The last fifty years have not been kind to the American working and middle classes. Variously dubbed “the Great U-Turn,” “the Great Risk Shift,” or “the New Gilded Age,” the modern era has been marked by rising economic inequality and a steady erosion in the quality and security of work. This transformation is captured by the divergent—but intricately linked—trajectories of manufacturing and health care. Consider these statistics: In 1958, manufacturing accounted for just under a third of nonfarm employment in the United States, and health care for less than a tenth of that (not even 3 percent). Two years ago, on the eve of the pandemic, manufacturing’s share had shrunk by more than two-thirds (to just over 8 percent), and health care’s had grown fourfold (to almost 12 percent).
In most accounts, the crossing of these trend lines is described as a long secular shift driven by powerful but discrete forces: globalization drawing labor-intensive industry from high-wage to low-wage settings; technological advances and changing expectations dramatically increasing the consumption of services (health care, education), especially in rich countries. These developments weren’t entirely bad. The tradeoff, at least for those in the global North, would seem to be a good one: greater educational attainment, longer life expectancy, and a reprieve from the satanic mills and mines. In this view, industrial capitalism is but a stepping-stone on the path to a service economy and so-called knowledge work.
Gabriel Winant’s The Next Shift complicates and challenges this story. Winant, professor of history at the University of Chicago, traces the relationship between industry’s fall and health care’s rise through the history of Rust Belt America and through two developments in particular: a demand for palliative care driven by industrialization and, subsequently, deindustrialization; and the emergence of a private welfare state in which government subsidized private job–based benefits rather than expand public provision, cobbled together and largely underwritten by postwar collective bargaining. The aggregate gains from postwar growth masked stark relational and distributional inequalities—especially by race and region—before and after the “Great U-Turn” of the 1970s. In the end, lousy jobs paying decent wages (such as unionized work in the steel mills) for those at the core of the New Deal’s industrial economy were displaced by lousy jobs paying lousy wages at the wide margins of the emerging care economy.