Trillbilly Worker's Party - Episode 276: Infirmary Blues (w/ special guest Gabriel Winant)

Episode Date: January 26, 2023

This week we're joined by University of Chicago professor of history, Gabriel Winant, to discuss the social and political origins of the modern healthcare industry in places like Pittsburgh and Appalachia. To learn more, you can purchase Gabe's book, The Next Shift: The Fall of Industry and the Rise of Healthcare in Rust Belt America: https://www.hup.harvard.edu/catalog.php?isbn=9780674238091 And you can always support us on Patreon: www.patreon.com/trillbillyworkersparty

Thank you. Tom and I were just talking about John Brown, as one does on an afternoon. I'm reading this book, Cloud Splitter. You ever heard of it? I've heard of it. I've never read it. It's pretty fucking good. It's like, I mean, it's just telling Tom.

It's just like, you know, just imagine getting a posse of your friends and going to Kansas and just hacking some slave owners to bits. It's just like, well, you know, it's a nice afternoon. Nice way to spend your afternoon. You know, I have a friend who, I think this is okay for me to repeat. I have a friend who was a student of Eric Foner. Oh, damn. And learned from Eric Foner that Foner and all, you know, he comes from a kind of old communist family.

Yeah. Going back, you know, to the 30s and so on. And Foner, I think, remained a member, if I'm remembering this right. from a kind of old communist family going back you know to the 30s and so on and uh phoner i think remained a member if i'm remembering this i say this with just a little bit of disavow um of like the friends of john brown society or something like that that gathered every year at his grave which is like way the hell up in upstate it's like at the canadian border yeah north elba yeah um they got you know like i imagine this is still happening to this day that on his i guess his birthday probably

i realize how much of this i'm making up maybe it's his birthday maybe the anniversary of the harvard ferry i don't know they gather like a kind of society of old communists who gathered his grave though which i've always thought was very cool that's the shit honestly just like a pilgrimage yeah yeah where where where is this grave at did you say it's called north elba it's like in the adirondacks interesting yeah it like it was this farm they lived on next to a settled community of former slaves like escaped slaves called timbuktu and in general escaped slaves gathered near the canadian border for obvious reasons right right uh but yeah no my my guy was like uh he definitely uh as tom said he's the first crazy crazy ass white boy you put i think a grand tradition i love the story of you know the the attempt to recruit frederick douglas to come with him on the harper's ferry

raid that's what i was just telling him about yeah frank douglas is like dude okay like go for it but you have to say i think in retrospect it's hard to come to a conclusion besides like it worked it didn't work in exactly the way he thought yeah right but it did it did actually work yeah and you know for that i mean you know it's impossible to kind of give enough credit no it's like i was telling, like as soon as like the Fugitive Slave Act and like Missouri Compromise and everything, like John Brown was like dead certain this was only going to end one way and it was Civil War. It's like he knew it really before anybody else. Yeah, and he also knew that there was going to be a central role for the enslaved in that process. Right.

Which, you know, very few northern abolitionists realized at that point. Right, right, right. of the Trail Bellies, everybody. This week, we are joined by Gabriel Wynant, Professor of History at University of Chicago. He's here to talk to us about his new book, The Next Shift, The Fall of Industry and the Rise of Healthcare in Rust Belt America. How's it going this week, Gabe? Good. Thanks for having me. Of course. But before we get, you know, into the weeds and everything, and before the listener sees this and they groan and they say, not another political economy episode. These guys are dilettantes. They don't know shit about political economy.

That's why we called in the heavy hitters, baby. We finally have someone who does know what they're talking about. Some heft. Yeah. we finally have someone who does know what you're talking about some heft yeah um and i and also like before we get started i just want to say that like in my opinion and this is also what tom and i were just talking about before you got on i feel like this is kind of going to be like a spooky episode like i don't think that was your intention in writing the book but sort of like Das Kapital, there is a lot of specters, like ghosts, residues from the past, like truly like, you know, history weighing like a nightmare on the brains of the living hours. For sure. I mean, I'm very curious to hear how, hear what you think about how the story I tell about Pittsburgh maps onto your part of Appalachia.

Whether Pittsburgh is part of Appalachia or not is, as you know, a kind of very contested question. Is it? I feel like the science is in on that. The Paris of Appalachia? Yeah, it's called Paris, right. Anyway, I think that, well, like I say, I'll be interested in hearing what you think about, you know, Kentucky and so on as compared to that. But definitely places where the history, I mean, what unites them in some form is places where the history of extraction and processing of mineral resources into capital continues to condition current experiences down to the present, even though that process may be long diminished. condition current experiences down to the present, even though that process may be long diminished. Absolutely. You have a line, honestly, that just really cuts straight to the core of it. And it's kind of like what we're going to be trying to figure out today, which is like, how do you explain

the, as you put it, the absent presence of one group of workers? In the case of your book, it's the steel workers. Where we live, it's the coal miners. How do you explain that along with the present absence of another group of workers, like the health care workers? Because as you point out, in Pittsburgh, you've got all these old markers of the past, like the Pittsburgh Steelers. Didn't you say there's a beer called Iron City or something? Iron City beer. It's like the local shitty lager. um we don't have that unfortunately we don't have any uh we don't have any i've enjoyed an iron city at primanti brothers with those big ass sandwiches um but like yeah like so yeah like before we get into it i just want to like you know maybe as a way to kind of like juggle these two locations or experiences like this

kind of started for me like i knew about your book all throughout last year but as i said to you in the dm like i'm a very slow reader and so i was like i'm gonna need some time to like go through that um and what made me go through it was this flood happened in our community, right? This like very catastrophic 1000 year flood. And I was at someone's house helping them do cleanup and we were, you know, cleaning out their basement and, you know, hauling everything out and everything. And like we uncovered under all this rubble, I mean, this is metaphorical too, in all kinds of ways. We uncovered under all this like mud and rubble, this is metaphorical, too, in all kinds of ways. We uncovered under all this, like, mud and rubble this big sign.

And it was from a strike, a steelworker strike at our local hospital, because all of our nurses here are steelworkers in the steelworker union. And it was from a strike in the 80s. And so I asked her about it. And she starts, like, going into the long history of, like, the, you know, the labor struggle in the hospitals around here. And it was weird. It just kind of opened something up.

If you live here, and you saw this with the teacher strikes in West Virginia, everybody always talks about the history of the coal miners' labor struggle here. It's like the heritage and everything. You never hear about the health care workers. you know, it's like the heritage and everything. You never hear about like the healthcare workers. You never, even though there's been multiple strikes, some of them have been quite, you know, nasty and, you know, contentious. And so it's like, you know, you never hear about that despite the fact that all the abandoned buildings in our,

formerly abandoned buildings in our downtown are now occupied by healthcare facilities. They're just gobbling property up left and right. Like it's the biggest employer. Particularly also like pulmonary clinics that deal with the legacy of black lung disease and those types of things too. Yeah. I mean, you know, I, when I, when I kind of take my show on the road and give lectures or whatever, I often begin with like a series of slides showing, you know, like

obviously you guys know the New York Times genre story where they go to report on like why do people in this diner support Donald Trump? Right. And so I collected a bunch of those. And not just the New York Times. You know, every national publication did a million of these between 2015 and the present. Last week. 2015 and the present.

Last week. And obviously they especially like doing it in sort of de-industrialized places. And so, you know, I paid attention to them and I realized, I noticed that very often in these stories, a lot of the people they're interviewing are actually healthcare workers. Right. Who they're interviewing about like what does it mean that the steel mill closed or whatever right and there's there's one of these from williams in west virginia um which you know it's a new york times story from 2016 uh and they interview a pulmonary i think a pulmonary um a respiratory therapist of some kind um who retrained

like to get oh no they that's right they interview someone who works at the yeah at the black lung clinic and they also interview someone who retrained as a phlebotomist but so many people have done that now that you can't get work as a phlebotomist and it was just like these people are forcing their way in to the story from the outside like they're not what's being looked for. They're not supposed to be kind of in the frame. But there's too many of them, so they keep showing up. Yeah.

It even slips into some of the criticism of your book, one of which I mentioned to you in the DM. But the end line was like, Dr. Wynott does not care about the steel workers in their plant. It's just like, where are the steel workers? It's like, where are the coal miners? It's the same thing. It's just like.

It's like you're more likely to find chimney sweeps these days, you know. It's like, they exist. I know we still do have, like, steel workers. And we still have coal miners, too. But it's not like the, obviously, it's not this region's biggest industry anymore. But that's why your book, if I understand it correctly, it's not a straightforward story of how this industry got to be so expansive and all-consuming. But it's really a story of working-class formation, like how this this class came into how this specific working class kind of came into being. And and that falls in line, honestly, like you had done a podcast on E.P. Thompson's book.

And so, you know, it's like there's a similarity there, like looking at like how these people get conscripted into this new industry. Yeah, I mean, you know, there's more to say about the kind of question, what are we talking about when we talk about working class formation? And I'll, you know, I'll comp to the fact that like E.P. Thompson's book is really the making of the English working class. Great book, 900 pages about village life in, you know, England in the late 1700s. So that's why we did a podcast to help people through it. So that's why we did a podcast to help people through it. But, you know, that's really a book about emerging forms of radical politics and radical working class politics.

Even, you know, you see people in that book kind of beginning to invent Marxism and socialism for themselves before Marx has been born. And that's why it's such a powerful book. And I can't claim that my book really does that for healthcare workers in the same kind of way. And so there's a, you know, there's a sort of a nuance I have to add to the, if I want to use the concept of class formation, which I do. And, you know, I'm writing about my own moment or the kind of immediate precursors to my own, our moment, right? And so it's, it's more of a kind of gamble that this is going to pay off in some political form. But basically, I mean, the thing that I mean by working class formation, and I think a helpful way of thinking about it, is that you have all of the people who, in the broadest sense, are the proletariat. Everyone who depends on selling their labor power for their survival because they have no other means of subsistence. And maybe they succeed in selling their labor power or maybe they don't.

Right. And then they're kind of thrown back into other forms of survival or punished or whatever. But then within that group, right, there are kind of that group is not kind of like uniformly evenly distributed across a flat landscape. Right. Right. It's lumpy and uneven. And there are clustering phenomena,

you know, particular occupations and industries obviously are bigger than others. Different kinds of people get involved in different kinds of occupations and work. That's a question often about race and gender, although lots of other things too, right? Education, skill, many, many different dimensions. And then, you know,

forms of kind of collective experience and identity and potentially consciousness and militancy, one hopes, coagulate in certain places, right? And so one thing I was trying to do in the book was to say, if we want to think about working class formation, we have to think about it as a kind of rolling historical process, right? class formation, we have to think about it as a kind of rolling historical process, right? As opposed to a moment when like the whole proletariat opens its eyes and sees what's going on, like all at once or something like that. And if you want to see it as a rolling historical process, you have to, you know, be able to account for like these kind of shifts over time.

You know, there's kind of what I described as a coagulation over here and then it kind of breaks apart. There's another one over there and you got to try to understand the connections between them and so on so let me just finish this answer by saying uh you know more concretely i felt like every story that we had about working class formation basically was in one way or another about the cycle from the mid to late 19th century through the 1917s and 1980s because that's like the main example right that's like when it all went down um and uh you know that left the kind of closure of the factory or the mill or the mine as the end of the story right um and or a little bit we had some kind of scholarly work on you know life and work in the low-wage service economy

or this kind of thing in which that precursor, that long previous cycle, was like a very distant and disconnected memory or not really relevant. I wanted to tell a story that had deindustrialization in the middle of it so you can kind of see that kind of shifting uneven rolling dynamic yeah because i mean a big argument right now is that yeah like we live in the post industrial like sort of a service economy um and there's all kinds of implications in that but it does seem to indicate that like um that there is no maybe i'm being unfair to people when i say this but like that that you have this idea of like the precariat and that i don't know i don't know how people use that term i don't know if they're talking about people mostly in the informal economy

like selling copper and stuff i think it means a lot of different things which is why i don't really use it right yeah but yeah it's it's it's it's too vague. It's too hard to like kind of like grasp on to. But yeah, like we can you know, we can start talking about this when we talk about Pittsburgh. But just like as a way of sort of comparison. So where we live, we live in eastern Kentucky. And the story that you outline, it's mirrors in many ways what happened here. You had the sort of labor battles of the 30s and 40s. The coal industry emerges from World War II, you know, with coal in high demand, but a lot of their union, a lot of their workforce is unionized. But they're kind of being priced out by the rise of oil. And so they need to cut costs and they need to mechanize. rise of oil. And so they need to cut costs and they need to mechanize. And so what happens is they sit down with John Lewis, you know, the UMWA leader in 1950. And prior to this, John Lewis had been trying to establish a, you know, wealth and retirement fund for the miners. And so like the negotiation, like the sort of bargain that they strike, is that the UMWA and John L. Lewis will sign off on the coal industry being able to mechanize in turn for getting these health benefits.

And so over the course of the 50s, they lose something like 300,000 jobs to mechanization. and jobs, you know, to mechanization. And in this process, it's even more kind of, you know, something about like living in a rural area is it kind of like cuts out a lot of the sort of like social buffers and these sort of like intermediary stages, because like the UMWA even wound up setting up its own hospital system at that point. Yeah., like, you can see the process that you're outlining, like, kind of almost perfectly, it was a little more staggered here, I think, because coal and like steel kind of has more uses in the sense that like, we use it for energy too. And so there was a huge coal boom here in the 70s. And I think that that may have kind of stalled out on the major healthcare expansion that you outlined happened in Pittsburgh in the 60s and 70s.

Although I don't know that for that for a fact. That's just kind of, you know, just looking back through newspaper articles and things. But but yeah, what you get is you get this process whereby like the UMWA basically signs an agreement that is kind of their own death knell in a way but it also becomes the basis for the gradual you know building up and construction of this healthcare industry but quite literally because the former umwa hospital system was eventually bought out by one of the biggest hospital chains around here, Appalachian Regional Healthcare. And so it's almost a quite literal just handing over of the reins. I think there's still a couple places across Appalachia that still have the name Miners Regional Hospital or something like that. I know there's one in Central PA somewhere.

There's different versions of this story around the country. I also like to point people to Kaiser, which people know about as a healthcare company, right permanent on the west coast mainly um kaiser was an industrial firm right it was a concrete construction and shipbuilding and steel firm uh really yeah i didn't know henry kaiser was a steel magnate yeah i didn't know and um you know in basically during the war uh you know he set up a kind of one of the very early, what would become one of the very early HMOs for the war workers, more or less, building ships in the ports of California. And, you know, gradually over time, like that became the whole company. Right, right.

right well you it seems like you have this moment in like the 80s 90s when you've got the uh sort of consolidation of a lot of health care but like the sort of precipitate precipitous decline of these industries i just wanted to read something for both of you guys um that i found very fascinating uh this is from an article in the year 2000. It's from Pikeville, which is a big, it's like this region's sort of biggest city. It's got like 8,000 people and a college. Yeah, it's not very big. But I thought this was a fascinating look

into how healthcare kind of became this quote-un unquote solution for quote unquote economic development in this area. This is the opening, this is the opening statement in this article from the Appalachian news express, August, 2000. Every time Walter may seize an ambulance from Pike County speed past him on the mountain parkway on its way to Lexington with a patient, two things immediately cruised through his mind with it. First and foremost, May, the president and CEO of Pikeville Methodist Hospital, said

he thinks of the safety and health of the person being transported. Well, that's good. Of course. That's his vocation. That's nice that that's where he goes. That's right. But he also can't help but think about the millions of dollars Pikeville and Pike County are missing out on because of the thousands of people who are taken each year to Lexington for medical care, both urgent and routine. It's almost like every ambulance going down the road.

There's an armored truck behind it taking money, May said. That money could go all over this community and we could benefit from it. Okay. All over. Okay. money may said that money could go all over this community and we could benefit from it okay all over i just okay i love it because it's like that scene and there will be blood he's like there's an ocean of oil beneath my feet for the i'm the only one who can get at it right you know as in that case it's sort of true right it's just that like the ocean of oil in this case is like the blood of the people almost literally right right yeah um so yeah like so let's that's that's eastern kentucky right let's talk about pittsburgh like you start your book with this kind of image of the university of pittsburgh medical center kind of like looking out over the entire city of pittsburgh you know from like the heights of the u.s steel tower um you know and you

and you give a kind of uh anecdote about how like i think it was like a court proceeding or something or a labor dispute they were claiming that their workers don't exist like you know why do they claim this why do they claim that their workers don't exist and like know why do they claim this why do they claim that their workers don't exist and like what what is you know what can it tell us about the kind of like various dilemmas or as you put it like trilemmas they're facing policymakers and technocrats in like wealthy western democracies yeah so um you know there's been a kind of on again off again campaign to organize the major tertiary hospitals in Pittsburgh since the late 1960s, and even with previous moments in the 30s and 40s, but really since the late 1960s,

when what was then a local 1199 tribe, which eventually became part of SEIU, continues to try to this day, against quite vicious anti-union resistance. And so in such a, you know, one such kind of flare up, you know, they're having a proceeding before the National Labor Relations Board over retaliatory firing, I think. And UPMC, which let me just say for the listener, as of today, is the largest private employer in Pennsylvania. It has, I think, over 100,000 employees. It operates a few dozen hospitals, many other kinds of facilities. It's a monster. It has a hospital in Kazakhstan.

It has a hospital in Ireland. It has a hospital in Italy. Kazakhstan. Yeah. In Kazakhstan, I don't quite know what that's about. It's Borat. He's got a high health bill. but uh this borat he's got a health bill uh so anyway they claimed in this nlrb dispute because seiu i think had filed an unfair labor practice charge against them if i'm remembering

right uh and they claimed in this labor dispute that we're not actually the proper target of this dispute because we upmc inc uh have no employees and the specific content of that argument was like a kind of parent company, subsidiary company type argument. Like you got to take it up separately with every hospital and whatever unit and whatever. But, you know, there's two things I want to say about this. One is three things. Sorry. One is, you know, when I was writing this dissertation, as a dissertation, I was a graduate student who's also being told I'm not an employee. Right. I was also trying to form a union in the teeth of that. And that was a big part of the motivation for kind of thinking about this story is a lot.

I went to grad school at Yale. I lived in New Haven, which is a deindustrialized, immiserated town with like, you know, the Death Star that birthed the CIA at the heart of it. Right. Right. town with like you know the death star that birthed the cia at the heart of it right right and so you know i was like doing a lot of kind of reflecting on my own situation in various ways and struggles there um through writing this two um i discovered as i was doing the research that actually after the wagner act was passed in 19, whether or not it covered hospitals was very ambiguous. That Wagner Act, National Labor Relations Act, the kind of basic labor law.

Right. Whether it covered hospitals was very ambiguous because it covered corporations engaged in interstate commerce. And hospitals at that time, there were no hospital chains then. There were no for-profit hospitals then, really. I mean, none that I know of, anyway, maybe one or two on the margin. And so hospitals were able to say, look, we're philanthropic charities. What we're doing is not commerce. And therefore, our relationship with our employees is not an employer-employee relationship in this legal sense. relationship in this legal sense. And indeed, there were efforts to organize by the CIO hospital workers in Pittsburgh in the 30s and 40s, which ran into this argument and it got litigated

and then eventually got resolved by everyone's favorite, the Taft-Hartley Act, which just said, okay, hospitals are out. And so from the 40s to the 70s, healthcare workers were excluded from labor law, excluded from wage and hour law to the Fair Labor Standards Act. And I think it's helpful to think of this – to get to your question about the trilemma. Yeah. It's helpful to think about this in terms of different levels of analysis. So what I just described is a kind of like legal institutional level, right? Like here is how this labor market is organized legally, institutionalized legally. That means that the employers in this labor market are going to have access to the most vulnerable in to the more secure parts of the labor market, which is going to mean women in Pittsburgh, African-Americans, elsewhere in the country, like immigrants. Tons of healthcare workers in New York City, for example, come from the Caribbean and so on.

And then finally, there's a kind of like economic layer that I think is helpful to think about because because health care, this is especially true in the earlier 20th century, but it remains true to the present. Health care is what economists will call labor intensive. Right. And like it's not an industry that lends itself that well to like productivity increase, whether in the form of mechanization or in the form of, you know, kind of improved processes, you know, refining of the division of labor. And here I think it's helpful to just, like, think about, like, if you ever read the famous beginning of The Wealth of Nations where Adam Smith talks about a pin factory. Right. I mean, nails, not, I mean, he calls nails pins.

And he's like, look, we used to have it so that each guy makes a whole pin himself and then we realized we could divvy it up so that each person kind of does a little part of the process of making pins and this means that we can make more pins for less money if we do that which means we can sell pins for cheaper which means more people will buy them which means we'll make more which means we can pay our workers better and our workers can buy more shit. And so there's a kind of virtuous circle that's supposed to come from increasing the productivity of labor. Then think about the elements of that, falling prices, rising wages,

and then think about the health care system, which has rising prices and stagnant wages. This thing that's supposed to be fundamental to capitalism, and we've long thought of as a kind of core dimension of what makes the capitalist mode of production this dynamic revolutionary force, that it gets more productive all the time, where increasingly a lot of our employment is in this sector

where that doesn't seem to be true. And so that's the economic reason why employers in health care are interested in this channel into the bottom of the labor market. is by controlling their labor costs, either by holding wages down or by holding staffing down, which has become a major thing in healthcare. Thus saying they don't exist. Right. Right. And, you know, finally, this brings me to the thing you asked about, the trilemma. So this is not my idea.

This is the kind of idea I imported from a sociologist. But this is the idea that, you know, overall, as industrial societies transition into service economy societies, right, they're going to encounter this bunch of zero-sum problems if it's within a set of capitalist social relations, because you don't have that kind of pie-getting-bigger thing in the same way. And so that sets up a choice between three things that you want as a politician, presumably, of which you can have any two. That's a trilemma. And the three are low unemployment, high wages, and a small public sector. Right? Because if you will accept a large public sector. In other words, bring service work into the public sector, right, and therefore guarantee that there's a lot of good jobs. Or you can have high wages in the private sector if you'll accept high unemployment, which means like the French do this kind of, or this was, they were long an example of this, regulate the labor market through labor law, through, you know, various kinds of rules about hours of retirement and unemployment insurance

and stuff like that. But that's going to mean you're going to have higher unemployment because it raises the cost of hiring someone. Or you can have low unemployment and low wages in the private sector. And this is basically the US path roughly. If you deregulate the private sector labor market so that employers can – it's then not expensive for them to create jobs and they can create a bunch of shitty jobs right which is what we have we have a bunch of shitty a lot of shitty jobs exactly exactly which gets back to what we were talking about earlier this process of like working class formation like i use the word precariat but only because that's a word that gets thrown around a lot but like yeah there's a question of like how do you characterize yeah the american workforce the american proletariat we have a lot of shitty jobs

and they don't pay good අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි අපි but like this also like the economic process you were just kind of talking about, like trying to, you know, do innovations in productivity in the workplace and everything. Like this affects the sort of pricing structure of health care. Like there's like a dynamic of health care that I kind of wanted to lock in early on, which is that like it is always inflating. It's always going like you can't as tom's pointed out you can't walk into a hospital and say uh all right there's the x-ray for 35 dollars and the you know splinter removal for five dollars you you don't you know you that's not up front none of this and you don't have any idea how those things are priced um and so i mean i don't know if they're i assume they're regulated there's no price controls on health care services

are there sort of i mean it's extremely complicated um and we and we don't have to get into it we can if you want we could probably save that maybe for later if we talk about like the medicare reform in the 80s but like yeah that's a good place to get into it but yeah i think the point is is that like there is a problem with this industry which that technocrats always kind of have to go back and try to tinker with it uh to kind of keep it under control in a way to keep the prices under control which is probably why you get the clintons trying to tinker with it in the 90s and Obama with the ACA in the 2000s. But, you know, so anyways, all that aside. So earlier you mentioned that you had started looking at this and then looked at the Wagner Act in the 30s and sort of like who got to be a worker and who didn't.

and sort of like who got to be a worker and who didn't. And this has like a basis, like the current status of a lot of these workers has a basis in, you know, what you call sort of social citizenship and, you know, determining who got to be a worker and who didn't in the 30s and 40s. So I kind of wanted to talk about that, right? Like maybe go back in time a little bit. Like what is the dissolution of the New Deal state? like what can it tell us about how it was set up and i guess can you can you explain to us the concept of social citizenship and like how that played out in determining who who wasn't a worker yeah i mean i think in a lot of ways you know the kind of long painful like period of neoliberalism

gives us the opportunity and maybe kind of forces us to just like look at the new deal in a different kind of way um you know when something falls apart you can kind of see more of its inner structures right yeah yeah and um you know i think we have had a story for a long time um about like the new deal was this kind of moment of working class unity right and it was that in really important ways um and then on top of that there was this story that kind of got added about like okay but like you know excluded african-americans in a bunch of important ways but like it was still good and we still you know should do it again or something

like that yeah without the bad parts right uh And again, I'm sympathetic to elements of that. It's not like I think the New Deal was bad or something like this. But it seems to me like that's a pretty unsystematic way of thinking about what happened in the 30s and 40s and in particular the ways that the places in the economy where organized working class organization really emerged in mass production industry in particular um you know and where working class people and their and their organizations had real economic

and political leverage so that's talking about coal, steel, auto production, electrical workers, these kinds of industries. Or if you want to think in terms of companies, you know, US Steel, General Motors, GE, right? Those workers led a kind of, there was a period in the 30s, especially where those workers kind of led something like a kind of class-wide movement, right? Not everyone participated, but they were kind of at the vanguard of something like a class-wide movement. It confronted in a new way racial segregation. It confronted in a new way the kind of constitutional order. For decades, the Supreme Court had been throwing out like every

kind of uh social policy regulation and that that had to go uh anyway then like through the experience of the war and especially the kind of red scare in the 40s um the like this movement kind of loses its initiative and momentum. It turns away from these sort of universal political questions. I think you have a sentence for kind of encapsulating this. But yeah, they kind of turn away from these universal political questions and then start, and this happened in the UMWA, start dialing in on how best to serve their own memberships. Yeah, and that doesn't happen because they're assholes

or they're up to no good. It happens because of pressures that they're under. It's a totally reasonable, I mean, would you make that deal? I'd probably make that deal. It's a totally reasonable. Now it makes sense to criticize Lewis for making that deal in retrospect. It's a totally reasonable – Now it makes sense to criticize Lewis for making that deal in retrospect. But like the environment of the late 1940s in particular, Taft-Hartley has been passed.

The labor movement goes into a period of very intense internecine internal conflict as it's being forced to expel its communists who have helped build it. So for example, just a good example of this, good Appalachian example, the United Electrical Workers, right, was the third largest CIO union after the auto workers and the steel workers, and they represented GE, Westinghouse, RCA, et cetera. You know, big centers

of power in Pittsburgh and Erie. And they were the most, of those three, they were the most militant. And they refused to comply with the Taft-Hartley exclusion of communist officers and so then had to exit or were kicked out of essentially the CIO. And the CIO then chartered another union called IUI to raid existing UE shops and bring them into the UE. So there's this, like, multi-year, incredibly brutal conflict between two unions that have almost the same name, right, fighting over this membership.

And, you know, think about what that's going to be like, right, in 1948, 49, 50, right, the Korean War. You have these Catholic priests kind of going to factories, telling people why their union is a communist front and is supporting the enslavement of their cousins back in Poland by the godless Soviets. Right. It's just like – I mean I'm not – it sounds hyperbolic, but that's actually what it was. Yeah. And so that's just like incredibly, you know, it's a body blow to that militant labor movement. It's a big part of the reason why the CIO has to merge back in with the AFL, right, from which it had seceded and which it was supposed to kind of overtake and surpass.

But by 1955, they merge again. So yeah, with all that, the CIO is like not in the position anymore to kind of represent the working class as a whole in the same way. I mean, it still typically kind of stakes out relatively progressive political position, you know, nominally, they still support like what we would now call Medicare for all, for example. But when Harry Truman tries to win Medicare for all, they're kind of like, we can't do this right now. And similarly on civil rights questions, right? I mean, CIO unions play a really important role funding civil rights action, lobbying for it at the federal level. But internally, a lot of their workplaces are kind of, you know, have forms of like deep rooted, if informal segregation that they're not that eager to confront. So, you know, that then I think like that's a story of the division,

re-division of the working class. Yeah. And, you know, I think that like over time, what winds up happening is that you kind of, I think you describe it as a public private welfare state, right? So like what happens is in order to meet out and distribute uh you know sort of the gains of the excesses of this sort of like post-war era they get distributed through like the privately operated channels of like union membership and so that kind of creates what you describe as like an inside zone and an outside

zone, right? So it's like the inside zone, you have like the workers themselves and they get healthcare and their families get healthcare. But then like on the outside of that, you have a large demographic, maybe like elderly people and the poor who don't get to partake in those same benefits. And so that kind of like comes to head, right, in those same benefits. And so that kind of like comes to head, right, in the 60s. Like that kind of, you know, is when we get some of these larger welfare reforms like the Great Society and the War on Poverty. Yeah, I'm realizing you asked me about social citizenship, which I did not answer before.

No, it's all right. But this is that, right? Social citizenship is like the concept for, or a concept to describe like forms of, you know, citizenship and inclusion that are not like political, not like the right to vote, serve on a jury, whatever, but about access to healthcare, access to retirement, to vacation, these kinds of things. And yeah, the weird effect of the division of the working class that I've just described is that social citizenship gets divided with it. And basically, the top tier access to social citizenship is private sector access. That's like not necessarily what you would expect, right? Right. still have a lot of economic leverage over their employers. They just don't have the same kind of political power over the society as a whole anymore.

And so they can win the kind of health and welfare plans that the miners and the steelworkers and so on win for themselves, which then cover their families. And, you know, among other things, one thing that this does is, over the course of the 50s, causes people who are in the working class so can't just buy their own health care but are not in that secure perimeter

to get priced out, right? Because like now there are actually millions of working class people who do have health insurance for the first time and they're going to the hospital and they're going to the doctor. And that demand is causing hospitals to upgrade and expand. Yeah, they're building up. Yeah.

This is a moment, for example, when hospitals switch from like these kind of 30 bed ward type setups to like the now familiar two bed room. And actually that's in the steel workers contract. Like our members get to be in a room with just two beds in it. So hospitals, you know, they want to build wards that can accommodate that or units that can accommodate that and benefit from that demand and charge more because the workers themselves are not bearing the brunt of the cost. And now that fit that very familiar dynamic where all this money is moving back and forth between your provider and your insurer,

kind of out of sight of you, starts to come online. Right. But if you don't have an insurer or if you don't have a good insurer because you're like a waitress rather than a steel worker, right? Or you're a retiree

living on your social security and you need to go to the hospital too. Now it's a hospital whose services and prices are targeted at that insured steel worker. And that starts to produce kind of anger and protest and resistance from poor and old people over the course of the 50s. And already by like 57, 58 in Congress,

they're kind of like, we're going to have to do something about this. This process eventually goes to 65 when they pass Medicare and Medicaid, which if you think about what are the two constituencies that are left out of the picture we're talking about, right? It's the old and the poor. Those are the programs for the old and the poor.

Yeah, it's interesting. This happened with the Wealth and Retirement fund here and with the, you know, minor memorial hospitals, which is that, like, this, you know, sort of social citizenship that gets kind of, like, meted out and funnels all of this revenue into the healthcare system, which also drives up the quality of care, which drives up the price. And so you kind of have this inflationary dynamic where you're right, like the people that are sort of outside of that zone can no longer afford those products. And it's interesting, like, because I think we have this idea, or at least I did prior to reading your book, is that like, yeah, Medicare, Medicaidicaid they were the results of well to be honestly to be honest I probably saw it way cynically which is that like medicare medicaid was probably created because we were losing the cold war blah blah we needed to prove

that we could do this stuff but like it's really it's really more um nuanced than that it's like they were trying to keep prices under control basically um or at least this inflationary spiral in a way um to kind of uh intervene in the market on the supplies or on the consumption side rather than on the supply side itself yeah it doesn't care so because they intervene on the consumption side rather than the supply side it doesn't keep prices under control right the government is like we're just gonna pay for the people who can't get there on their own and you know i'm not saying that's bad i'm glad people got medicare medicaid um but uh you know that imagine if instead the solution had been the federal government is going to stand up a system of hospitals for people who don't have private

insurance right now that's not an out of you know like an insane idea insane idea. We did that for veterans. The federal government operates a system of hospitals for people who it deems deserving of care and wants to provide it to. There's no reason in principle that they couldn't have just supplied the care, which would have done a lot to reduce health care inflation because they could just set the you know price or the non price right right um but instead they said we're basically going to give people coupons um and right that's basically what insurance is it's a coupon yeah or it's a voucher it's a good way of thinking about it right um and um in light of that like the ACA is like the ultimate like it's like the ultimate intervening on the consumer, on the consumer. Well, everything has been right. Like once you had this pattern in place, I mean, there have been efforts to establish Medicare for all. I mean, there was one in the 1910s. There was one in the 1930s.

There was one in the 1940s. They kind of thought Medicare might somehow like gradually grow into it, but they didn't really have a strategy for how that would happen. In the 70s, they kind of thought about it again. And then by the 90s and then 2000s, basically the solution increasingly was like, well, if you want to reform the health care system, you just have to buy off part of the industry. You just have to buy off part of the industry. That's the only way you can do it because the industry has become so embedded in like the structure. It's like the structure that holds so much of our society together now. Right. So you can't just go hacking off parts of it, right, which is what Medicare for All would do.

Right, right. Well, part of the reason – were you going to say something, Tom? Well, I was just gonna say you're talking about these these various attempts at the reforms is it true that as part of the new deal that uh roosevelt wanted to have some sort of like universal health care but the ama stepped in and were concerned that the profession of doctor might lose its prestige. It's more or less true. What Roosevelt himself wanted is like a notoriously impossible question to answer.

Roosevelt is like a sphinx, you know. But the committee that wrote the Social Security Act, it was called the Committee on Economic Security. And just let me add, the Social Security Act is not just the thing we call Social Security, right? It's also unemployment insurance it's the thing we call welfare is in there also which is today TANF but at the time was Aid to Dependent Children and a bunch of other stuff is in there too. It's like

the whole welfare state is in there and eventually Medicare and Medicaid those are amendments to the Social Security Act that's how they were passed. So anyway, that committee, when they wrote the bill, you know, they had various working groups, one of which was on the question of medical care. And the medical care working group wrote up a whole plan basically for what a kind of national health insurance system could look like that would be administered by the Social Security Administration. And then the AMA got it flipped out.

And it's interesting, right, because there was no organized hospital lobby, really, at this point, or organized insurance lobby, because those industries still had to be created by the process we've been talking about. It's really the doctors. And probably to a significant extent also just employers who already were beginning to experiment with providing healthcare to their employees as a form of social control.

Right. We had like community hospitals or company hospitals here. Right. Or the checkoff system. Like the miners would – the cult operators would hire a doctor or a company doctor. Exactly, yeah. And so between those forces, the Committee on Economic Security basically gets word from somewhere in the administration, like, okay, we're not going to push this right now.

Like, maybe we'll try again next year. not going to push this right now like maybe we'll try again next year and i think that was widely thought among you know new dealers that like i get close we'll get it soon you know yeah truman that truman thought he would do it right yeah um you know what one of the reasons that i wanted to sort of like dial in on the social social citizenship question is because it's like an important link in because like what your book does like you go from sites like you know you start with the factory in the mill like a site of like action and accumulation and then you go to the home which is like the site of caregiving and in the hospital but like i feel like social citizenship is kind of like mediating force between like the factory and the home and you know kind of gets got gets spit back out the other side

as earlier we were talking about like in the 60s and 70s medicare and medicaid and these other programs kind of sort of becoming like the gnaws in the gas tank like the fuel in the gas tank to building up these hospital hospitals if that happens you have to have people to work at them and one of the craziest things in your book was this ad that you found for like i think it was like a nursing home it was like in the 70s or 80s and the ad like literally says like are you a homemaker a housewife like you have all the skills to come work in the nursing home basically something like that like you just transfer your skills into this industry so it's like i guess what i'm getting at is like social citizenship is that kind of like mediating force that kind of like determines what happens in the home and um

and then that kind of gets subsumed into this new hospital industry i don't know if that's yeah like yeah yeah i mean uh you know i one point i guess i like to make is that like the things that we often think of as like social welfare welfare benefits whether or not they're public or private like we we tend to think of those as like money basically, right? Like, oh, you have this benefit. It's worth this much for this number of weeks or whatever. And a lot of them are kind of like that. But actually, so like the thing that welfare benefits in any form, whether pension, unemployment, health insurance, whatever,

any form, whether, you know, pension, unemployment, health insurance, whatever, the thing that they provide is like, again, a kind of coupon for labor of some kind often, right? Right. And this is even true of like a lot of the ones that seem not like health insurance. That's kind of obvious in a certain way. But even like something like unemployment insurance for a steel worker. So like, you know, the Social Security Act has unemployment insurance in it, right? It's a state federal cooperative program. But then unionized industrial workers negotiate additional unemployment benefits.

The steelworkers won this in 56, I believe. And, you know, steelworkers are like being laid off cyclically all the time. I mean, every couple of years you're laid off for a few months or something in a you know a little downward dip in the economy um so it's an important benefit for them but like what does it buy them right it like buys them like the food and you know the rent money and whatever right that like then their wife is actually going to kind of put together into like them continuing to be alive and have a family right um right and in a certain way it's not that different in that sense from like the way that health insurance buys you the attention of a nurse um and so you know one thing i try to show in the book is like as you say social citizenship

and the entitlements of social citizenship are in various ways either explicitly or implicitly, entitlements to labor a lot of the time or in important ways. And, you know, then we could talk more about what causes the kind of increasing demand for health care services in particular. But of course, it's always been true. And I think we all probably know this in our own lives, like a lot of health care provision at the kind of bottom level of intensity happens in the family right like you take care of a sick kid or a sick parent or a sick loved one or whatever that happens in the family you know at a low level constantly um before it

happens in a hospital and of course in a society like mid-century industrial pittsburgh that's you know part of the social citizenship of the industrial family. Part of what it buys is the care of the wife and mother, right? And like, if you grew up a girl in Pittsburgh in the 50s and 60s or something, you know, you got used to, you know, being sent to check in on and take care of your grandma after she got sick. You volunteered at the Catholic hospital. You just like, that was part of life in your world and being a girl and then a woman in

that community, right? Because it was connected to industrial work right it was what industrial work bought through social citizenship um and it was i mean i think you even point out that it was kind of crucial to you know the accumulation process itself like it was kind of a i don't know what the word would be a complementary aspect of like keeping the workforce kind of subdued isn't that maybe not the right word but you know what i mean like keeping them i mean this is not my insight this is like the core insight of you know marxist feminism going back a long time now right that like it's women's job to produce and reproduce and yeah and maintain labor power that gets sold in the factory.

Yes, yes, yes. It's the same dynamic that we pointed out at the top of this episode. You've got the steelworker in the home. He's present yet absent, right? Like he's there, but he's not doing any of the work in the home. Where like the wife or the homemaker ormaker the kids like they're absent but present or you know what i mean they are there but their their their work is not it's not recognized as such it's not like work you know what i mean yeah i mean what you i hadn't thought about it in this

way but you just say keep saying makes me think about um you know a very common refrain from i bet uh colthouse families have a version of this uh very common refrain from, I bet, uh, coal town families have a version of this, uh, very common refrain from steel worker families, which is, you know, the mills run 24 hours a day, um, three shifts, uh, it's too hot. So you can't, you can't turn it off and on for the night. You got to just keep it going. Right. Um, cause it takes so long to heat it back up.

Um, and, uh, you know, all steel workers, you know, would eventually therefore at some time be on, you know, the 4pm to midnight or 3pm to 11 depends which company shift or the, or the midnight to 8am shift. Um, and you know, that means that their wives probably have to make a couple of dinners, right. Um, and, uh, you know, clean off their grimy clothes when they get home in the middle of the night. Very often steelworkers would have a drink after they got off the shift because they had to calm their nerves down, basically. And then he gets home maybe a little drunk

and that adds to whatever. But also, a lot of these households had more than one steelworker in them. Although we have a weird image of blue-collar post-war America, it's like everyone's living in nice like nuclear family, 2.1 kid, suburban, whatever. Like actually that's just not what it was like at all. And it was really common like if you're growing up in a household like this, like you had a couple of uncles living upstairs, shit like that. like this you know like you had a couple uncles living upstairs you know shit like that and um that was very normal just because people actually had to cooperate economically to get by yeah um and so you know now think about what that means for these shift cycles and all these kinds of

questions and like the story i was going to tell was you know how many i just everyone i've met who grew up in a household like this talks about their mom hushing them during the day because dad is – he has to sleep during the day because he was working all night at the steel mill. And he has to get some rest so he doesn't go in a zombie to the mill tonight and die in an accident or something, right? Yeah, that's still very much the same thing in coal families. Yeah, third shift. Yeah. My brother-in-law still works it. And every time I go to my sister's house, we've got to kind of tippy-toe. Yeah.

And I thought of it because what you say about the absent presence thing, right? It's like literally he's there, but he's asleep, right? And everyone else has to not – although they're there, they have to not really be there, so they don't wake him up. Yeah. Right, right. Yeah. there they have to not really be there so they don't wake him up yeah right yeah well it's like that that sort of like process that dynamic gets kind of like you said like sort of subsumed into the the care work at the hospital itself and like maybe this is a kind of like you know we're

closing in on an hour here and i kind of want to start trying to like you know bring us up to the current moment but like you know a big part of this book is about the crisis of the 70s. And obviously there's all kinds of debates on that. I'm not really smart enough to understand. We even wouldn't. It is. Like what the crisis of the 70s was. But something that you did say in the book that I think is very fascinating.

And I think a lot of our listeners that will be interested in exploring a little bit is we talked about how that role of that caregiving it serves a social function. It's like serving a society wide function.

And then obviously once you build that out into a massive industry, like you're dealing with all the sort of you know concurrent issues of the day addiction and everything else but like there is this other aspect of this that i find very fascinating and you mention it with just like one line but i think it's very fascinating is that the rise of this industry kind of is is similar in many ways to the rise of mass incarceration and i kind of like just wanted to ask you about that like is it like that we have this massive surplus population and they need to need to be cared for um you know because

of the crisis of the 70s and 80s or or um is it even more expansive than that no i mean i think that's the right way of thinking about it uh it you know this is a comparison that i think is useful and i hope is important but you've got to be careful with it yeah right it's right uh it first dawned on me when i was doing research uh kind of side or tangent that arose out of this book i eventually wrote up as a separate article and then summarized really quickly in this book. I was doing research on this horrific episode of nursing home abuse in Pittsburgh in the 70s. Huge public nursing home, 2,200 beds. So like your average general hospital

is like 300, 400 beds, just to give you a sense of how big we're talking here. County owned. And basically, you mentioned surplus population one thing the book tries to show is how deindustrialization makes the population older and poorer obviously

and also sort of sicker and more disabled both because of the direct health effects of deindustrialization and industrial work before it right right? Those things take a toll directly on people's health and bodies, but also they cut them off from other kind of forms of social support and social access. And so if they can get sucked up into the health system, that gives them some access to those things, which means that in a weird way,

there are not advantages, but there's kind of something that you get from being sick, right? That doesn't mean people like pretend to be sick. It means that like, you know, realistically, we're all kind of a little sick, especially after some decades in a place like de-industrializing Pittsburgh. And so, you know, the kind of health aspects of your larger social situation are going to be how you get yourself access to social services and support what this means is that um nursing like this nursing home you know it's county owned it's for the poorest elderly and disabled people therefore it becomes very overcrowded

um and it's like about it's at like 110 capacity or something like that. And meanwhile, it's becoming increasingly understaffed because deindustrialization is also fucking with the finances of the county, which draws its revenue from taxing steel mills, but steel mills aren't operating. So that means that the staff have been cut. And overcrowding and understaffing,'s the that's the um formula basically for nursing home abuse um and so you know i found these records of this episode where like this period of time where you know these overworked staff people in this nursing home are basically mechanically and chemically sedating the patients because they can't manage their needs and then this is kind of escalating and as the patients kind of resist it to the extent that they're able, some of them start to kind of get tortured basically. Yeah.

And I was like this – I mean you can't see this and not think about the way the prisons are growing in a very similar dynamic at the same time. Right. In both cases, it's about like these kind of imbalances that arise because of deindustrialization and surplus population. arise because of deindustrialization and surplus population and then like what kinds of position it was sorry what kinds of institutions are positioned to grab people up yeah it's uh i don't know it's it's a very interesting thing to think about because um you know i had written this thing about this drug enforcement program uh you know basically because like there was these books out about like the opioid epidemic right and like we have this kind of like accepted uh inherited view of how the opioid epidemic happened right but it's like once i actually started like digging

into like the news archives and everything it kind of became more clear that the crisis was constructed. But not just that. It happened at this very specific moment of the final endgame of the coal industry. You get mountaintop removal. This happened during the 90s, the organized abandonment of the coal industry. And then you look at this drug enforcement program. It's called Operation Unite. And like the people that sat on the board of it were like health care executives from around here.

And they, you know, filled up the jails. And now you have this situation where drug enforcement is kind of like our county government's best source of revenue in a way because they can sell bonds to keep building more jails because there will always be people who are addicted and selling illegal drugs and everything. All of which is to say that I was thinking of that when I read your book and you kind of see a similar process occurring in places like Pittsburgh. You've got this crisis that is not just like an economic crisis of unemployment and everything else, but it has these reverberations through the municipal administrations and trying to plot out the future.

There's one industry that's kind of standing there ready to absorb all that. I think you even use the term like medical shock absorber. Like, it's the healthcare industry. And they're there to absorb a lot of that sort of social disruption caused by that deindustrialization. So I just, you know, we've kind of outlined that process. We've outlined, you know, how like the tasks and duties and roles of the home kind of got subsumed into the the workforce of those places but like to kind of just bring us full circle i kind of just wanted to talk about like the the current health care landscape i mean because the last bit of your book talks about like corporate consolidation of a lot of these health care giants

and like earlier we had talked about like Medicare reform, probably don't want to get into like the weeds on like pricing of individual like procedures and everything. But I just, yeah, I kind of wanted to ask you about, yeah, the process of sort of corporate consolidation of a lot of these hospitals and, and, you know, what we're looking at now when we we look out and we look out at the the sort of like landscape of of health care in this country yeah i mean you know i'm a

little reluctant to weigh in on like the present present because you know i'm a historian and my book kind of runs out of gas about 20 years ago but that's like the respectable limit that's still history. But I guess I'll say, you know, I do think, I mean, the book makes this argument about how deindustrialization, first, you know, the workers, industrial workers welfare state, and second, deindustrialization, kind of feed into the healthcare industry, right? Make, position the healthcare industry as the shock absorber, cause it to grow as everything else around it shrinks

and kind of suck in, you know, de-industrializing society kind of into itself. And, you know, at some level, the kind of initial impetus for that, you know, seems to kind of be gone in some ways, right? Like the, there are no longer huge numbers of steel workers getting laid off or something like that um but i do think that uh we got kind of locked into like a past

dependency where the health care industry like is the thing that absorbs social problems and in particular social inequality uh to a significant extent like became medicalized like it's just uh let me explain how i think this works i guess um basically i think that uh the overall kind of downward pressure over the last generation or two on working class people's standard of living, and this is a story the book tells a part of, has forced what economists call the increase of household labor supply, which means that more members of households have to work more, right? And in particular, the main form that that took between like 1970 and 2000 was women

entering the workforce in large numbers in the working class. with women entering the workforce in large numbers in the working class. And, you know, then the kind of disintegration of job quality, like part-time jobs, this kind of shit, has kind of further fragmented the kind of everyday routines of working class households and families and their ability to kind of, like, continue to, you know, care for themselves and each other kind of internally,

which means that this, like, this is the opening that the healthcare system kind of, through which the healthcare system steps into our lives, right? It's the reason that home health care is the fastest growing job in the country and has been for years now and will be for the foreseeable future.

Home health aides are doing things like wives once did. And that's not all bad or it's even in some ways not mostly bad. Like the idea that women are equal participants in the labor market is important and good. But home health aides are like you know paid like shit everywhere in the country and often treated like shit um and you know that system has gotten increasingly detached from the kind of like thing that you think about when someone says health care and medicine which is like doctors and hospitals. So like keeping you alive in a day-to-day way and, you know, like treating your cancer when it happens

are like increasingly become pretty distinct kind of sets of institutions that do that, where they used to be closer together. And again, it's not all bad. But I think it does mean that, you know, I guess this is a kind of generic statement, but the healthcare system like has become so large and so complex that we like we depend on different and multiple forms of it in different and multiple kind of parts of our lives and over the course of different parts of our lives. parts of our lives and over the course of different parts of our lives um again quite in contrast to like a steel worker in 1960 who was born at homestead hospital whose kids were born at homestead hospital and who died at homestead hospital right um yeah and um you know this makes the system very difficult to reform i think well uh sorry go ahead no i don't interrupt you but like as you as you pointed out,

this system was politically and socially constructed, not necessarily in the same way that steel was or coal was, with investments and capital. This was a socially and politically constructed system, and as such, it contained a lot of these contradictions that are very, as soon as you start to try to tackle them, I don't know, it triggers, it sets off a whole other sort of array of contradictions. Yeah, I mean, I say in the book, you know, like the main way that healthcare appears in our

national politics as a problem is as a set of costs that we need to get down, right? Yeah. But the set of costs that we need to get down are actually like why healthcare is a solution to every other problem, right? It has all these costs that we need to get down are actually like why healthcare is a solution to every other problem, right? It has all of these costs that we need to get down because it's proliferated so many kind of tentacles that can do so many different things that no one else can do or will do, right? And again, that's not to say like the healthcare system is good as it is by any stretch, just that like it's kind of sucked everything into itself, I suppose.

Yeah, well, maybe that's a, maybe a good way to ask this last question, which I think would be good to end on. I guess this last question would be, like, why this way of looking at this? And the reason I ask that is because some of the criticisms and stuff i read uh the book is like i don't know someone i think you're a social justice warrior apparently

gabe uh a new cultural economist which is on the shit um but like but i you know obviously for me the answer is like you don't use this word at all in the book, but, like, to me, you're outlining a dialectical process. It's, like, just walking through these various stages and sites, you know, throughout history and looking at how some, you know, there are parts of them that get dropped out of some of them, and they get subsumed back into the next one. And so, like, I'm just asking, I guess, why this kind of lens or way of looking at this? What applications does it have? I'm glad you described it as dialectical. I very strongly agree. agree. You know, I guess from my perspective, what historical materialism allows us to do is to confront our own situation and to think about what are the kind of forces,

historical forces that have produced our situation, always, all of which have in some ways a kind of negative and a positive side right um that's not to say like you need to celebrate what's going on or whatever or but you know but that you know uh the historical development of capitalism is contradictory right it generates both exploitation and oppression and misery and at at the same time, always is generating a form of possibility for human liberation, right, within itself, that it's also stamping out all the time. And that's a very generic description of it. But then, you know, in any given society, in any given moment, you got to look at, okay, what are the versions of that that are happening here now, right? Like, what are the materials that are kind of being assembled

by the automatic processes of capitalism that might enable people to kind of then act kind of in willful and deliberate, solidaristic ways? And that's how I view this story. It's like, it's a story, you know, the reason i think of it as a story of or kind of partial or potential classification at least um is because you know my view is like there are structural forces that simultaneously make the care workforce the care industries and the care workforce grow and also prevent it from um achieving economic security and well-being. And moreover, those same forces also cause the rest of society to depend on these workers while preventing the quality of the care system in general and the health care system in particular, maybe kind of bind us together and create all these relationships of interdependency that have a real positive valence at some level. Right. Like the idea that there is kind of collective capacity in society that has expanded for taking care of elders and children and disabled people and each one another, right?

And that that doesn't have to just be mediated through like kinship. That's actually a good idea from my perspective. It's just that it's happened in the shell of these kind of private and, you know, exploitative entities and institutions. And that's the kind of central contradiction that I think, you know, if we kind of think of that as a terrain of possible struggle, it gives real potentiality to, you know, all kinds of even like ordinary everyday struggles, like how many nurses are going to be on this shift how often is my um you know my my grandmother in a nursing home going to get checked in on um you know these kinds of issues uh i think like arise out of a really really deep structural contradiction in

our society which potentially gives power to struggles around them yeah i mean i'm glad you said that and and it's not to say that like um the choices that were made like in the it's like you said earlier it's like i guess it's easier for us to say to look back and say like oh that was a stupid choice like they were selling their workers down the river or uh or you know like the the you know manly workers who participated in steel like they they uh you know relished their masculine role in the home and all this i mean it's it's like we're applying like current you know it's moralizing it doesn't it does no good to moralize right i mean you can think whatever you want it doesn't actually help you see anything differently about our situation and what we could do about it exactly yeah you're taking yeah i told a friend a mutual friend uh jack norton as like when i was reading your book

i was like you know like chef's kiss like the dialectics man it's like it's like it's like it really does it it it's a book that shows you how to do historical materialism honestly because it's like it's like it's like it really does it it it's a book that shows you how to do historical materialism honestly because it's like um for me i i guess i hadn't really thought about uh how it's not just a coincidence that you know this industry falls and then the other rises like there has to be a sort of interfacing process there and like the two feet or have to have to feed off of each other um and the way that you see that is like this a the social role that it fills and be the internal dynamics and contradictions of those workforces themselves like you can detect it it's like i mean there's debate over whether marxism is a science but like

you know we're we're not like applying these sort of like moralizing principles to it or, or anything like that. This is a strictly scientific, you know, dialectical analysis of how these, how, like how this institution, as you put it,

became socially and politically constructed rather than just like a strict, like business investment that people thought would make a lot of money it's like no it's it's more complicated than that yeah i mean you know and in some ways the way that it has so often been an afterthought like you know these aren't real employees from then to now right um arises out uh i mean it its quality as an afterthought, exterior to the real economy, an adjunct, a helper, right? It's like institutionally the healthcare system had the kind of position of wife, right, to the husband of manufacturing. Right, right. That's right. That's a good point. Yeah. Yeah, it's interesting. Yeah, it's interesting.

Well, I don't know. It's probably a good place to end it. I could keep talking about this, but I'm not going to take all your day, Gabe. But I just encourage everybody to read it. Like I said, it's also just a good manual of how to look around at your own community and say, oh oh this is a thing that exists i mean why does why does it exist that way you know because like these are

the questions that tom and i have been asking for years like why you know why is the health care industry the biggest employer in the region now i mean uh you know you can you can apply this method to um this historical method to kind of like understand how these institutions came into existence um and that's why i like at the top of the show it's like yo it truly does weigh like a nightmare though it's like right it's like some of them can't die out they contain a lot of the same sort of tensions and contradictions that were always there for like decades, but like in this kind of reconstituted, regurgitated form that makes it extremely hard to sort of understand or interact with. I don't know. Yeah, I mean, well, that's a good way of describing the healthcare system. It's extremely hard to understand and interact with.

Well, we's a good way of describing the healthcare system. It's extremely hard to understand and interact with. Well, we certainly know that. Tom and I have definitely had no shortage of interaction with our local healthcare industry. But, Gabe, thanks so much for coming by and talking about the book. Thanks for having me. This is great. Yeah, the book is called The Next for having me this is great yeah the book is called the next shift anything else you want to plug you got like i said earlier you got a podcast about ep thompson i haven't listened to it yet because i don't want any spoilers man is that the one you and alex pressed yeah it was a limited run just to be clear it's not an ongoing

project early pandemic right uh let me just say while we're you know before we can stop alex it arose because alex was gonna read a read the making of the english working class aloud on a live stream it's a 900 page book interesting digging around early lockdown experiment or something like that and i was like don't do that let's like let's like you know let's do this true masochist shit right there wasn't that the one who was it which which mp was it uh that jumped in yeah yeah yeah jumped in with y'all that's yeah it was very cool so we kind of had a you know discussion group that went along with it and so on oh wait he joined y'all's podcast yeah fuck i didn't know that it was was very cool. What's the shit? You know, I mean, he's an old socialist, you know?

Yeah. Corbyn, I think, Corbyn is a good dude, but, like, kind of comes out of, like, an ethical pacifist, you know, I'm going to sit down in front of the South African embassy type tradition. Very respectable and honorable. McDonald, I think, comes much more from, like, a kind of, like, Irish, you know, immigrant to england working class liverpool like marxist tradition right uh and so he was all you know he like he knew the book really well he read it i think you know multiple times in his life damn um yeah it's cool that's awesome um well anyways yeah like it it's not an ongoing series but um but i do think that it's complementary to kind of like what you're talking about in the book. Yeah, I'm always thinking about E.P. Thompson.

Yeah. And then, yeah, you've been published at many other places, all of which you could find with quick Google search, I'm sure. But anyways, by the book, any other final thoughts, fellas? All hearts and minds cleared. Same. All right. Sounds good. Thanks for listening this week,

everybody. We will see you next time. Adios. Thank you.