since President Jimmy Carter in the late 1970s, mass unionization and militancy may be on the horizon. If a wave of organizing and strikes occur, cities like Pittsburgh and Detroit will be at the center of the future of the care economy labor movement.
Ø History of health insurance
○ Private
§ BCBS
○ Medicaid, Medicare
○ Through insurance paid in part by employers, and by 1965, Medicare and Medicaid, healthcare became a key aspect of the social economy.
○ A pivotal moment in this history, and perhaps the larger history of neoliberalism to which the book contributes, is the shift from decommodified health care to corporate health in the 1983 Medicare reforms. Congress and the President approved a major change from a “labor-intensive, durational model of care to a capital-intensive, interventionist model of treatment.” Here was the pinpoint for a major expansion and transformation of health. Prices skyrocketed while hospitals pursued new avenues of revenue generation and cost reductions. As the demand for care increased, the need for labor did as well.
Discussion sources pulled from
Sources:
From
https://en.wikipedia.org/wiki/Reuther...
From
https://newrepublic.com/article/16186...
Book Overview:
Introduction:
Pg. 17 - Unions became more and more confined to a parochial economic project, advancing the narrow interests of their own memberships
Pg. 23 - Taft-Hartley act excludes hospitals…"no profit is involved in this work"
Section I:
Down in the Hole - Steelmaking Pittsburgh in the 1950s
Pg. 44 - Inflationary cycle of unions - causing "the mirage of blue collar - working class stability"
Pg. 49 - Increasing productivity = smaller crew sizes because no investment was made in efficiency gains…
Pg. 55 - Maintaining and reproducing authority (salaried from wage earners).
Pg. 61 - Remaining human throughout the toll of the steel work
Pg. 73 - Working class man did not only love and draw strength from this work. They also dreaded spending their lives doing it…
Section II:
Dirty Laundry - Labor and Love in the Working-Class Home
Pg. 76 - Working class was supposed to have gained a proper domestic life
Pg. 79 - Women's work not only produced and sustained living labor but also continuously forced into alignment the conflicting pressures of work and daily life… Human personality is not born but must be made through the socialization process that in the first instance families are necessary.
Pg. 90 - Homeownership… was another way of trying to resolve the contradictory obligations and rewards of family into a coherent and continuous material reality.
Pg. 104 - Distinction between working class and middle class - parent/child relationship
Section III:
“You Are Only Poor if You Have No One to Turn To” - Race, Geography, and Cooperation
Pg. 112 - Collective anchoring of churches, fraternal organizations to working class people
Pg. 115 - Layout of segregated areas of Allegheny County
More generally - Black vs. white working class families experiences weathering the coming deindustrialization
Pg. 140 - Traditionally high-wage, high-skill, union jobs in construction would represent a leap from the world of last hired, first-fired dirty work that defined even many unionized Black jobs. The industry’s record, moreover, was indefensible.
Section IV:
Doctor New Deal - Social Rights and the Making of the HealthCare Market
Pg. 153 - [For white people] hospitals symbolized their inclusion in the social contract
Pg. 154 - By delivering care through public support for demand in a fragmented and privatized system, the institutional architecture of the postwar health care system locked in an inflationary dynamic. …
Pg. 155 - Public intervention into the market w/ Medicare and Medicaid…
Pg. 156 - health care system… a mechanism for channeling income into different buckets
Pg. 157 - Hill-Burton Act (1946) - federal funding for new hospital construction, particularly in rural areas
Pg. 158 - BC Western Pennsylvania - every steelworker in the country, union preserved "community rating" in which insurer charged all subscribers the same rate, regardless of health.
Pg. 167 - Medicare & Medicaid - public-private welfare state
Pg. 182 - High utilization of health care as a substitute for familial types of support and care both materially and emotionally
Section V:
Enduring Disaster - The Recycling of the Working Class
Pg. 216 - Acceleration of mass incarceration following collapsing labor market
Pg. 223 -
Ron McMunn, a Homestead steelworker, was laid off in 1983. “I worked
all them years at the plant and I have nothing now. I feel all tied up. I feel like
I’ve been all balled up tight for so long now,” he lamented. “I lost my wife
and my family. I used to get very angry. All the time I was filled up with
hatred.” Harry Rhodes, a millwright, hanged himself May 17, 1985, a week
after he relented to early retirement. “I can’t go on without working,” read
his suicide note. Georgeanne Koehler, a psychiatric aide at St. Francis
Hospital, remembered “a lot more people thinking about suicide, I would
say. So you spent a lot of time making sure that they knew that somebody
loved them, whether or not they worked.”53
Pg. 241 -
• DISCUSSION POINT
Ø The trilemma - increased debt, reduction in wages, or lower unemployment
Section VI:
“The Task of Survival” - The Commodification of Care and the Transformation of Labor
Pg. 243 - Shift of Medicare reimbursement from cost-plus to Prospective Payment System
transition of the hospital from a labor-intensive, durational
model of care to a capital-intensive, interventionist model of treatment. This
transition induced a shakeout, with far-reaching effects across the health care
system. Smaller and poorer hospitals faded while larger, richer ones grew,
leading to a process of industry consolidation. The old communitarian health
care system was not so much dissolved as enclosed by emergent corporate
giants in the field.
Pg. 253 -
Reform changed whom hospitals treated, how, and for how long. Lengths
of stay shortened, diminishing preoperative and recuperative days. Before
the reform, recalled Maryann Johnson, a registered nurse, “People weren’t
sent out of the hospital after a day or two.” Stays frequently exceeded a
week, even for minor procedures. “The nurses took care of you, prepped you.
… We didn’t do outpatient surgery back then.” After the reform, however, the
actual mix of patients in a hospital at any given time shifted toward needing
more acute care. Inpatient populations became sicker and older. This, in turn,
triggered adjustment in the daily round of what hospital workers actually
Did
Pg. 261 -
Warehousing of elderly population in nursing homes
Topics:
Ø Micro vs Macro
○ DISCUSSION POINT - What is the next shift? Global impact of shift towards a service economy?
○ Micro -
§ granular exploration of the ways this transformation affected individual neighborhoods
§ The social worlds that steelmaking and steelworkers made were gendered and racialized, reproduced along social hierarchies, and unevenly laid across space and time.
□ "A person leaving a steel mill and walking uphill from the Mon Valley floor in 1960 would, within five or ten minutes, enter and exit the Black steelworker neighborhood. After another twenty minutes, the white steelworker neighborhood would come and go, still displaying some internal ethnic gradations: Slovaks and Poles here on the hillside, the Italians there, the Irish a bit higher, and managers over the ridgeline. With the spasmodic decline of the steel industry, insecurity worsened for many working-class people but did so more severely for African Americans. A wave of layoffs, as it ground its way through the steel mill seniority list and through hierarchies of race and skill, would creep up the hillside like a rising tide."
□ Fumes and filth meant considerable cleaning labor for women—rubbing overalls with lard to remove industrial grease or scrubbing the basin of a washing machine to excise dust and silt. One steelworker’s wife described herself as “an unpaid clean-up woman for industry.” Fathers, sons, and brothers often worked different shifts, necessitating women being “in and out of the kitchen all day long,” as one steelworker’s daughter recalled. Surveys revealed housewives working more than 50 hours a week. And, in an industry where pain and slow violence were the norm—and where to “drink, fight, drag heels, or sleep constituted a form of resistance,” as Winant notes—many men had trouble turning this off at home; mental and physical abuse were not uncommon.
Ø Domesticity, the family unit,
§ Winant builds off this work to explore how the social crisis of deindustrialization led to a shattering of social reproduction and the reconfiguration of daily survival strategies. Those who had family and friends to turn to obtained loans, food, daycare, and for the lucky, a job prospect. Those who did not found aid in their neighborhood or at community institutions. At the level of the neighborhood, deindustrialization reconstituted familial structures and community relationships.
□ As a result of automation and capital flight, the steel jobs gradually began to disappear in the 1960s. From 1960 to 1970, the number of metal manufacturing workers in the region fell from 162,514 to 128,142, part of a broader, massive decline in blue-collar industrial jobs across the country. This decline hit Black workers hardest. Layoffs often affected them at more than three times the rate of their white counterparts. Relatives, churches, and ethnic community centers had long shared money, food, and assistance, pooling their resources to care for families suffering as a result of a strike, an injury, or a death. But these ties and institutions began to strain under the weight of so much need.
□ As community networks frayed and mutual aid resources started crumbling, former steel families were increasingly forced to turn to the health care system for care—and, eventually, for jobs. Steelworkers had won robust health insurance decades before; Medicare had “seemed to open a faucet of limitless funds” for hospitals and insurers, and facilitated greater access for elderly people. This was of enormous importance in the Pittsburgh area, as more and more people were becoming sick. The economic downturn and decline of manufacturing jobs brought devastating health impacts; rates of heart attacks, schizophrenia, alcoholism, depression, and suicide rose sharply, far outpacing the national average.
○ DISCUSSION POINT - Is there a generally agreed upon way to construct a bridge from one economic pillar to another such that the people of a given place don't have the rug pulled out from underneath?
§ Decline in steel led to the rise in healthcare need but not by some grand vision
§ The idea of regional pride for a given economy making tangible goods that serve as the backbone of the country - Pittsburgh - steel, Detroit - auto… How do we understand that status? Today we have Silicon Valley - which isn't a tangible good
□ Few jobs have been as fetishized, as mythologized, and as misunderstood as that of the steelworker. It’s certainly true that the steel mills of western Pennsylvania provided steady, relatively stable employment for generations throughout the twentieth century. By the 1940s, these jobs were heavily unionized. Years of strikes and solidarity led to average hourly wages of $3.36 by the early 1960s (equivalent to $28.53 in 2020 dollars). But these jobs were also brutal and dirty and dangerous. They slowly wrecked men’s bodies, and often injured them much more quickly. In one mill in McKeesport, Winant notes, 500 injuries were routinely reported per month in a facility with just over 4,000 employees. Coke ovens, blast furnaces, and open hearths exuded a punishing heat, with some workers inhaling so much burning dust that they vomited blood. “Working-class men did not only love and draw strength from this work,” Winant writes. “They also dreaded spending their lives doing it, imagining all that it would require of them and all that it would do to them.”
□ To grow up in Pittsburgh in the 1990s and 2000s—as I did—was to experience something paradoxical: slow-motion whiplash. In my early childhood, everyone seemed to agree that the city was dying around us—another victim of deindustrialization and globalization and a general brain drain, the factories gone forever and talented young people fleeing for greener pastures. A city that had once provided the steel to win world wars and been home to more Fortune 500 companies than any other except New York and Chicago had, by the early 1990s, lost almost half its people (down from a peak in about 1950) and nearly all of the industry that had employed generations and made the resplendently bearded robber barons—like Carnegie, Frick, Heinz, Mellon, and Westinghouse, whose names adorn virtually all of the city’s institutions—so damn rich. Pittsburgh exemplified “Rust Belt decline.”
At the start of the 1950s, few people in the region worked in health care, while nearly 20 percent of jobs were in the metals industry, especially steel; today, few people in or around Pittsburgh work in steel or other industrial jobs, but health care jobs account for nearly 20 percent of the area’s workforce.
○ Macro -
§ private-public welfare state, collective bargaining, and the impacts and reforms of Medicare and Medicaid
§ If industrial work was steadily available and robust unions represented workers, millions of industrial employers, including their families, absorbed the new social rights. But this system was on a timer, and even at its peak, it was uneven and differentiated by race, gender, and space.
§ Like mass incarceration, health care was a way for capital and the state to respond to the crises and surpluses of the late twentieth century. When deindustrialization shattered communities, traditional support structures fell apart. Young couples and single men left to look for work elsewhere. Many left their elders in nursing homes primarily staffed by low-paid women of color. While the decline of industry hit Black men the hardest, it opened opportunities for Black women. Care work was gendered and racialized, associated with domesticity and servanthood. This understanding of care labor devalued the work despite its social, political, and cultural importance. Existing hierarchies of race and gender, imposed by the postwar welfare state and the political economy of industrial production, were reproduced in the newly emerging care economy.
§ DISCUSSION POINT -Care work was gendered and racialized, associated with domesticity and servanthood. This understanding of care labor devalued the work despite its social, political, and cultural importance.
□ Is this the current perception?
§ DISUCSSION POINT
□ The big question for our times that Winant poses is whether this emergent working-class majority can become a potent political force. If the Covid-19 pandemic has taught us anything, it is that low-wage, service sector workers have an immense reservoir of power and public support. And with the Biden administration moving towards the most pro-labor policy since President Jimmy Carter in the late 1970s, mass unionization and militancy may be on the horizon. If a wave of organizing and strikes occur, cities like Pittsburgh and Detroit will be at the center of the future of the care economy labor movement.
Ø History of health insurance
○ Private
§ BCBS
○ Medicaid, Medicare
○ Through insurance paid in part by employers, and by 1965, Medicare and Medicaid, healthcare became a key aspect of the social economy.
○ A pivotal moment in this history, and perhaps the larger history of neoliberalism to which the book contributes, is the shift from decommodified health care to corporate health in the 1983 Medicare reforms. Congress and the President approved a major change from a “labor-intensive, durational model of care to a capital-intensive, interventionist model of treatment.” Here was the pinpoint for a major expansion and transformation of health. Prices skyrocketed while hospitals pursued new avenues of revenue generation and cost reductions. As the demand for care increased, the need for labor did as well.
November 13, 2025
Very academic, which is fine. Being from a deindustrialized, now prominent health/higher ed center city, I found a lot of what the book discussed informative. But beyond that, the book felt very long for what it's worth. The conversation on the rise of health industry felt almost secondary to the labor history element, and despite the author's obvious interest in amplifying women, and women of colors' voices, I never felt like their voices carried much weight other than providing narrative. I also found it a bit weird that the solution, single payer health care, only gets referential treatment in the prehistory of the health care explosion, as labor intensified it's struggle for member benefits - this could have been part of the epilogue as well, where no answers are provided as to how to address the crisis today. And for a regional analysis, I feel like it would have been helpful to understand how workers won bigger things in other countries, as a means of assessing the outcomes of the US labor movement comparatively. I suppose I'm asking for more than the author had in store, but the book fell flat for me.
October 31, 2021
Impressive analysis of the economics of healthcare in the context of rust belt decline. Applicable lessons to many urban economies.
June 12, 2023
This is a wonderful book that covers a sprawling history of Pittsburgh but it is really a history of America’s shift from industry to healthcare and how the two verticals are linked.
The book connects the two industries but shows how a safety net was established for heavy industry that relates to health but how healthcare has deftly built a new industry without that safety net. Both exploit their workers savagely.
Along the way this is a fascinating history of Pittsburgh from many different neighborhoods and perspectives.
The book connects the two industries but shows how a safety net was established for heavy industry that relates to health but how healthcare has deftly built a new industry without that safety net. Both exploit their workers savagely.
Along the way this is a fascinating history of Pittsburgh from many different neighborhoods and perspectives.
October 4, 2023
It takes a certain amount of fortitude to read this, especially if you live in Pittsburgh. Winant does a great job of detailing how the comprehensive healthcare benefits won by the Steelworkers union in the postwar era, the way working-class families were molded by the steel industry, and the long deindustrialization of the Steel City combined to produce our modern healthcare system, its economic irrationalities and its dependence on a vast low-wage labor force.
It’s a story not confined to Pittsburgh — the cities that used to be most closely associated with mass production industries, mostly in the “Rust Belt” but also in New England, the Mid-Atlantic and California, all now find their economies dominated by healthcare. As capital gradually disinvested from and then discarded unionized manufacturing plants throughout the 70s, 80s and 90s, they left behind an “aging, ailing, [but] well-insured population.” In the absence of a strong welfare state, retiree health benefits were called upon to manage the social, economic and psychic wounds left behind by deindustrialization.
One of the book’s central points is that the modern U.S. healthcare system developed, in large part, as a political solution to the problems caused by the incomplete welfare state, as it struggled to deal with the consequences of capital’s flight from the geographies where unionization had won a half-decent life for the working class.
The book’s vivid portrayal of the social lives of steelworker families, especially their gendered and racial dimensions, tells another tale that also seems almost foreordained: how the steel industry also created the healthcare workforce. In the heyday of union power, Pittsburgh was one of the places in the country with the highest percentage of working-class women who did not do paid work outside the home, only unpaid care work within it. Their labor power (especially that of Black women) was an abundant resource, ready to be sucked into low-wage care jobs in the growing healthcare industry as their fathers, brothers and husbands, their bodies and spirits often broken by work in the mills, were spit out by the dying steel industry.
Anyway, a great book, and glad I finally got around to reading it.
It’s a story not confined to Pittsburgh — the cities that used to be most closely associated with mass production industries, mostly in the “Rust Belt” but also in New England, the Mid-Atlantic and California, all now find their economies dominated by healthcare. As capital gradually disinvested from and then discarded unionized manufacturing plants throughout the 70s, 80s and 90s, they left behind an “aging, ailing, [but] well-insured population.” In the absence of a strong welfare state, retiree health benefits were called upon to manage the social, economic and psychic wounds left behind by deindustrialization.
One of the book’s central points is that the modern U.S. healthcare system developed, in large part, as a political solution to the problems caused by the incomplete welfare state, as it struggled to deal with the consequences of capital’s flight from the geographies where unionization had won a half-decent life for the working class.
The book’s vivid portrayal of the social lives of steelworker families, especially their gendered and racial dimensions, tells another tale that also seems almost foreordained: how the steel industry also created the healthcare workforce. In the heyday of union power, Pittsburgh was one of the places in the country with the highest percentage of working-class women who did not do paid work outside the home, only unpaid care work within it. Their labor power (especially that of Black women) was an abundant resource, ready to be sucked into low-wage care jobs in the growing healthcare industry as their fathers, brothers and husbands, their bodies and spirits often broken by work in the mills, were spit out by the dying steel industry.
Anyway, a great book, and glad I finally got around to reading it.
July 16, 2022
I liked "The Next Shift" and was also frustrated by it. It describes the collapse of the steel industry in western PA. and its new substitute, the health care industry. Steel industry jobs were a gateway for blue-collar families into middle-class life. Their new lives weren't glorious but definitely improved from the poverties of the past. Steel working families didn't make a lot of money, but they enjoyed a stable existence, until, of course, the steel industry collapsed in western PA. in the 1980s.
So how does today's health care jobs compare with yesterday's steel mill work? In some respects, they're similar but in other ways, they're completely different. I struggle to understand my place in the new western PA. jobs landscape. I live in Pittsburgh, have been a full-time Registered Nurse since 2006, and continue to work. The work is rewarding but also frustrating. Staff shortages are constant; the workload unrelenting at times. Health care seems incredibly corporate in nature, with little appreciation for the front-line workers at the bottom. How does this compare to the steel mill jobs of the past? I'm not sure. I can't tell whether I'm part of the low-wage strata of health care workers that Winant describes or whether I'm a step above them. I like to think that I'm underpaid and overworked, but I'm also a nursing professional. I don't know how to approach myself in terms of the transformation that has taken place in the Pittsburgh area since the 1980s.
Winant is much clearer as he describes the social makeup of the steel worker communities. There were strong racial components to them even as they were close-knit. Black steelworkers didn't enjoy the same job promotions, pay rates, or living standards as their white counterparts. Racial differences existed just as blue-collar middle-class communities were being created.
So how does today's health care jobs compare with yesterday's steel mill work? In some respects, they're similar but in other ways, they're completely different. I struggle to understand my place in the new western PA. jobs landscape. I live in Pittsburgh, have been a full-time Registered Nurse since 2006, and continue to work. The work is rewarding but also frustrating. Staff shortages are constant; the workload unrelenting at times. Health care seems incredibly corporate in nature, with little appreciation for the front-line workers at the bottom. How does this compare to the steel mill jobs of the past? I'm not sure. I can't tell whether I'm part of the low-wage strata of health care workers that Winant describes or whether I'm a step above them. I like to think that I'm underpaid and overworked, but I'm also a nursing professional. I don't know how to approach myself in terms of the transformation that has taken place in the Pittsburgh area since the 1980s.
Winant is much clearer as he describes the social makeup of the steel worker communities. There were strong racial components to them even as they were close-knit. Black steelworkers didn't enjoy the same job promotions, pay rates, or living standards as their white counterparts. Racial differences existed just as blue-collar middle-class communities were being created.
May 4, 2021
Follows the destruction of the good-paying jobs of the steel industry to the conversion to low-paid, low esteem jobs of the massive healthcare industry in Pittsburgh. Through legal means and through social evolution, health care became health business and that bottom line now governs the entire workforce of our massive hospital systems. Anecdotal testimony of real people drives home the fact that essential work is not rewarded, while hospital CEO’s garner exorbitant compensation. Shameful. Thanks to author Gabriel Winant for his intelligent and sympathetic treatment of the subject.
Displaying 1 - 30 of 84 reviews