Transcript for Episode 55
Grant:
My guest today's Gabe Winant. Gabe is an Assistant Professor of US History at the University of Chicago; he’s a historian of the social structures of inequality in modern American capitalism. Gabe published his first book recently called The Next Shift: The Fall of Manufacturing and the Rise of Healthcare in Rust Belt America. Gabe came onto my radar when I read a review of his book in The Hedgehog Review a few months ago, and his book discusses a number of issues that really interest me, including American working class, healthcare, and particularly Pittsburgh. I love the book and I wanted it to have a more extensive conversation with Gabe about it, but really about all of his work and his thoughts on a slew of topics related to healthcare and American labor.
You'll see that Gabe and I are working from very different conceptual frameworks: Gabe describes himself as a non-believing Jewish Marxist, where my interest in labor issues emerges from Catholic personalism, especially found in Dorothy Day, Jacques Maritain, and John Paul II. So many of our solutions and argumentation may differ, but we certainly are united our concern for the wellbeing of the American working class.
I'm excited to engage in this multidisciplinary conversation. Welcome to the podcast, Gabe.
Gabe:
Thanks for having me. I'm excited too.
Grant:
I wanted to talk a little about your identity as Marxist. That word does a lot of work these days, and people invoke it for all sorts of different purposes, in many cases incorrectly. What does it mean to you to be a Marxist in the 21st century?
Gabe:
Marxism means a lot of things, because it's an intellectual tradition, and like any intellectual tradition [it] has many branches, many internal contradictions. Those who would attempt to turn it into something more dogmatic than that serve the people who would be interested in caricaturing it.
Marxists often talk about base and superstructure. I'm sure folks will know that kind of metaphor: that there's an economic base and that there is a cultural or political superstructure that rises to the top of it. Especially if you're thinking about how to use Marxism to analyze history or society, that metaphor will present itself to you.
For me, Marxism doesn't mean that you can read what people are doing politically or culturally or socially directly off of their position on the so-called economic base; rather, it's a kind of intellectual order of operations. There's a prime mover in understanding any historical situation—you have to understand how people are making their living; what problems arise for them as they try to make their living; what larger social structures their living is tied up with. So in Pittsburgh in the fifties, and the steel industry, the steel market—how is it organized? That will then give you a whole set of questions to ask next about political beliefs and ideology and culture and so on. So it's not a question of linear determination of social or political behavior or cultural meaning from an economic base, but rather a procedure that we can follow. That's the primary thing I think it means.
And then tacit within that is the idea of totality, which is a fundamental idea in Marxist analysis that we have to try to grasp society as a whole; that it's in some way an integrated whole, even the parts of that whole are different from and in conflict with each other.
Grant:
Maybe we can do a little application here. We've talked a lot about the question of deaths of despair. We've had a number of guests on the show that have been thinking about this issue; we know that those without college degrees are experiencing high rates of suicide, drug overdoses, alcohol abuse; and then among whites without a college degree was seeing this decrease in life expectancy. This was shown by Deaton and Case in their famous Deaths of Despair book. I've had a number of guests who propose a Durkheimian account of deaths of despair: basically long-term loss of social institutions and norms leading to meaninglessness and lack of purpose, and that’s the primary lens through which they've understood these deaths of despair.
Why is that account not convincing to you?
Gabe:
It's insufficient, is how I would think of it, and there's a few reasons for that. For me, the key way into this problem is if you start to think about race. Case and Deaton are very explicit [that] the phenomenon of deaths of despair, what makes it novel, is that it's happening to white people. There's in fact a long term life expectancy difference along racial lines going back a far ways. If you start to think about that, you can then ask, well, okay, so what is it that white people are catching up to? I think that is actually a more useful way of seeing it. It’s not a good catch-up, but white people are catching up to somewhere that black people have been already for a while.
And then I think that the answer that presents itself is deindustrialization—which is obviously associated with the Case and Deaton argument, is underlying it various ways. But they developed this argument at the level of social institutions, as a Durkheimian question of social integration.
From my perspective, we can see this much more clearly if we say, since the mid 1950s, there's been a gradual process working its way through the American working class, through the American economy, eroding secure industrial employment. It really starts as soon as the Korean War is over, but it starts at the bottom, and that's where it starts to affect African-Americans first and most intensely. And it gradually kind of eats its way up toward the top of the working class, and so increasingly affects white people by the end of the 20th century.
Grant:
Do you think it's fair to say that the crack epidemic was the first opioid epidemic?
Gabe:
Yes. I mean, I haven't studied that directly, but I often have that thought. We can see drug epidemics as phenomena of what Marxists call relative surplus population—that's to say a population that's kind of dispensable from the point of view of capital.
Grant:
That's really interesting. Deaton and Case certainly do not ignore the economics. It seems to me that the basic argument is that economic decline leads to this sort of Durkheimian anomie, which doesn't seem totally inconsistent with what you're arguing for.
Gabe:
No, I don't think so. I think that to understand it, you'd want to see it in light of ongoing political class struggles over the social wage. What is the shape of the welfare state? What are the forms of organization of the working class? How are those defeated or destroyed? What kinds of racial differentiation play out in those kinds of political processes? The kinds of social disconnection that are at the center of the argument, it's very difficult to contest that; I just think exactly what they mean and exactly how they arise is something that we need to argue about more.
Grant:
One thing I like most about your book were the case studies and interviews with actual people. I was hoping you could tell a quick hypothetical story of a family in the Mon Valley. I'm thinking of a man and a woman. Maybe they were born in Homestead in 1930. The husband started working in Homestead Works in 1948. They have five or six kids, as they would have at that time, and a couple of those children or daughters. The fact that a couple of the children are daughters is important. So maybe tell a little story about how the work prospects changed for those two generations as a way to illustrate how a city like Pittsburgh transitions from manufacturing to healthcare.
Gabe:
So this basically is my grandparents’ generation that you're describing. Let's say they're born in 1930. That would be a little too young for World War II for the man; maybe he fights in Korea. Let's say he gets a job in the steel industry in the military industrial boom that lasts from 1940 to 1955, between World War II and Korea. His wife, she probably had a job as a waitress or something like that when she was a teenager or early in their marriage; but after he has kind of gotten through his probation period at the steel mill, she realizes that it's time to have kids; they settle down, she quits her job, and he digs in for the long haul. This industry is unionized now as of 1937, and so accumulating seniority is a real path to economic security.
One point I try to make in the book is that actually, even that economic security for that generation is not quite the golden image of it we might have. A guy like we were describing here, he's going to be laid off for a few months every couple of years. For a working class family, that's a significant economic problem. Or on strike for a few months, every couple of years also. So between those things, they often have income shortfalls that might push the wife back into work, various things like that. But nonetheless, it's a life and they can basically make it work.
However, there were fewer steel workers every decade of the post-war period, and that’s starting already in the fifties. It's automation, it's trade competition. It's various forces. What that means is that if we fast forward from when he's gotten this job around 1950, to the seventies when his sons are coming of age and his daughters are coming of age, and he is approaching retirement, it's much less likely that his sons are going to be able to follow in his footsteps and the way that he very likely followed in his father's footsteps. Maybe one of them gets a job in the mill, gets laid off, doesn't get called back. Maybe another never gets a job in the mill. Again, this is going to depend on race, on if these people are white or black.
And then thinking about the daughters, who probably are getting married, and their husbands are going through a similar kind of thing. Some of them maybe are still going to be able to seek out these jobs, but it's getting harder and harder, less and less likely. So although the jobs themselves have gotten better over this period of time—the wages have gotten quite good, the benefits are really good—the number of people who have them has shrunk. Their overall ability to blanket the working class in economic security is not improving in the way that just looking at wages would make you think it is.
So now imagine that this older couple, he retires. They're in their sixties or even late fifties—steelworkers can often retire in their fifties—they have a lot of health problems. He's worked all these years in the steel mill. That's a hard life in various ways.
Grant:
They've both been breathing in coal dust for 65 years.
Gabe:
Exactly. So just epidemiologically, we know that they're likely to enter retirement with a higher disease burden. Back a generation before, a lot of the manifestations of that would be chronic and would be easily manageable most of the time by the daughters or by their daughters-in-law, or maybe nieces. But by the younger generation of women in their family, and it would be women who did that. That was part of how that whole household division of labor works.
But now if you think about this moment in the seventies, where the sons aren't getting the same kinds of jobs, either the sons and their wives or the daughters and their husbands are becoming more likely to leave town—Pittsburgh sees this huge immigration to the south and southwest. Or if they stay in town and the daughters are more likely to enter the labor market.
And of course the seventies, eighties, and nineties—this is the period of very intense transformation in women's workforce participation. We think of that as feminist opportunity, and it is that in many ways, but it's also economic compulsion, especially the lower in the class system you look. So women are starting to enter the labor market, and that means that they're not going to be quite as available if dad's condition is acting up, or mom fell, or whatever. They're not going to be quite so available for that in terms of everyday chronic care management needs.
This is the core argument of the book: what this older couple is likely to do is use their extremely good insurance, which they have from this career in the steel industry, to seek care in an institutional context. Particularly in the community hospitals of the Mon Valley, every steel mill has its hospital basically two blocks away. The community hospitals in the Mon Valley function kind of like this combination of what we think of a hospital as being, and also kind of like nursing homes, and also kind of like social work providers. They have this different array of functions because people lean on them for all of these functions that the family has provided before, but are being externalized out of the family, and that causes these institutions to grow really dramatically.
Grant:
Can you explain the concepts of dualization and polarization and the impacts that they have on the fortunes of American workers within the service economy? As these women are leaving what was historically being the stay-at-home mom or a housewife, now they're entering the labor force, but in a very different type of industry than the steel industry. So dualization and polarization—how that really shapes the current form of labor?
Gabe:
I have to admit, I tended to use them together in the book, because they mean slightly different things, but I'm not really interested in litigating which one is the right one. I'll describe each of them. Polarization is the description of something happening to workers incomes in the labor market; if you look at workers incomes quantitatively, you see that they're moving toward the edges of the scale over time, and that's why it's called polarization. In the mid century period that we were just talking about, there were more jobs—often it would be called semi-skilled jobs or something like that—that were in the middle, and that people with some education could get and build economic security around. But increasingly there's so-called high skill jobs—and I think we can interrogate skill here if you want to—but there's so-called high skill jobs that involve higher credentials at the top of the scale, and an increasing proportion of low skill jobs that are trapped at the bottom of the scale. And that's polarization.
Dualization is a structural account of what's happening in the organization of the economy. So it's not just that the distribution of jobs is changing, but that the actual structure of where employment is found is changing. In particular there's an increasing separation sectorally within the economy between engines of growth and engines of employment. If you think about U.S. dealer GM earlier in the 20th century, you think of those things as going together. But today, the firms that employ lots of people are typically these kinds of low wage service sector firms, which are not really able to—for various reasons—generate a lot of productivity growth, which is the very essence of economic growth in capitalism.
Thinking about hospitals and hospital systems, there's not really a way that we’ve figured out to replace labor with capital in hospitals in a systematic way, or to refine the division of labor in such a way as to make the work more efficient from a financial perspective or an economic perspective. That's part of why the cost of health care always goes up, is that hospitals and lots of service industries seem to have these intrinsic qualities that make them less amenable to productivity increase, and therefore not drivers of economic growth, even if they eat up more and more of the economy.
Grant:
What I found most troubling and most compelling was this central characteristic of the service industry: that it takes a lot of employees, but it's very low margin, which means there's this constant pressure to reduce labor costs, which puts a serious ceiling on the ability for workers to increase wages.
Gabe:
This is a core paradox that I try to get at in the book, is that if you think about healthcare, at the social level the demand for it is bottomless. We need a ton of it. And there's a lot of complicated reasons for that, and the book is trying to explore some of them; but for whatever reason—bracketing that for a moment—it seems like we are willing to consume an enormous amount and demand an enormous amount of care, and that drives the industry's growth. It has grown and grown and grown; it grew right through the great recession, it was basically untouched by it. It's today the largest sector of employment in the country, and even bigger in places like Pittsburgh, where it's about one in five jobs, slightly less maybe.
That's at the systemic level; but at the level of a given employer, when a given hospital or nursing home or home care agency is trying to figure out how to do in a day-to-day way is to get their patient's needs met with as few people as possible. So this is a core contradiction between the employer level logic and the system level logic. Employers, as you say, are doing their best to make their margins work, in basically the best way, or the only way, often, that they really have, which is by passing their costs on to workers in the form of intensification of work.
Grant:
And we're also in this period where the most profitable companies basically employ nobody. Google and Facebook make such tremendous profits and employ almost nobody.
Gabe:
Yeah. You know, people often hear I work on Pittsburgh, and they're like, oh, Pittsburgh's had this amazing Renaissance because of the tech industry. And I'm like, yeah. That's what, a couple thousand people maybe are actually part of that?
Grant:
Yeah. And so much of the profits get extracted out of Pittsburgh to San Francisco or wherever else. I'll probably put a pin in that because you don't want to get me started on the transformation of the tech industry in Pittsburgh. I could take over the interview. So in the interest of keeping the focus on your work, we'll just move past the transformation of the Pittsburgh tech industry.
So is inequality then necessarily built into this sort of economy, and is really the only answer just major income redistribution, maybe universal basic income? Or is there something else that we could do to right this sort of economy?
Gabe:
I struggle a lot with this question, because I don't want to give the impression that there's nothing we should do in the near term. I certainly think unionization in the healthcare industry, it does help, and it's important. There’s all kinds of regulations that we could do, not just [to] help with workers and working conditions, but simultaneously also the conditions under which care is received. A classic example of this would be regulating staffing hours in nursing homes, for example, which are chronically understaffed because they have an acute version of the problem I was just describing. We've seen the results of that and in a horrible way in the last few years.
I do think that ultimately the problem lies in the distribution of care through the market, though. It's subsidized by the public and organized by the public in all kinds of ways, but it's basically distributed through the market and administered by market actors. I think that is going to set us up for some version of this problem, inevitably, even if we can kind of ameliorate it.
Grant:
And that's due to the conversation we had before: the interests of management are always to depress wages. Is that the issue?
Gabe:
And to provide as little care as possible, which is not what we want from a health care system, or any kind of caring—education or long-term care or whatever.
Grant:
We’ll return to the healthcare system in a little bit. One thing I'm really interested in is how the lives of working class women have changed over this period. Again, there's been this commodification of caring labor: those that were once family caregivers are now wage earning caregivers to strangers. I'm interested to understand how the role of the stay-at-home mom or the role of the housewife is understood within a Marxist framework.
Just so you know, I was reading your book right next to Sally Rooney's new novel, and she refers to herself as a Marxist novelist. I don't know what that means, but I'm starting to get some sense. At the end of Beautiful World, Where Are You?, there's almost this argument for the goodness of the stay-at-home mom. Is this unique to Sally Rooney, or can there be a Marxist appreciation for the stay-at-home mother?
Gabe:
That exists. I would disagree with it, but it exists. I can give you a sense of the landscape of these arguments. There's a few different kinds of Marxist traditions of analysis about the family and the home, and in particular the figure of the wife and mother. One central debate is how to understand the relationship of housework to value accumulation. In the Marxist tradition, what capitalism is defined by is the production of value through labor. We can then look at the family and say, obviously, in some way, the family is connected to that process. Is the family itself producing value in some way, in the form of the husband as the available worker in this family configuration; but that value is embodied in him and gets cashed out when he goes to work. There's one tradition that kind of argues that.
There's another tradition that says, no, we don't actually have to say that value is literally being produced in the family to understand that the family is still a precondition for the accumulation of capital. You have to have some systems of what we call social reproduction—that's to say, social institutions that are able to produce and reproduce and sustain and give subsistence to the working class such that it's available to be employed in the steel mill. Again, this is to kind of simplify it; but in the latter tradition, which is often called social reproduction theory, there is an argument that in fact, capitalism both depends upon having a kind of uncommodified exterior zone like the family, but also constantly kind of transgresses upon it. It has this contradictory dual impulse. Given that, a common tactic of resisting capital accumulation for workers is to defend the sanctity of the family, and to argue that the family is his own beyond commerce, and that a worker should be a breadwinner, should be able to support his family. And this is indeed a mainstay of socialist and working class movements all through the late 19th and through much of the 20th century.
I think if you take it beyond the analytical account I just gave to a kind of defense of the single breadwinner family, it departs from Marxism and becomes closer to a Christian democratic tradition. There are various strands of conservative social democracy; obviously there are kind of blurry boundaries here. But I guess the boundary of commodification is the key thing to think about.
Grant:
How would you relate Marxism to Christian social Democrats? Sometimes people refer to themselves as democratic socialists, and I've a really hard time distinguishing that from good old fashioned liberal Democrats. In many ways the Catholic social teaching would end up in many of the same sorts of policy solutions that a Marxists would, but of course there's a difference in understanding of religion and family. So how would you relate those two movements?
Gabe:
It's a really important question, and it's one I’ve struggled with, to be honest. Because I think you're right, that in the everyday question of who are we going to vote for, what kinds of movements should we support, there's an enormous amount of overlap that's good from the perspective of a Marxian socialist like myself. I'm glad to have allies like I think you are, and I think of something like Dorothy Day with an enormous amount of admiration.
I think probably on both sides, it makes sense to see that as an alliance, rather than a merger, because I think it postpones questions that we don't need to answer now. But Marx described his project as the ruthless criticism of everything that exists. From a Marxist perspective—I'll say, not all Marxists or even most Marxists would say this—but I would say that it's difficult for me to see how one would uproot capitalism and the fundamental distorting and harmful effects it has on human beings, without making the family into an entirely different kind of institution in some way. It's not that I think that mothers and fathers shouldn't get to see children or something like that, but I think what we're really talking about is a very far reaching transformation in terms of human responsibility for one another that goes beyond kin relations.
Also I think even more strongly than the family question—because I think people who love one another should get to organize themselves however they want—but I also think the far-reaching transformation that Marxism ultimately posits does imply not just the change, but the abolition of gender as we know it. And that I think is a scary and exciting prospect from a Marxist perspective, and probably not from a Catholic social democratic one.
Grant:
I think that's fair. I actually just taught this afternoon in my class called Health Policy and Human Flourishing. I did a whole thing on post-liberalism, and I think one uniting factor between Marxism and Catholic social teaching is a commitment to the good above right, in turning liberalism on its head. But when we get down to questions of what is the good, that's when the real battle begins. But again, I think that we can agree on a number of things, and in terms of unionization and economic justice and those sorts of questions.
Gabe:
I like to think of it as like we can tease each other for now and we can figure out if we have to have it out later.
Grant:
That's right. Well, although if you asked a lot of Catholics in Poland and in 1955, I think they'd get a little nervous about this teasing.
Gabe:
I'm sure that's true.
Grant:
Returning to the question of the housewife, who is more exploited: the mother who's the family caregiver, or the daughter who is now a wage earning professional caregiver? Who's more exploited?
Gabe:
I don't think it's a question of more, in a quantitative way. The mechanisms of exploitation are different. The mother as a family caregiver, the second chapter of the book is really about that figure. It's about what's involved in making a family from the perspective of a housewife and a mother in the working class world at Pittsburgh. And the main thing I'm trying to show there is that it's not to debunk that these were relationships of love and care and that they meant an enormous amount to people. I take great pains to try to affirm that they did. But work that means a lot to you, or relationships that mean a lot to you, that doesn't make them not exploitative or make them not work in some way. Those things are incommensurable with one another.
And because there's a kind of nostalgic glow about it, I think people just do underestimate how intense and often hard it was to be a working class housewife in an environment like that. There's a diary that I got ahold of, of such a person. Every day in her diary, she just kept an entry of the work around the house that she did that day. And I was thinking about the entries where she's describing doing the laundry between one and two in the morning, because that's the only time when no one is making any demands on her.
That's not to say that the process of that labor or parts of that labor being absorbed into the market is a straightforward process of liberation either, which liberal feminism has historically argued: that the home is a space of exploitation or imprisonment in some form, and therefore the solution to it is let women out of the home to work like men, and then the scales will even.
Grant:
Wendell Berry refers to it as being liberated to now be enslaved in the highest paying prison.
Gabe:
Right. As I said earlier, that's a process of economic compulsion as much as or more than it's anything else, and brings with it a whole set of exploitative dimensions—some of which are parallel to or even kind of continuous with and built upon the structures of exploitation of wives and mothers. I think that's important to say, that it's because this work is like wife- and motherhood—like in a hospital or a nursing home—that it has some of the exploitative dimensions that it has. But it also has new things, new qualities.
From my perspective, the question is not which is worse, but rather what possibilities are embedded in each. This is again a kind of Marxist move: the point isn't to arrive at a moral judgment, but to arrive at a historical analysis of historical possibility that is opened up by any development. I think one thing that is enabled by the absorption of women and their work into these kinds of caring industries is what Marxists would call the socialization of labor. People come to know each other, they come to work together to depend upon each other; out of that is a possibility of political power.
Grant:
One critique that's always been internal to me in regards to Marxism is I often feel the causal model is insufficient and a little weak. When I think about the 1950s housewife, there has to be an account of love. You mentioned that yourself; but it seems as though the causal model within Marxism is so overdetermined by class, that we lose some of the other causal mechanisms that would motivate a woman in 1955 to be at home with her family.
I'm wondering, does love factor into the Marxist analysis, or is that just something that other people think about?
Gabe:
That's a good question. There's not really a Marxist theory of love, but I think if you're dealing with a social world where love seems like it is present, Marxism to the theory of totality. What that means is that we can look at any area of social activity and social life and try to understand both its specificity and its kind of particularity, and also the way it's linked up to larger social structures without despoiling the specificities of it. I guess that's how I try to think of love in this particular context. That's what I mean when I say it's not to dismiss; it’s to say that’s just alongside and imbued within exploitation and overwork and exhaustion and even fear. Lots of women fear and love their husbands. That's a very normal thing, actually.
Grant:
And I think a lot of men fear and love their wives as well.
Gabe:
Totally, yeah.
Grant:
Another really important part of the book is the description that you give to the changing demographics of American labor. What was historically white men is now primarily African-Americans and women, and also primarily African-American women—which is different than African-Americans and women is as you have argued. So what do we do with all these men that haven't gone to college? Can we make these health care jobs appealing to them? Should we just ask them to change their feelings about women's work? What are the possibilities for working class men?
Gabe:
This has to go beyond the book, but more speculatively. I would like to live in a world where we were responsible for one another’s care in a much more deep and rich way. That sounds abstract, but if you just think about the block you live on, you know probably who are the kids on the block you live on, who are the old folks; there's probably someone whose sidewalk you shovel when it snows because they can't do it, someone who you’d watch your kids for them. If you think about those kinds of relationships that we have already, deepening those in a kind of systematic way or a much more intense way, so that we just are more responsible for one another, that it's something that our society rewards in a systematic way. It's impossible to achieve that vision if men aren't part of it.
That's a kind of utopian vision of it, but between here and there, I think it's difficult to say in many ways what the steps are. If nursing assistant jobs pay $25 an hour, would men do them? I don't know; I think it would be worth finding out. But I also think this goes to our discussion about the family, or about the Marxist understanding of gender. Because if that world where we all take care of each other requires me to participate in it, and men right now are unlikely to participate in a lot of elements of that, then I do think we also probably have to change what it means to be a man in some way. And, again, that's a kind of exciting prospect, and I think it's one that we can only really get leverage on if we imagine what the economic structures of gender are.
Grant:
So how do you respond then to this critique of inherent sex differences in terms of employment, where you have the men doing “thing” things, and women doing people things? Is that rejected out of hand, or does that factor in some way in the way that we organize labor?
Gabe:
I would reject it out of hand. I just find it very hard to see any real meaningful basis for that in the constant flux of the division of labor in human society. It's true that women historically have always had to do more people things, but women have also always done many “thing” things, and we also have many examples of men doing people things, such that it seems to me that we really have much less basis than a kind of common stereotype would lead us to think about any intrinsic capacities.
Grant:
So here's a question: when we think about the 1950s breadwinner model, where it’s typically a white man bringing the income in for the family, it's often referred to as patriarchal and racist. Now we have a labor system that is primarily black and female. What do we call it now? Do we rethink that sort of question of racism and patriarchy?
Gabe:
I think the structure of society is patriarchal and racist at a pretty general level, and then particular institutions—family, employment—take particular shapes within that which are shaped by that, but need to be examined as they are in specificity.
It seems to me that when I call the 1950s nuclear family structure patriarchal and racist, I think that's a very, very easy position to defend, to be honest. I mean, it depended on structural privilege for men and for white people in how the welfare state was organized, who got which kinds of benefits; it was basically compulsory for women to marry men if they wanted access to the best kinds of social benefits; on and on like this. So now, if we want to think about institutions at the bottom end of the labor market that depend on the exploitation of women and African-Americans and African-American women—in other places, we would talk about immigrants also, not really so much in Pittsburgh— then I think those institutions also are, in different but related ways, are embodiments of patriarchal and racist institutions. They’ve had to get reorganized in how they work since the industrialization, and so are embodying those larger structures of hierarchy in different fashions, but the structures of hierarchy at some high-level are continuous.
Grant:
What if by some stroke of regulatory change, these become very good jobs? They pay well, and they're very stable—would that compel us to rethink how we understood how race and gender played out in this particular context? Is it just that they're sort of bad jobs, and therefore they're sort of perpetuating racism and patriarchy?
Gabe:
Well, it's [that] they’re bad jobs, and it's a question of why they're bad jobs. There's a lot of different layers to that. There's the economic layer, which we talked about earlier. There's the institutional history of these kinds of jobs. So healthcare, to stick with our example, was not protected by labor law until the 1970s, by which time it was sort of too late, even when you could organize, to really change the structure of things. There's even a cultural dimension to this, which I think is less decisive but I think matters, in terms of how people think and talk about these kinds of jobs and whose job it is to do them, and what you're entitled to from a nurse or nursing assistant and so on. Ultimately [there are] all of these layers of action that embody race and gender in different ways to give the healthcare industry, and the jobs within it, the shape that they have, which is why such a magic stroke couldn't happen.
But if such a magic stroke somehow did happen anyway—just to entertain the hypothetical—that would require the whole meaning of what these jobs were, and who held them, and the place that they have in our culture, would start to change. And men would start to do them, and it would probably take on a more scientific and less altruistic understanding of what it means to be a nurse. That's actually a good little example of how a Marxist analysis works: you couldn't change that economic dimension without having it ramify upward through culture and ideology.
Grant:
This actually leads into my next set of questions perfectly. So I'm in a nursing school; that's my academic appointment. I actually am a nurse. I haven't practiced really ever, but my wife is a nurse. So we have these conversations quite a bit about the nature of nursing and labor. Do you consider nursing to be a working class job?
Gabe:
It's a fantastic question. It’s such a vexed question and I can't give you a satisfying answer.
Grant:
Give it a shot.
Gabe:
I have a lot to say about it. Let me go back to basics. There’s a kind of problem in Marxism going back now over a hundred years of what to make of the middle-class. There's been thousands of books written trying to resolve this question. I won't go too deep into the details of it, but one of the classic critiques and problems in Marxist theory is that Marx, at moments, seems to predict the polarization of society into two classes; but we know that there’s this thing in the middle, and so how do we understand that? What defines it?
In the 19th century what defines the middle class is small property. People who own workshops, were artisans, small farmers, shopkeepers, this kind of thing. That middle-class was ground into dust by industrial capitalism. At the beginning of the 20th century, the new institutions of industrial capitalism—the industrial corporation, the research university, the large government institutions, the universal public school system—begin to give rise to a new middle-class, which is defined not by property, but by credential—professionals, basically. [The new middle class] on the one hand is employed for wages in the way that working class people are, with many of the vulnerabilities that come from that; but on the other hand, it seems to have higher social status, and is often involved in regulating or controlling the lives of working class people, if you think about a social worker, for example, or foreman in a workplace.
Nurses you can see within that analysis as having this contradictory place where they're both kind of in the working class and kind of in the middle of class. Thinking about nurses I know, and nurses in the book, it seems that RNs very often, who have degrees and often make six figures, they are very frequently the peak of their own family or class system. They're the success story of their extended family; they’re the person who managed to get a good amount of school, get a really good job. They often support a larger system around themselves, not just their kids. I know nurses who, after the foreclosure crisis, had people move in with them, because they were able to keep their homes.
So again, that's that kind of blurry boundary, where we can distinguish them analytically in some ways from a more classic working class, but they're also obviously socially connected to it. And also, as any nurse right now will tell you, subject to tons of the same forces that working class people are subject to all the time, such as under-staffing and speed up—which like every nurse is being driven insane by right now.
Grant:
What's interesting is a lot of the class issues that you're describing are actually playing out nursing education. There's a big movement among deans and nursing schools to move away from associates and diploma programs and really encourage bachelor's programs, and to move away from LPNs towards RNS. I'm trying to make an argument within my own circles to say, what you're actually doing is functionally shutting off a pipeline to the working class for the working poor. It might be good for nursing as a profession, but it's very bad for American labor. I'm interested in your thoughts on that particular issue.
Gabe:
I don't have a really well formulated position of my own. I know there’s this long-term decline of LPNs in particular. From my view, there should be lots more nurses. The way the profession is unsustainable for lots of people is a huge problem, because it needs to grow, not shrink. I'm not trained as a nurse; I haven't been to nursing school, so I don't have an extremely clear sense of what we'll learn through those second two years and how that division of labor works within a hospital. But it seems to me that more avenues for more people to become nurses are unequivocally a good thing.
Grant:
That tends to be my position as well. I'm one that really values diversity in preparation. And there are some studies that show that care delivered by a bachelor's prepared nurses tend to produce better outcomes; but there's some methodological questions about those. My point is always: [for] a very, very small but statistically significant, increase in quality, I don't know if it's worth shutting off employment to a large swath of the American public.
So here's one question from my wife; we had this conversation last night. My wife believes nursing strikes are unethical given their special relationship with patients. How would you respond to my wife?
Gabe:
I understand and respect that position. It does seem to me that there's no way nurses can shut down a hospital. I'm someone who supports basically all workers and all strikes all the time, and wants them to have their maximum effect all the time. But when nurses strike, that doesn't shut down the hospital. What they do is they force the hospital to spend more money on travel nurses. That's the mechanism of leverage by which nurses are supposed to win strikes, and that's a more indirect lever than the factory is not running.
So from that perspective, I don't think that is unethical. If we lived in a world where there was a real possibility of nurses shutting down hospitals, that would be a major problem. We can sort of see the middle ground when you think about teacher strikes, which drive everyone crazy because they generate childcare problems; but they don't kill people. From my perspective, we've got to support the teacher strike. Since nurses can't do that, I think that it's not unethical to try to impose these costs on hospitals as a way of getting leverage.
But it raises this bigger political question, which is, is it possible for nurses to wield economic power? And if so, what does it look like? My analysis of this is, the travel nurse cost thing is good; it's valuable, they should do that. That doesn't have the dire ethical problem that shutting down a hospital would have. But where nurses’ power really can come from is not just in classic industrial confrontation, like a strike; but it has to be political in some broader way.
Because hospitals themselves, although they're private entities, are products of public policy. We should see them not as private, but as privatized, or even as franchises of the public, where the public is setting the terms, is cutting the checks in various ways; and then there's private subcontractors that we call hospital administrations. And so nurses—there's a ton of them; they know lots of people; everyone loves and trusts nurses. And for that reason, I think they can potentially form a very powerful political constituency. That is another direction where nurses’ political organization can go.
Grant:
I forget the number, but one in X number of people are nurses, and every single person knows a nurse, and everybody loves a nurse; so that's actually the nexus of our advocacy power. At least that's what I argue for in my graduate level policy classes in the nursing school.
Gabe:
I lived in Massachusetts when there was a ballot initiative for a mandatory staffing level for hospitals, so I canvassed for it. And I realized that the thing to say, when I knocked on someone's door was, Hey, you know any nurses? And people say, yeah, because everyone knows nurses. And I'd say, do they seem kind of tired to you? Everyone would be like, God, I guess they do!
Grant:
Would you want to be in the hospital with this nurse?
Gabe:
Exactly.
Grant:
One thing I’ve noticed—and this flows from what you said before—is that many people that I’ve talked to who are within the healthcare system really struggle to see healthcare as an industry in the same way we see steel manufacturing as an industry. It's difficult for them to see the health system is the primary setting for a contemporary labor struggle. Is that your experience, and what can account for this sort of disconnect?
Gabe:
That is my experience. It comes from a couple of different things which are related to each other. One is a revulsion at the idea of healthcare as a site of profit-making, which is a valuable impulse, a humane impulse, even as it can lead people to not be able to get what's going on. It's not supposed to be an industry. It's not supposed to have a market; it's not supposed to be for-profit in a basic way that even the hospital administrators and insurance executives would have agreed with, within my own lifetime. That stuff has only become explicit in the time that I've been alive.
Then there's something about the organizational structure of the healthcare industry which is connected to the question of what would it mean to have a marketed life and death in this way? It's so fragmented. I was alluding to this before, but the structure of intense public regulation, quite a lot of public funding, third-party insurance payment, private administration, the separation between the hospital and the doctor—all of that, which makes the industry so unintelligible from the perspective of people who don't work in it or study it or know it really well, makes it hard to grasp it as an economic unit in the way that is implied when we say “the healthcare industry.” People maybe know their doctor; they have their insurance company that they hate; there's a hospital that they were born in. But the system of linkages that tie these things together is extremely obscure; and it's obscure for many reasons, but a fundamental one is to not too badly offend our basic revulsion at the idea of it being an industry. So that's hidden from us.
Grant:
One thing that this is making me think of is if we make this system public, I don't know if these labor issues go away. The NHS in England, their nurses have a union, and they're always angry with labor conditions. How does that help? Maybe in a philosophical sense, but [also] in a practical sense, how does that help?
Gabe:
I think it helps on the margin, just in [that] public employees typically have better working conditions than their equivalents in the private sector. Not radically so, but significantly; they're unionized much more heavily and can get a little further through those kinds of collective actions. All else being equal, you'd rather be working for the NHS than working for an American hospital.
But the problems are still there, you're right. That has to do with how they’re lodged within a larger capitalist society, in my view. But the other thing that's useful to think about here is to say, the problems are still there, but they're subject in a different kind of way to democratic politics. If you ever pay attention to a British election—this blew my mind the first time I saw this—they'll have a debate between the Labor candidate, the Tory candidate. And the Labor candidate will get up there—this is part of their national message—and say, let's increase the NHS budget by X amount, hire 30,000 nurses and 10,000 doctors. And the Tory candidate will say, no, no, let's increase the NHS budget by slightly less, hire 20,000 nurses and 5,000 doctors. That's what you're arguing about? We can't do that in this country, because we administer those questions through markets rather than through public policy, so they're not subject to democratic contests.
Grant:
One thing I found really interesting about the article you just put in the New York Times is where you made an analogy between Medicare policy and industrial policy. You argued that essentially Medicare policy was this enormous industrial policy that we don't think of as industrial policy. How would it change practically the way we do Medicare and Medicaid if we actually thought of it as industrial policy?
Gabe:
It's exciting and it’s kind of overwhelming to think about, because it would be such a dramatic thing. So Medicare and Medicaid are just this enormous stream of revenue into all of our communities, all over the country. And this is the kind of thing I try to work out in the book, is to show how those streams of revenue have consequences on what jobs people have. People work for Medicare and Medicaid, mediated via the hospitals and nursing homes. What you could do with that—and we can't right now, but in principle there’s no reason you couldn't—would be to use those levers to compel all different kinds of changes that we thought were right on hospitals and nursing homes, on home care. Whether it's the amount of time that a home care worker or a nursing assistant in a nursing home gets to spend with someone under their care; or you could directly regulate wages.
There was an amazing thing a few weeks ago where Congress was talking about capping wages for nurses. Nobody's wages in the private sector, anywhere in the country, are directly regulated in this way by Congress as an occupational group. But they're talking about capping nurses' wages; and that's the kind of thing that we can even contemplate, because actually we have these huge streams of income going into this industry, shaping the jobs within it. And so in fact, we could think about, okay, we don't want to cap wages, what we want to do is lift wages for people at the bottom. We want to increase staffing levels. We want to improve conditions of care to make it more humane. You would need to change CMS to do that—the Center for Medicare Medicaid Services is not set up to do that. But it's not a crazy idea to start to imagine how it could be set up for that, especially because at the state level, increasingly Medicaid programs have started to take on some of those characteristics.
Grant:
What are you referring to?
Gabe:
So all long-term care that's not privately paid is paid for by Medicaid, whether it's institutional or home and community based. Medicaid is a state federal program, so that means states administer it; and states do a bunch of interesting things if they administer it. Here in Illinois, nursing homes have to do simultaneous continuous reporting on staffing levels and hours of care per patient, per staff, and the staff-patient ratio. There's a Medicaid office in Springfield that is actually monitoring working conditions in nursing homes. There's other examples like that, that you can start to think about with Medicaid on the state level.
Grant:
Although what they're thinking about is the patient, not the labor; but it's not that hard to reimagine that. Actually, Medicare has a really easy mechanism to fix a number of things: it's the conditions of participation for hospitals. Every hospital has to meet some benchmark in terms of their physical plant and staffing numbers. It wouldn't be all that hard for Medicare to include staffing levels in their conditions of participation. There's not the political will, but there's the functional way to do it.
Gabe:
There's a Supreme Court decision that nobody but me cares about, but I'm sort of obsessed with, called Illinois Council on Long-Term Care vs Shalala in 2000. And in this decision, the Supreme Court found that if a CMS finds a hospital or a nursing home insufficient on a quality inspection and certification process, the institution has no right to resort to the judicial system on that finding until it has exhausted its administrative process of appeals and reviews, which is a lengthy and very expensive process. It just actually means in a way that nobody's quite recognized that some state capacity for forcing some of this stuff on these employers is already there.
Grant:
So are you someone who would be concerned with healthcare costs? I'm a health services researcher; we talk about cost, quality and access. Is that something that's important to you? Because a lot of the things that would be industrial policy would require a lot more money.
Gabe:
I go back and forth on this. On the one hand, our healthcare system is obviously grossly inefficient, and costs from the perspective of the patient are a horrific nightmare that we definitely need to be concerned about. One of the major social ills of our society, I think. Obviously one of the attractions of socializing at the very least health insurance is that it gives you an incredibly powerful tool for dealing with those costs.
That being said, I'm not that concerned about the size of healthcare in our society, the percentage of our GDP that it's eating up on its own terms. When the composition of that size is patients getting gouged and that kind of thing, then we should be concerned about it. But in principle, I don't think it's bad to have a big healthcare system; because as it grows, we can start to imagine how it becomes a way of concentrating social resources and meeting social needs on a wider and wider scale. And I think it's good for us to have social institutions that meet lots of social needs.
Grant:
In my class today, I made some parallels for the students between the Gilded Age and this particular moment, at least in terms of inequality, weakness of labor, polarization, individualism, et cetera. Maybe we can conceive of health systems and universities as robber barons of the 21st century. What are the limits of that analogy?
Gabe:
There's good reason for making it. I had my first class for the quarter an hour ago and I did that too. There's reasons we do that, it's not a crazy thing to do; but I do think there is an issue with it. And the issue has to do with where each period, the Gilded Age and our own period, fall in the overall trajectory of American capitalist development. So the Gilded Age arises in the first great orgy of capital accumulation, and that's what gives rise to these broader barriers. My students were just reading Andrew Carnegie this week, and those guys are figuring out how to take the process of the incorporation of the newly conquered continent and its natural resources—its plains, its mines—and lay railroads across it, dig canals through it, and turn it into capital. So the great inequality of that period arises from this process that is captured in the word absorption. Things are being absorbed into the capitalist system: new regions, new people, new processes of production. And it's expensive in that way.
Our period on the other hand is unequal because it's characterized by a process of expulsion. People who once were assigned to a productive role in the system are being expelled from it—and this is where we began our conversation with deaths of despair. Although it's parallel, [that’s] still quite [a] different dynamic. The difference is that something happened in between those two. You can't really repeat history, because stuff happens all along the way; you can't just wind back the clock. What happened in between the two was the period of the industrial capitalist golden age regulated by the Keynesian welfare state, which laid down various kinds of complex legacies that are still with us.
And so even as the capitalist elite went on a new offensive starting in the 1970s and successfully brought about a massive upward redistribution of wealth and power, and gutted various institutions of social solidarity, they did so in such a different historical context that it means a whole different set of things about how to understand our own period of inequality and what to do about it.
Grant:
Is a solution reabsorbing workers back into the system? Would you be someone who would have a national employment policy where you have total employment? Or is the solution to recognize that Bezos is going to have his gazillion dollars and just tax the heck out of him and give everybody UBI?
Gabe:
This is a very familiar debate to me. It's one I find hard to reconcile or resolve for myself. I think some combination of those things is probably where I would like to go. A world of shorter hours and less work is a world we want to live in, for many reasons. Both because it's more humane and gives us more time to cultivate ourselves and our relationships: our families, our gardens, our hobbies, whatever.
Grant:
Pieper says leisure is the foundation of culture.
Gabe:
Absolutely. I think there's also a good ecological argument to make in this vein, that lowering the level of economic activity—if we could find a way of doing it without immiserating ourselves—would be a good thing to do.
That being said, there is always work that has to get done. Someone has to wipe the asses of the elderly, even if they're in a communist utopia. The question is how to relate to that as part of our freedom, as opposed to a source of oppression. That it’s part of our freedom that we can depend on one another, and that dependence takes a form of responsibility as well as getting hedonism or something like that.
Grant:
There's this central question that sort of relates to what you're talking about: we do find a lot of our meaning from work, but that's also that has this downside—we get burned out, and as soon as we lose our job life isn't worth anything anymore. But at the same time, there is something actually good about being a productive contributor to the common good that a UBI in some ways potentially undermines.
Gabe:
The capitalist labor markets are a kind of abstract whip over our heads, and we need to feel free to break that whip, and UBI I appreciate as a way of imagining how to do that. I don't think that we should be subject to immiseration if we're not willing to take whatever job is on offer. You don't even need to be a Marxist to believe that; that's the basic premise of social democracy in a pretty mainstream form.
But again, from my perspective, the difference between Marxism and liberalism is the idea that others are the source of our freedom rather than the obstacle or obstruction of our freedom, and that in our social interdependence that our possibilities with self-realization are their greatest. In that sense, a society where everyone has the opportunity to do some kind of meaningful work that does contribute to a public good—not necessarily in a grandiose way, but just taking care of the elderly folks on their block—I think that that's a quite radical change actually from where we are at. And I think it's the way to think about these kinds of questions about the future of work.
Grant:
Gabe, I hate to tell you, but you sound very much like a Catholic personlist right now.
Gabe:
Well, this is what I'm saying. We can get along in a lot of ways.
Grant:
I totally agree. I only have a few more questions, but I found this one kind of interesting. The New York Times op-ed is called “Manufacturing Jobs Are Not Coming Back.” However, COVID seems to be raising this important question about the security of domestic supply chains. Do you think COVID is going to change the way that we think about outsourcing jobs and recognizing the need for a secure supply chain? Is there a future in which manufacturing might maybe not come back, but have a comeback?
Gabe:
There's some phenomenon of partial decoupling, with China in particular, of some global trade in production networks that had already begun in some ways it's likely to go further. There are some limits on how far that can go in terms of how global trade systems work; but even if it goes farther than I expect, and there are more firms starting plants in this country to produce things that hitherto we have imported, the labor market consequences are just not going to be that great. I'm not saying that's bad to do or it doesn't matter, but I just don't think that we're ever going to be in a world again where capital investment in manufacturing sets millions of working people newly in motion.
I think steel is a very good way of seeing this, actually. This country makes as much steel as it did in the heyday in terms of tonnage. But in terms of employment, very few people are involved with that. Nonetheless, steel still figures as one of these trade goods that you hear talked about in conversation about de-globalization and decoupling and so on. If a new steel mill were to start someplace in your region, certainly your local congressmen would brag about it, and if Trump were president, he would show up. But that steel mill is just not going to be like Homestead Works, which employed 12,000 people and was one of eight institutions like it within a few miles.
Grant:
I want to get your take on the gig economy. In some ways, the gig economy could be good for workers. They're free to sell their labor when and how they choose, sort of like journeymen selling their driving skills, I guess you could say. But at the same time, as technology can be used to more deeply manage and control workers, how do you situate the gig economy in terms of your own theories of labor?
Gabe:
I appreciate what you're saying about how there's a world where one could imagine the flexibility of the gig economy as a kind of emancipatory element. But in reality, we've seen none of that side of it actually play out. It’s very difficult to imagine a story where the gig economy left to its own devices, even though maybe it lets us see that that could happen, it's not going to take us there. My view is that we should be ruthlessly regulating, basically destroying through regulation if we can, the gig economy as it exists now. I certainly supported the proposition in California to mandate classification of Uber drivers as statutory employees for purposes of benefit collection and unionization and so on. I think we should do that wherever we can. These workers should organize themselves wherever they can. Whatever emancipatory possibilities might lie within the gig economy are more likely to come out of that process than anything that can happen by just letting play out.
Grant:
How in the world do you unionize gig workers? At least at the Homestead Works, you can walk down to the homestead works and there they all were. The gig economy, the evil beauty of it is you don't know who is working for Lyft, and how in the world would you ever find them to unionize them?
Gabe:
There are people who are working very hard on this problem, and there's all kinds of things that they do. For one thing, drivers tend to have some sense of each other a little bit, especially the people who are driving more for a living; like there's a place near the airport where we all hang out, for example. So they'll know each other that way. And they find each other online to a significant extent. But it's very hard. There's not only not a physical location, but there's also not in any legal sense that employer.
Grant:
Well Gabe, this is a lot of fun. Unfortunately we hit the end of our time, but I want to thank you for coming and havin such a fun, robust conversation. I'm really glad that we had the opportunity to do this.
Gabe:
Yeah. Likewise. Thanks for having me. It was really nice.