In 2018, the Massachusetts Nurses Association (MNA) fought a long, bitter campaign for an initiative called Question 1, which would have capped the number of patients who could be under a nurse’s care: up to five non-urgent stable patients at a time for one nurse; only one in critical or intensive care. The proposal would have compelled hospitals to hire thousands more registered nurses (RNs), and it polled well initially. When I canvassed for it, I found that it was remarkably easy to win over voters. Do you know any nurses? (Yes, almost without fail.) Do they seem tired? (Yes, almost without fail.) Do you want a tired nurse for yourself or your loved ones? (Of course not.)
The hospitals of Massachusetts responded to the initiative with a fierce $25 million campaign fronted by a management entity, the “Organization of Nursing Leaders,” which sounds to the casual listener like an organization of practicing nurses. ONL blanketed the state with ads warning of hospitals that would have to close under the financial burden; skyrocketing health care bills; and the overall decline of the quality of care under all the red tape. To politicize caregiving would only create a giant mess. Nurses themselves appeared to be divided. Support plummeted steeply over the course of the fall. I realized we were dead when I canvassed a woman in Cambridge who turned out to be a retired nurse and former MNA member herself. She was white and quickly self-identified as queer; she had a Black Lives Matter sign in her neat yard, where she was gardening when I strolled up to her house. On the question, she was on the fence. The proposal, which once looked like a winner, wound up with only 30 percent of the vote in November.
Hospitals in Massachusetts and around the rest of the country and the world are now under extreme pressure. In a late February report for Johns Hopkins University’s Center for Health Security, Dr. Eric Toner and Dr. Richard Waldhorn urged hospitals to dedicate specific cohorts of staff to coronavirus in order to limit the overall numbers risking exposure. “Normal staffing ratios and standard operating procedures will not be able to be maintained,” they wrote. To make up the gap, the report urged the use of targeted childcare for hospital staff, the recruitment of retirees and volunteers, and the introduction of “just-in-time” education. Such proposals have recently begun to be heeded. The New York Times reported on March 14 that Northwell Health, which operates twenty-three hospitals around New York state, is asking retired nurses to come back to work. Mount Sinai is requiring preapproval for use of vacation time; New York-Presbyterian is telling employees to cancel all travel plans. Hospitals around the state are also seeking clarity on whether they are obliged to send home staff who may have been exposed to the coronavirus because they were not wearing proper protection. In Connecticut, Governor Ned Lamont warns that hundreds of nurses have been furloughed for fear of exposure, leading to severe staff crunches. Similar stories are everywhere. As of March 17 the CDC was urging hospital staff to compensate for missing safety equipment by substituting scarves and bandannas for masks. The severe lack of capacity is not limited to the United States. We have all heard the accounts of the collapsing Italian health system.
Yet one of the most obvious public health failures underlying the pandemic is rarely mentioned: it would be easier to manage if there were simply more hospital staff and they were better paid and more respected. But workers are expensive, and hospitals have spent the last generation trying to hold down costs. This is not just a problem in the US. At Lewisham Hospital in London, the first institution in that country to treat a COVID-19 case, cleaning workers—who are essential to preventing the spread of the disease—walked out for a day earlier this month over late pay and wages stuck at £8.21 an hour. “There’s a recruitment crisis in the NHS,” says union officer Helen O’Connor of the strike at Lewisham. “That’s not going to be resolved unless it’s made a more attractive place to work.”1 Stories of overwork and exhaustion are pouring out of China, Italy, Washington state, and seemingly every other place where the virus has taken hold. Childcare for health care workers’ children is an urgent need—sufficiently pressing in many cases for school districts to stay open longer than they should have done otherwise. Like a radioactive element injected into the veins for an x-ray of blood flow, coronavirus is making plain the crisis of care in our society.
Even more than staff, we’re hearing about beds—that is, undersupply and malapportionment of hospital capital. To prevent the pandemic from becoming a waking nightmare, we need to generate fewer critical patients than there are available intensive and critical care beds. But here too, our capacity has been cannibalized. Just this past fall, Philadelphia saw its venerable 496-bed Hahnemann University Hospital closed by the investor Joel Freedman, who bought the facility and drove it into bankruptcy, planning to sell off the prime downtown carcass for redevelopment. Hahnemann accounted for 52 of the 941 critical care beds in Philadelphia County and the neighboring Bucks County, Montgomery County, Delaware County, and Chester County. Of the remaining 889 beds, 627 were already occupied as of March 14. Today, health administrators are talking about an emergency reopening of Hahnemann to clear space in other hospitals for conversion to critical care.
Hahnemann is no outlier. Thirty hospitals closed nationwide in 2019, the worst year yet. The wave of closures has been particularly intense in rural areas, where 119 hospitals shut down over the past decade. Hahnemann represents the urban side of this pattern, recognizable also in the much-protested closure of Braddock Hospital outside Pittsburgh (torn down) and St. Vincent’s in Greenwich Village (sold to a developer). Whether rural and poor or urban and poor these hospitals couldn’t bring in enough complicated, remunerative cases to appease their financial masters: they are doing poverty medicine, for people with poor coverage, for conditions there’s no money in treating.
Today we have thousands fewer hospitals than we did a handful of decades ago, and hundreds of thousands fewer beds. In 1975, the United States had 7,156 hospitals, collectively operating nearly 1.5 million beds. By 2015, these numbers had fallen to 5,564 hospitals and 897,961 beds—even as the total US population grew from 220 million to 320 million. While the system has shrunk in absolute terms, there has been a modest increase in the capacity of intensive care facilities, roughly keeping up with population growth. In 1980, we had 68,000 ICU beds. Today, we have 96,596, approximately 10 percent of all hospital beds and the same number of ICU beds per capita—although our aging population has a larger medical footprint per person now. A significant number of these, too, are neonatal, pediatric, burn unit, and other specialized critical care beds. (Had we kept all our hospitals and beds since 1975 and still sustained this 10 percent proportion of intensive care beds, we would today have 50,000 more.) Hospitals that became increasingly dependent on debt for capital needs over the last decades of the 20th century are now facing soaring interest payments in the same moment that they need to rapidly expand capacity.
While not as severe as the fixed capacity shortfall, the labor supply is a problem too. In 1980, when a national shortage of nurses became widely acknowledged, there were 1.3 million employed RNs and 550,000 employed LPNs (licensed practical nurses, typically holders of one-year or associate’s degrees) in the United States. Today there are nearly three million employed RNs and about seven hundred thousand employed LPNs. Taken as a whole, then, the professional and paraprofessional nursing workforce has doubled in size in the last forty years. But we should not take too much encouragement from this fact, given that the population has grown by almost 50 percent in this time and also has aged steeply. We are not, in other words, awash in unused nursing talent. The average hospital case, too, has become significantly more acute, demanding greater attention from caregivers. And today more nurses work outside hospital walls, in outpatient clinics, nursing homes, private homes, and for drug and insurance companies. In 1980, 66 percent of RNs and 47 percent of LPNs worked in hospitals; today only 57 percent of RNs and 13 percent of LPNs do. The hospital nursing workforce thus has not grown nearly as much as it would appear. In a somewhat analogous pattern, the overall number of doctors has doubled since 1980 although, infamously, the medical school debt regime and the stratification of reimbursement rates have caused an increasingly outrageous maldistribution of practitioners into high-paying specialties. Should we expect to see oncologists and orthopedists deploying to the front lines?
Overall our hospital capacity does not give much reason for confidence, decreasing on many measures at the same that the health system has become increasingly disintegrated and unequal. In a process sped by Medicare reform in the 1980s, a growing proportion of care that once would have happened in the hospital has been shifted into nursing homes and home health care. Dependent on Medicaid for most funding for its 2.5 million residents, with a preponderance of for-profit operators and a growing presence of private equity ownership, the nursing home industry has long been a time bomb. There is no way to squeeze profit out of these institutions except by cutting corners, particularly on staffing and training. Negligence and abuse are inherent in the enterprise under this funding structure, and in a pandemic environment there is a high risk of any such institution—but particularly one where beds have been financialized—becoming a lazaretto, if not a charnel house. We have all heard about the nursing home in Washington, Life Care Center of Kirkland, which has been linked to twenty-seven of the forty deaths in that state as of March 14. This is just the beginning. As of March 18, nineteen facilities in Florida had suspected or confirmed cases.
Alarmingly, the Trump Administration has been busy over the past few years weakening the regulation of nursing homes. Fines for violations on inspection have been falling steeply. In October, the Center for Medicare and Medicaid Services (CMS)—headed by Seema Verma, a loathsome new dissembling presence on television during the pandemic—rolled back an Obama Administration rule forbidding nursing homes from locking patients and families into arbitration agreements. Under the new rule, elders and their loved ones are limited in their ability to turn to the courts if they are victims of abuse or neglect. (It’s an unsurprisingly well-supported empirical reality that privatizing dispute resolution diminishes the quality of nursing home care.) More recently, CMS has been preparing to loosen the requirement for nursing homes to employ specialists in infection prevention. Where there has been a mandate of at least one such specialist per facility, the new regulation—developed at the behest of the industry—would require only that infection specialists “spend sufficient time at the facility,” a deliberately meaningless mandate. With 380,000 residents already dying annually from infections before a lethal pandemic was on the loose, Trump’s bureaucrats bear reasonable comparison here to the commandants of concentration camps, liquidating the feeble.
There is a great contradiction embodied in the facts that the virus is fundamentally a threat to the old; that this threat has been magnified enormously by the incompetence and malice of the ruling regime; and that the old are the primary mass political constituency of that regime. The coincidence in time of the outbreak of coronavirus in the United States and the crushing of Bernie Sanders’s bid to democratize our health system and face the related crisis of climate change—a defeat inflicted through extreme generational polarization—intensifies this contradiction further. The young are trying to save the old, as well as themselves; the old are trying to kill the young, as well as themselves.
It is common to observe that we are now reaping the whirlwind of a broken health system and weakened social safety net. But let us be more precise: our health system’s cruelties are unevenly distributed by wealth and by its correlate, age. In its institutional structure, the hospital system was built up in the postwar decades through and around the institution of large-scale collective bargaining in industry. When they failed to win a national health plan in the 1940s, the great industrial unions, together with their employers and Blue Cross, invented the public-private hybrid we have now as an alternative, as Jennifer Klein’s history For All These Rights shows. The fundamental principle of this regime, from the standpoint of the individual worker, was seniority: it produced a new working-class life-course in which the end would be better than the beginning, culminating in secure retirement—a principle made concrete by Medicare after 1965. To supply this booming market, hospital capacity rapidly grew, financed through publicly subsidized municipal bonds. But as the generation who took lifetime jobs after World War II and the Korean War retired or were laid off (never to be replaced) in the 1970s and 1980s, the politics of health care underwent a profound shift. For younger generations, the growing difficulty of landing jobs with livable wages and high-quality benefits resulted in a rapid decay in health security, as the link between employment and health care, mediated by productivity, fell apart. Meanwhile elders became entrenched incumbents in a system that was only superficially being maintained and renewed for successors—although the poor among them still may fall through the cracks into the nursing home nightmare. If it is not really accurate to describe health insurance as something that only exists now for people born between 1920 and 1960, it is still close enough to be a useful exaggeration.
This generational entrenchment—manifest in patterns of wealth ownership, life expectancy, and much more—underlies the basic pattern of political polarization we have experienced over the past two decades. As the sociologist Gøsta Esping-Andersen observed in his 1999 book Social Foundations of Postindustrial Economies, “A new, asymmetric ‘chrono-politics’ appears to be displacing the old political frontlines when it comes to welfare state support. Not only is the median voter ageing, but as the necessity of financial cuts mounts, the need for trade-offs mounts.” Presciently, Esping-Andersen grasped that retirees would enter any such conflict over trade-offs doubly advantaged. First, the old are far more organized than any youthful challengers. Second, the young are not interested in reducing old-age benefits but rather increasing other ones. This is why the conflict is “asymmetric.”
One manifestation of this generational imbalance of power is the immense difficulty of health care reform, since major constituencies—not just profiteering corporations, but segments of the markets they’ve captured, and the people who compose those segments—are materially tied to the current system. This is the underlying social basis of the attempts to fend off Medicare for All through appeals to incumbent health insurance, in particular Medicare itself. “Keep your government hands off my Medicare” is not—contra liberal snobbery—simply ignorance and false consciousness. It is rather, as Esping-Andersen would put it, the slogan of asymmetric chronopolitics. It is important to understand that chronopolitics remains only the political and cultural modality in which class conflict in recent decades has appeared. But this does not make generational conflict superficial, any more than the mediation of class through race makes race superficial. There is a genuine divergence in life chances and social power along the lines of age.
At some point this regime was bound to give way as the social distribution of risk became increasingly divorced from the system of social protection constructed between the 1930s and 1960s. It was out of this widening gap that the young left sprang. And over the past four years, since the Sanders campaign, it seemed clear who held the keys to the future, although the process of change by no means looked smooth or inevitable.
The pandemic has truncated this transition severely. Conventional constraints of neoliberal governance are giving way at an astonishing pace. It looks likely that we will see direct federal control over some areas of the economy, particularly the health sector: state manufacturing of ventilators and masks will probably come soon, despite Trump’s foot-dragging over the Defense Production Act and his Administration’s efforts to siphon funds to private actors while displacing responsibility elsewhere. Military deployment for the construction of hospital capacity likely won’t be far behind. (Though we must brace for the emerging possibility that the administration chooses to accept millions of deaths in a vain mass sacrifice to the gods of capital.) As commenters everywhere have observed, all-out mobilization is now necessary in a desperate effort to patch the huge gaps in our social fabric revealed by the virus: to secure food, shelter, schooling, and of course care for a population in lockdown requires social coordination on an unprecedented scale.
What we now know, with absolute certainty, is that capital will not achieve these tasks. Trusting the profit motive to deliver already left us a world of homelessness, hunger, debt, imprisonment, exploitation, addiction, racism, premature death, international strife, and rising temperatures before the pandemic struck. While these worsening crises are rooted economically in the regime of capital accumulation, their political intractability—the defeats thus far of the movements to address them—depends on the asymmetric conflict between the generations. The old have formed into battalions to mount a defense of the predatory and destructive capitalism we have known. With their votes especially, but also in their practices as managers of workers and owners of property, they have forced the young into compliance. Lacking structural power, the young have done our best to resist up to a point, then mainly fallen in line.
Now, though, the pandemic has given us—of all things—leverage. As Friedrich Engels wrote in 1872, “Capitalist rule cannot allow itself the pleasure of creating epidemic diseases among the working class with impunity; the consequences fall back on it and the angel of death rages in its ranks as ruthlessly as in the ranks of the workers.” We can transmit the disease, and this means our behavior matters and we must mobilize to contain it. As in any mass mobilization, there is a compromise to broker, and now we can see the shape of it. Dr. Deborah Birx, coordinator of the coronavirus task force, began to articulate this bargain half-heartedly at a recent press conference with the President.
Now, to our older population or those with preexisting medical conditions, everyone in the household needs to focus on protecting them. Everyone in the household.
I want to speak particularly to our largest generation now: our millennials. I have—I’m the mom of two wonderful millennial young women who are bright and hardworking, and I will tell you what I told to them: They are the core group that will stop this virus . . . The millennials can help us tremendously . . . Public health people, like myself, don’t always come out with compelling and exciting messages that a 25- to 35-year-old may find interesting and something they will take to heart. But millennials can speak to one another about how important it is, in this moment, to protect all of the people.
Is it surprising that in attempting to make the case for the crucial role of the young, figures in authority cannot articulate a vision of a positive task for millennials, beyond compliance and repeating what they say? The cohorts under 45 have seen their future stripped away and their increasingly clear and united protests mocked, belittled, and crushed. Now these generational burdens are piling up further as joblessness, homelessness, and indebtedness take their toll most of all on them—a toll that will be all the more powerful the more care we take to meet what is our real ethical and epidemiological obligation to our elders.
Social distancing is an unquestionable necessity and act of solidarity, demanding our fullest commitment. Still, more than submission is needed now. Unemployment is spiraling rapidly, but the displaced—especially the young—can be enlisted through public spending and planning to take on the creation of emergency housing friendly to social distancing and quarantine; cleaning and sanitizing public facilities, most of all transit systems, groceries, pharmacies, and health care institutions; tending to the children of the frontline workers. Many restaurants may not survive, but with public support we could reestablish them as neighborhood-level sanitary food production and delivery systems. It’s not possible to train an RN or a doctor in eighteen months or less, but it is possible to train an LPN in that time.
Such a reorientation, however, will not succeed on the terms of employment under which millennials have spent their whole lives. But the worm has now turned. Workers are already beginning to claim power for themselves—demanding the equipment and sanitary conditions they need to stay safe, walking off the job to resist endangerment by bosses; longshoremen on the West Coast are tacitly threatening to choke off commerce. New York teachers and Philadelphia librarians forced their systems to shut down. Detroit bus drivers won free fares, a demand based in both the needs of the riders and the safety of the drivers. Amazon workers in New York shut down a warehouse when they realized management was not taking sanitation seriously. Auto workers have launched wildcat strikes to stop production completely while maintaining full wages. Verizon and McDonald’s workers (at non-franchise locations) secured paid sick leave.2 Nurses at Kaiser Permanente protest in the streets for adequate safety equipment—no Organization of Nurse Leaders now interrupts and distorts their message.
As the primaries, settled by the weight of the elderly vote, have wound down, commentators and political insiders have pondered how Joe Biden can win over the youth vote that has been so skeptical of him. Perhaps adding Kamala Harris—California’s chief truancy officer—to the ticket would excite the young? Like Dr. Birx’s call for millennial help devolving into a plaintive request for memes, the question is far too small. The path to collective survival runs through working-class empowerment, the political and cultural manifestation of which will be the increasing leadership and authority of people under 45. Much more than the selection of the Democratic vice-presidential candidate, what matters now is the balance of authority in everyday life—between young and old, worker and boss.
That in turn is only possible to renegotiate through a transformation of the state and a displacement of the prerogatives of capital. This means an end to financialized hospitals and nursing homes stripped to the bone of staff and capacity, and the rapid emergence, instead, of full-capacity integrated care systems: behind the fully-staffed and expandable ICU, the hospital with pandemic-scale emergency capacity, there must be publicly available childcare, communal food delivery, and the provision of companionship and entertainment for isolated elders. It means safe food and stable housing for all—including the homeless, who have no place in which to shelter in place. It means putting money in the pockets of the millions of new unemployed and shielding them from the predations of landlords and bill collectors. It means freeing the prisoners, whether on the border or in the gulags operated by every city, state, and county—as well as by the federal government. It means building up international trust and cooperation, without which the global coordination necessary to fight the pandemic will be impossible. It means training for all the work that needs to be done.
The crisis of care that has left us so unprepared for this eventuality is precisely a crisis of the devaluation of labor in general, and the devaluation of feminized labor in particular—whether cleaners, daycare providers, nurses, or respiratory therapists to operate ventilators (67 percent of whom are women), the most important jobs in a pandemic. An increasing gap has opened up socially between those who are responsible for these types of labor (think of the hospitality workers in Las Vegas defiantly caucusing for Bernie Sanders) and those who own some amount of property, who have aligned themselves politically with the interests of capital. That gap has manifested itself in generational political polarization, both between the parties and within the Democratic Party. The sudden, rapid increase in risk for the elderly, however, creates the possibility for new forms of solidarity: to resolve the generational polarization in favor of a society led by the working-class and the young, to protect the old and vulnerable and secure the dignity of all.
In the depths of World War II, the British government put out a document known as the Beveridge Report, which historians have come to understand as something like the mission statement of the 20th-century welfare state. The report identified “five giants on the road to reconstruction”: Want, Disease, Ignorance, Squalor, and Idleness. It outlined a comprehensive attack on these giants through a system of “cradle to the grave” social protection. “Now,” the report declared, “when the war is abolishing landmarks of every kind, is the opportunity for using experience in a clear field. A revolutionary moment in the world’s history is a time for revolutions, not patching.”
Want, disease, ignorance, squalor, and idleness remain the giants we must slay, but the shapes they take are different than they were in 1942. The protections we inherited from that moment have degenerated partially into new obstacles, yet the beneficiaries of the legacy of Beveridge—the degraded legacy, that is, of social democracy—have refused until now to allow us to clear them away and begin again. But the old and the young need each other now: we need the solidarity they have withheld from us, they need our active participation as workers and caretakers. And now for the first time the immediate question of our survival depends upon resolving the antagonisms that have separated us and joining together against the regime of capital accumulation that has brought us to this precipice.