BOB GARFIELD This is On the Media, I'm Bob Garfield. As we've heard in the telling of a rising health care economy, we must deal with a number of bewildering paradoxes. One is the Orwellian newspeak that asserts employees are not employees and so largely unprotected by regulation and collective bargaining. Another is that, on the one hand, from the manufacturing days, health care evolved into an entitlement. But on the other hand, it is propped up by exploiting the labor, the very people made vulnerable by the death of manufacturing. The median wage in the United States for nursing assistants, phlebotomists, medical assistance and home health care aides in 2019, according to Brookings, was 13 dollars and 48 cents an hour. 28,000 dollars a year, just above the poverty line of 26,500 for a family of four. This on top of a brutal shift schedules and sometimes harsh working conditions. Gabriel Winant introduces us to a UPMC worker named Nyla Payton. 

GABRIEL WINANT Nyla Payton is a medical assistant working for the University of Pittsburgh Medical Center. She helps people call in, make appointments and understand things the doctor said. I asked her. are there other primary conditions you hear from people about. She said, black lung and mesothelioma, both pathologies caused by living in the kind of ruins of industrial capitalism. You know, her phone rings and rings and rings. There's no one but her to take those calls. The damage that one economy did to a whole set of bodies appearing in the form of mesothelioma and black lung was now taking a toll on her body in the form of her having to sit at her desk all day, not able to go to the bathroom because she was trying to take care of those people.

BOB GARFIELD And furthermore, she is in medical debt to her own employer.

GABRIEL WINANT So there was this process over the 80s, 90s into the 2000s of consolidation in Pittsburgh. Big academic hospitals buying up a little ones, the insurer getting freaked out to the insurers trying to consolidate. And the insurer tries to buy some hospitals and the hospital system by insurance companies. And they try to each not accept payment from the other one to build these monopolies that enable them to keep prices high. If you don't have gold plated health insurance, as most working class people don't, the toll of that is going to fall on you. And it's not a perk that these hospital systems give to their workers. If they get free care, that's not how it works. And they, as much as anyone, have to bear the brunt of these rising costs which leave them in these kind of companies store like debt relationships.

BOB GARFIELD Another paradox is the notion of communitarianism, which you invoke at various points. Yet UPMC Health Systems is something like a 20 billion dollar organization running at approximately a 2 billion dollar annual profit. When community hospitals they acquire run at a loss, management shuts them down, leaving the local community without services. Which doesn't sound very communitarian to me. What kind of beasts are these holding companies? Whom do they serve and to whom do they answer?

GABRIEL WINANT UPMC is a nonprofit, as are many of the big academic hospital systems. Cleveland Clinic would be another classic example, which is on and off the biggest employer in Ohio. Johns Hopkins Hospital System in Maryland is again the biggest employer in its state. However, these big nonprofit hospital chains have come to behave in very market conscious ways, right? They're very, very concerned about accumulating and maintaining market share, about having leverage over insurers and about holding wages down. It's not as though they have shareholders in the same way as a for profit corporation might, but it's difficult to figure out how to distinguish them from a for profit corporation. There's a story I tell in the book. A new accountant has been hired at one of the kind of more successful hospitals. He said to his boss, "Hey, I'm looking at the account sheets here. And, you know, I'm seeing something funny. It looks like here is all of the revenue that we're making beyond our costs. Isn't that what we would call profit?" His boss says, "No, no, no, that's not profit, that's net aggregate revenue after losses" or something like that. The accountant says, I don't understand why we're using eight words and we can use one.

[BOB CHUCKLES]

BOB GARFIELD From wages to publicly financed debt to the dubiousness of growth as a measure of success, it makes you wonder the city that likes to think of itself as the miracle on the Monongahela, miracle?

GABRIEL WINANT I'm sure you've heard someone say this, right? Oh, it's great now. It's had this recovery, there's  all these young people that these tech companies. There are neighborhoods in Pittsburgh where you can buy a 16 dollar sandwich. Now to the broader thing that you're getting at in your question. We are undergoing a kind of polarization of the entire economy. There are some sectors that generate a lot of profit, you know, attract a lot of capital but don't generate a lot of employment. You know, in Pittsburgh, because of Carnegie Mellon, there's a lot of robotics in this kind of thing, and that's a big source of the city's story of its own recovery, but, you know, not that many people in the grand scheme actually work in that industry. Not in this country. So the industries like tech, like finance, that are major drivers of profit and accumulation are not drivers of employment. And the industries that are big drivers of employment like health care, are actually not major centers of profit. Generally speaking, hospitals and nursing homes are actually pretty low margin operations. So employment is on one side, and profit and accumulation are on another side. And the two are not necessarily so directly linked, as we might once have thought.

BOB GARFIELD If the trilemma you mentioned dictates that payrolls must be suppressed to achieve low unemployment and affordable public expenditure, how to de-impale the health economy from the horns of the trilemma?

GABRIEL WINANT I think there's a lot we can do encouraging unionization, you know, raising staffing mandates, improving safety standards. There's a lot that would improve working conditions and caring conditions in the immediate term, but until the provision of care is extricated from the logic of market discipline, then the question of how to make either patients or workers or both pay for it is going to recur and recur and recur. But once you're talking about what we call de-commodifying or socializing, so large a sector of the economy, I mean a trillion dollars here, trillion dollars there, pretty soon you're talking about real money. We're not really the same kind of society anymore, after we do something like that. You know, there'd be huge sectors of the labor force shielded from the kinds of market pressure that have brought us the bloodbath of COVID-19 just to take the most recent example. So that's a really a very big social transformation,

BOB GARFIELD But not a new one. Right? I mean, it was a decision made long ago with public education whose employees do not get free market sorts of wages and benefits. But it's a hell of a lot better than what the health care sector enjoys.

GABRIEL WINANT Yeah, and it's, I think, the best example we have for what it could look like to allocate care democratically as opposed to through market processes. It's not that there's no conflict over allocation of education resources. Far from it, obviously. But we can all easily think in our own community of all of the conflicts over who gets to go to what school and whether the teachers union want versus what is the city saying you can give them and all of these kinds of things. But these processes are subject to democratic politics, right? People actually can organize and they can agitate and they can vote. They can unionize, do all kinds of things. They can protest. And it affects how education is provided. It affects teachers working conditions. It affects the conditions under which students learn. And I think it's very difficult to say that both education in terms of students experience and also as a place to work are not both much, much better for that fact.

BOB GARFIELD It was rejected in the midst of the revolutionary New Deal that was rejected in the administration of Harry Truman. It was rejected in the Clinton administration. Some degree of reform was achieved in the Obama administration and was immediately subject to hundreds of attempts at repeal in the 2020s. Guilded or not, do you believe that circumstances have converged to make this politically achievable?

GABRIEL WINANT I feel like I can predict with some confidence that the logic of the trilemma will continue. That we shunt more and more both social problems into the healthcare system and labor, into the healthcare system to manage social problems. As that's the work that people can get, then the health problems associated with economic inequality will continue to persist or get worse and the cycle will continue and continue and continue unless there is major political change. There are so many people who have been dragged into this system to work for it and to depend on it for their care. And so that's created these potential constituencies who scale is just enormous, right? Again, the largest sector of employment in the country. And just think about everyone, you know, who has gotten gouged by the hospital, or by a doctor, right, who's gotten screwed over by their insurance company, I mean, it's just kind of unimaginably vast potential constituency. And the question is one of organization. What would it take to articulate the common interest that these millions, millions and millions of people would have in a more humane, democratic care system?

BOB GARFIELD Gabe, thank you very much.

GABRIEL WINANT Thank you, Bob. Really appreciate it. This is a great conversation.

BOB GARFIELD Gabriel Winant is a historian at the University of Chicago. His book is called The Next Shift: The Fall of Industry and the Rise of Healthcare in Rust Belt America.

We are left then not with simple answers or immediate solutions, but an understanding of the forces that shaped the sooty colossus of steel and manifested again in the antiseptic corridors of health care. Not ending socioeconomic inequities, but dressing them in scrubs. As the Biden administration dedicates itself to infrastructure, Winant has given us a close look at the decaying steelwork beneath a gleaming economic sector and at the working class it dis-serves, but change, and political will, require a reckoning. Is this the moment? Can we even imagine a day when the looming silhouette of the former U.S. Steel building casts not a sinister shadow, but is instead a lighthouse illuminating a humane and equitable course? Maybe the question is, how can we not? 

That's it for this week's show! On the Media is produced by Leah Feder, Micah Loewinger, Eloise Blondiau, Rebecca Clark-Callender, and doing this week's heavy lifting: Jon Hanrahan. Xandra Ellin writes our newsletter. Our technical director is Jennifer Munson and our engineer this week was Adriene Lily.

On the Media is a production of WNYC Studios. I'm Bob Garfield.

Copyright © 2021 New York Public Radio. All rights reserved. Visit our website terms of use at www.wnyc.org for further information.

New York Public Radio transcripts are created on a rush deadline, often by contractors. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of New York Public Radio’s programming is the audio record.