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The Making of a Caregiving Crisis


Allison K. Hoffman (@allisonkhoffman) is Professor of Law at the University of Pennsylvania Law School.

This post continues a symposium on Gabriel Winant’s The Next Shift. Read the rest of the posts here.


The past two years have made painfully clear the problems with undervaluing care work. As COVID-19 has torn through nursing homes—one in ten people living in a nursing home has now died of COVID—it has also exacerbated labor problems caused by decades of neglect. Daily news stories describe shortages in nursing staff, caused by burn out, illness, or nurses taking traveling jobs with considerably higher pay. By January 2022, hospitals were so understaffed that some were telling workers to show up even after testing positive for COVID, blessed by crisis guidance from the Centers for Disease Control.

The Next Shift helps readers trace this result backwards through time to some of its root causes. In a story that starts with the growth of the steel industry and ends with a massive industrial health care complex that rests on the shoulders of low-wage workers, Gabriel Winant leads readers through an intricate tale of the incremental steps that produced our low-wage health care workforce. The more a job focused on the so-called “custodial” aspects of care—like nursing aids and nursing home workers—the lower the work was paid and more likely it was held by women, especially black women. The book shows how the caregiving crisis we are witnessing today was produced by policies and markets, as they fed off each other to create a gradual accretion of power and money for some, and diminution for others.

What I most appreciated is how this book thoughtfully connects labor and healthcare history with regulatory policy to show the interplay between the two. By telling the stories of the people and places of Pittsburgh’s Mon Valley (even mapping, literally, the shift from steel mills (29) to hospitals (249)), Winant links historical moments that are often studied discreetly. Yet the interaction between these different historical pieces can be almost dizzying at times—like a Rube Goldberg machine, each piece sets the next in motion.

I first offer a simplified recounting of what stood out to me as critical moments in the complex interactions among unions, labor and health care policies, and private and public health insurance that built today’s oversized health care complexes, as well as the low wage workforces that keep them running. I then consider what conclusions, if any, we should draw from this history about the development of U.S. healthcare policy, and whether a more a promising future could be possible for health care workers, especially those focused on caring.

Health Care’s Rube Goldberg Machine

Workplace benefits: the initial domino in Winant’s story falls with the adoption of workplace healthcare benefits. Employer-based healthcare benefits began at Baylor in 1929 with the creation of a prepaid plan that provided local teachers up to 21 days of hospital care for $6 per person a year. This idea evolved into Blue Cross, which, as he describes, made it to Western Pennsylvania in 1937, just as steelworkers won union representation. In 1943, the National War Labor Board allowed labor to bargain collectively for benefits, including health benefits, which the steelworker unions won in efforts from 1949 to the mid-1950s.

Hospital revenues surge: as steelworkers and their families began to use those benefits, hospitals saw a flood of business and revenue. Winant describes that from 1948 to 1953, Blue Cross payments to hospitals in the area grew 2.5 times (141). Just prior, Congress had passed the Hill-Burton Act to support new hospital construction in lower-income areas with growing demand. Flush with revenue and aided by Hill-Burton, hospitals grew like weeds. They also began providing more sophisticated care, which allowed them to charge more for their services.

Enter Medicare: Here is where the pieces start to tumble quickly, with the interplay between private and public health benefits. Steelworker negotiations to slow this inflationary cycle stalled out (145-156). High prices left most people without job-based benefits unable to afford care and spurred the need for federal intervention that eventually resulted in the passage of Medicare and Medicaid in 1965. With public and private insurance reimbursing care generously, hospitals hired more healthcare workers, but many were low-paid jobs held disproportionately by women of color. Unlike steelworkers, they lacked the protection of labor laws to use to organize for more (152-157).

(As I’ve written elsewhere, the passage of Medicare and Medicaid also cemented long-term care’s place at the margins of health care financing, excluding it from Medicare, covering it only partially under Medicaid, and, in effect, relegating much of it to friends and family.)

Steel recedes and health care balloons: Through a set of especially interesting stories, Winant shows that as steel work began to disappear, workers, retirees, and their families retained health benefits and used a massive amount of health care, especially hospital care. Winant’s first description of this trend veers close to economic “moral hazard” territory, explaining that hospitals “offered a service their workers and their dependents did not have to buy, for which they could find many uses” (158). He later, however, probes more deeply to explain that people turned to the health care system to fill gaps in mental health care and other community supports. To accommodate this need, hospitals expanded even more and, as Winant describes, “absorbed social problems dislocated from other sectors of the economy that lacked access to public support” (169).

Consolidation & Erosion: To perhaps oversimplify from there, health care spending skyrocketed though the 1970s and into the 1980s, and Medicare responded with payment reform. Hospitals, instead of being reimbursed for their full costs of care, were paid a fixed amount per encounter (e.g., normal newborn delivery, pneumonia, etc.), based on the average costs of those encounters. This prospective payment system squeezed hospitals (229). The most prestigious and specialized hospitals, especially academic centers who received extra reimbursement, continued to thrive, while the community hospitals that were providing more of the hands-on social supports to communities struggled. Eventually, the specialized institutions gobbled up struggling community hospitals, producing the consolidated system we have today. In Pittsburgh, the University of Pittsburgh Medical Center (UPMC) was the main gobbler. UPMC, like its supersized brethren across the country, uses its heft to demand higher prices from insurers and lower wages of workers, as Winant describes in the first pages of the book. UPMC has drawn antitrust scrutiny, resulting in several settlements in recent years but no major structural changes – a common picture among mega hospital systems.

The Inevitability of Health Policy and The Post-Pandemic Future

Scholars often describe U.S. health policy as predestined from the moment when the U.S. chose an employer-based system over a national health insurance system. In recent debates over Medicare for All, this story of path dependence suggests major reform is now impossible because structural factors are all pitted against fundamental change. In some ways, Winant’s book confirms this hypothesis. The creation of a rich system of employer-based health benefits for some catalyzed not only a fragmented health care financing structure but also, over time, an extremely powerful and consolidated industry that now resists changes to that structure.

However, it also undermines this theory by showing just how many discreet parts were necessary to pave the current path. Imagine that just one piece shifted, the constellation of power could be quite different than it is today. What if Medicare were enacted initially with checks on inflation, dampening the initial expansionary push? What if Medicare included high reimbursement for long-term care and mental health care? What if Hill-Burton placed more thoughtful constraints on hospital expansion? What if health care labor had full organizing rights? If any of these factors were different, today’s health care delivery system could look quite different.

This thought experiment raises the question of what might transform what we see today: powerful health care systems and marginalized workers. Winant concludes with this question, wondering whether a rebound in collective action in the 2010, including among health care workers, might foretell change. When workers are willing to walk away, it seems that structural changes might be in store.

The Next Shift went to press just as the major problem it illuminates was about to become more relevant than ever. Over the course of the pandemic, our lives came to depend on marginalized workers. Given prevailing conditions, low-wage heath care workers—including nursing home workers, custodians, nursing assistants, and others profiled in this book—may be better positioned than ever to demand the wages and security they deserve.  

A pandemic silver-lining could be political momentum to pass much-needed policies that have long proven elusive, like long-term care payment reform. Yet, two years into the pandemic (and a year into the Biden Administration), I’m increasingly circumspect. Whether or not Build Back Better passes, one of the first pieces abandoned was proposed funding for long-term care; efforts by nursing home workers to organize continue to fail even in settings most ripe for action, largely due to the lack of labor protections; and health care workers who put their lives on the line and who have worked tirelessly have received little or no hazard pay. We are learning how deeply difficult it will be to change the structures that, as Winant artfully describes, have been a century in the making.