How Health Care Became the Big Industry in Steel City
Old and worn colorful construction helmets

The replacement of blue-collar work by pink-collar work has been much discussed, but what makes this book stand out is Winant’s argument that two seemingly distinct phenomena are in fact inextricably connected: “It was not a coincidence that care labor grew as industrial employment declined.” In the 1970s, deindustrialization pushed an ailing and aging population into unemployment, toward the welfare state — always tentative, in the American case — for their survival. Unlike other social institutions, which buckled under political pressure and austerity cuts, the American health care system flourished, having grown already in response to the rise of collectively bargained health insurance during the flush postwar years.

Despite the sentimentality that has attached to the steel mill, the work it generated was not only dangerous, it was also unpredictable and not infrequently alienating. Winant describes how a coke shoveler working night shifts lost “control over his body’s rhythms — eating, sleeping, toiling,” which in turn made it harder to maintain the performance of masculinity that was so central to his identity. Not to mention that the job security afforded by the union’s collective bargaining wasn’t evenly distributed. In the 1950s, as the demand for steel slackened with the end of the Korean War, layoffs hit Black workers first — they tended to be marginalized within the union, and kept in the worst positions at the mill.

For a time, steelworker unions obtained higher wages, outstripping inflation; then, responding to government pressure to keep wages down, they bargained for better health insurance, which generated its own inflationary dynamic in the health care system. Winant offers a lucid explanation of how the peculiarities of this system developed into what he calls the “public-private welfare state” — a dysfunctional realm of escalating health care costs and entrenched and entangled interests that no one seems capable of replacing.

This public-private welfare state was what awaited the workers cast off by a collapsing industry. Winant notes that the two social institutions that have prospered since the 1980s have been prisons and health care delivery: “Like the expansion of the prison system in the final decades of the 20th century, the rise of the health care industry afforded an economic fix to the social crisis brought about by deindustrialization.”

Read more in the New York Times or buy the book.

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