 to introduce our author and our two discussants here. We're excited to have Gabriel, why not who wrote the next shift, which is this terrific book about. Well, I'll let him talk about what it's about. I'm a labor historian at the University of Chicago, and also a labor activist and organizer. I'll let you talk more about I don't know how much of that you want to disclose but I'd love to have you share. We also have two nurses from our network, who are leaders in their own locals feel like top Felix Thompson from SCI you tend to one in Oakland, and John Heronimus from National Nurses Organizing Committee at the University of Chicago. So with that, I will hand it over to Gabe, and let you talk from it and then we'll let Felix and John introduce themselves after that. That's good. Okay, well thank you Sarah and thanks to Labor Notes and to john and to Felix and everyone for coming. So what I'm going to say for a labor historian like the dream is that the, when you write about workers and their struggles that, you know, workers who are in struggles and want to, you know, we what you said and talk about what you said and find something useful in it so it's very cool for me to be able to do events like this and I really appreciate everyone who helped make it happen and everyone everyone who came to as Sarah said, my name is Gabe, I am a labor historian I do have a kind of maybe organizing history that's worth mentioning in some way I mean started in my graduate student union which was a United here local where I spent eight years organizing and elected leadership, and I've done various things since then in DSA. And currently I am volunteering with the emergency workplace organizing committee which I imagine folks here maybe know about but is a DSA project to support workers organizing in an unorganized shops that, you know, need a little volunteer organizing advice and help. So, I'm doing that lately and have to talk more about that if that's useful. I was just saying before folks got out we just want to victory in a little bit T cafe here in Chicago. I would spend like two minutes just summarizing the book in an extremely extremely compressed way. I imagine some folks maybe have read all of it maybe some have read a little bit and probably most have read zero to some. So, basically, you know I wanted to write this book because it seemed to me that we talked about class and the working class and working class power had not really been updated since the industrialization and that a lot of our kind of. It's not our fundamental concepts and a lot of our kind of working kind of every day, kind of short cuts let's say for thinking about class working class power, we're really still rooted in the industrial world, which is why we were so disoriented by the industrialization right it is a real material reason for that obviously but then also that lead in the kind of academic and discreet world of sort of discourse about class to say, let folks to say well class doesn't exist anymore right, and that is. I mean, you know if you're rooted in some way in a socialist or Marxist tradition that can't be true but then that imposes a burden on us to think about well what does it look like now. And so that's what I wanted to do with the book. I didn't set out to write about healthcare I set out to try to answer that question and healthcare became the way of doing that or in particular. The story of the transition of the city of Pittsburgh and it's region from being a steel town, which everyone knows that it used to be to being a city where healthcare is the largest employer at almost 20% of all employment now. And I found in the process that that pattern actually, well it's a national pattern healthcare is the largest sector of employment nationwide around 13% of all jobs that that pattern is overstated in places like Pittsburgh that's to say former industrial cities. And that's because the healthcare industry was built as a kind of external adjunct to industrial production to manufacturing healthcare workers were not covered by the National Labor Relations Act until the 1970s. And that's just one of many ways that healthcare was really kind of created as a kind of mass sort of a mass service industry to service industrial workers and they're really good fringe benefits that they bargained over the course of the post war period. Over the course of the post war period, as I say workers like steel workers develop really good health benefits in their one really good health benefits in their contracts and simultaneously industrial communities got older and sicker and eventually poorer as they started to lose their jobs and that healthcare industry became the most important part of the kind of social safety net to manage all the social harm and damage and dislocation and deindustrialization and a function like that, because it was partly privatized and so someone could make money off of all of that social harm. And so as everything was collapsing in places like Pittsburgh or Detroit or Cleveland or Gary or you name it in the 70s and 80s, healthcare boomed. And, you know, it was the only kind of only game in town basically grew really rapidly, because it was something that could absorb a kind of function as kind of shock absorber of this horrible social and economic blow that was dealt to these working class communities. It's equivalent in that way to the prison system, it's the only other institution that really prosper and that's sort of a dark thought but I think it's an important one. And that's the kind of basic story that the book tells and then I try to show how the way that the healthcare industry had been designed and set up in the 40s and 50s and 60s meant that when it really started booming in the 70s and 80s and 90s. They continued all of the patterns and marginalized workers and made it hard for them to build power and claim a share of, you know, economic security in that industry. And that has to do fundamentally with the ways that healthcare is actually hard to turn into a profitable commodity it can be done, but you sort of have to fuck up the care that you provide to do it. And that tension that contradiction is at the core of the kind of hyper exploitative nature of the healthcare industry and I'll just wrap this up by saying I think one really clear way of seeing this is that as our society has gotten more and more and more unequal. It's needed more and more care because healthcare is one of the main ways as I'm saying that we kind of deal with social inequality, or one of the main places where we kind of process social inequality. And so we kind of dump inequality on the healthcare system that generates this relentless growth in demand and rising costs that we all know about right. And system wide growth, that cash is out in the form of system wide growth the healthcare system is always getting bigger, got bigger straight through 2008 recession for example. And that's happening at the system wide level, but because individual firms are trying to make money hospitals nursing homes home care agencies are trying to make money. And because they can't really replace workers with machines or find good ways of making healthcare provision, more efficient without messing it up too badly. Individual firms are always trying to employ as few people as they can. And I think there's a really profound contradiction that's like central to the healthcare industry and how we ought to think about it and we can talk more about this if you want. System wide imperative for growth, and the firm level pressure to stay small on the for the employer right because that's how they that's how they make the margins work. And that contradiction is really deeply tied up with our experience of the healthcare system as a place that we need to keep us alive the real way that it is actually essential I know healthcare workers hate the phrase essential workers and for good reason right but there is a kernel of truth in it. We do actually depend on you. So, for that reason I you know the book is trying to ultimately work out an argument for how healthcare workers power and socialism and in particular socialized medicine are all irretrievably connected to each other basically so I'll stop there I don't want to go on and on about it, but I'm happy to chat with panelists take questions whatever you all want to. Thanks so much for that game. I will hand it over now to john and Felix please introduce yourselves and I'll let you kick off the questions you brought. Oh, I'm muted okay so my name is john heronimus I am a nurse rep at university of Chicago. I work in perioperative care which is basically post surgical recovery area. Before that I was a medical ICU nurse I've worked in the ER at community hospital on the southwest side Chicago in market park as well as nursing homes hospice and long term acute care. I was in the LPN and the CNA before I became a nurse or a registered nurse. And I'm also co chair of the University of Chicago Labor Council which is where we met Gabe, and have done a lot of the organizing that's kind of made the, you know unions more powerful that would have individually kind of been kind of stuck in their own little sellers or silos, not to talk to each other. And it's amazing how when you have the same boss, whether you're in a classroom or in, you know, an operating room or in an ICU room. You, there's still these really amazing like connections to how our problems seem to be the same. I'll hand it over to Felix. I'm Felix Thompson I'm a nurse at Highland hospital in Oakland which is our safety net hospital in Oakland or public it was the county hospital and it's been semi separated from the county and a kind of weird quasi privatization effort. But it's still the public hospital and I'm also a shop steward in my SCI you local. And I this book was really exciting for me because it's the nexus of my interests which are in workplace organizing, especially in healthcare, but also in health, the economy of healthcare that I think is something that we could benefit from engaging with more seriously or with more complexity on the left. So, it was exciting for me to, to read your book and feel like I had a framework to think about these issues and that's historical. I think the reason why this, these healthcare economics questions are most interesting to me is that I've been a nurse for about 10 years and I've always worked, pretty much always worked in some part of, even though I've always worked for nonprofits, or for the health system, I've always worked in jobs that are related to either making the hospital money, or saving the hospital money. And so that can look like a lot of different things. But one example is I worked for Kaiser so if you have like, if you have Kaiser insurance, and you have a horrible accident and they bring you to the closest trauma hospital. So the job would be to look at your chart on the internet and decide if I, if we could transfer you in an ambulance back to a Kaiser hospital so that Kaiser wouldn't have to pay the bill to this other hospital rate. So I don't do that job more fortunately but that's like a nonprofit hospital model in my current job which I really love actually. I work with the high utilizers of the system, the folks who come to the ER four times a week or they get hospitalized every month and it's a really cool job because I get to get to know people in the community. I spend months or years getting to know them I go to their encampments or their homes, and I go to their clinic visits and if you're like a workplace organizer it's really cool because I get to like go to all different parts of the health system and talk to them in all different departments so it was great when we were like getting ready to go on strike and I could have a reason to do like site visits all over the health system. But obviously that's not why my employer pays me to do my job, they pay me to do my job because it saves the money to keep these folks out of the hospital. So anyway I'm just really excited to kind of engage more around the economic piece and how we on the left should be kind of building off what Felix is saying I became aware of Gabe's book when I was listening to a podcast and the reason why we're even talking about now is because after all of my years, working in various aspects of healthcare as a nurse in places where I'm taking care of very underserved patients in places where I'm taking care of patients who everything is paid for, and it's considered a place it's like a money maker for like a healthcare system. But seeing to Gabe talk about the origins of the system was the first time I'd heard someone explain it in a way that made sense to how is it that we've gone from hospitals being a place where, you know, people go to get taken care of. They're kind of like part of a community like in my hometown in Ohio, in Lorraine County, every little town had a small little hospital that was maybe like 25 or 50 beds. And as I was a kid in the 90s, I was watching those get shut down and shut down and shut down at the same time. In Cleveland, where I was at, you know, the biggest city to where I was living Cleveland hospitals like Cleveland Clinic Case Western Reserve were just expanding and becoming these huge things that were eating up neighborhoods and driving like property values up and all this crazy stuff. And, you know, and Gabe's book was the first time where I kind of understood why is it that University of Chicago Medical Center is this huge employer. It's the largest employer on the South Side of Chicago. And not only is it the largest employer in the South Side of Chicago but the Medical Center makes so much money for the university that we're the largest single source of funding for this huge global institution. It's interning those profits even though it's a not for profit institution, turning those profits into investments. It's leveraging the money that they're making and using it to buy a property building new huge new capital facility, you know, capital improvements and all those sort of things you would expect in these, you know, big corporations, and it clicked to me a few years ago while I was working with my union on our strike campaign and, you know, grad workers on their strike campaign that the University of Chicago is like the 21st century equivalent to one but of like a huge steel mill, like in a way that like me and, you know, other nurses and other workers at the at the university both in the hospital on the university side we're like, we're really sitting in the middle of this huge engine for capital. And we're the only people who seem to have any capacity to pump the brakes and change how the university maybe relates to the community in terms of we had a campaign about reopening our trauma center University of Chicago was had a trauma center up until the 80s and, ironically enough, Michelle Obama was one of the people instrumental in shutting that down because trauma patients don't pay. Right. If you are a young, you know, teenage male on the south side of Chicago and you get shot. You don't have insurance, you're not getting you're not bringing in all this money you're not a liver transplant patient you're not, you know, a cancer patient you're not bringing in value into the institution so we were literally in our community. Like, like, in my neighborhood, their people have been shot like a block from my house, but in spite of being next to this world class institution, you're going to be. Oh yeah sorry so you're going to get sent to somewhere 2030 minutes away and every minute that you're like dealing with being shot is a minute that you're might die, and we had a campaign about that we talked about a little bit later, but I'll pass on to. I just wanted to bring us like that's why we're talking about this because this book is the first time where it started to make sense how we got from small community hospitals taking care of people to these massive institutions that are like just making money hand over fist. So I'll pass it back. Well, maybe I'll ask a question cave of you. And I don't know maybe this is a hard question but one thing that you talked about that I think is a bit of a hard topic for us in the left is the economic incentives for the providers. And for example, in the, the model we're used to which is the like bed per day payment model. The hospital gets paid to keep people in the hospital beds they get paid for every day somebody's in a hospital bed. And there's many gradations between this and the other version, but the other version is like a capitation model, where you get, they get paid to like take care of a certain group of people and so it's actually cheaper for them. If they pay for preventative care, because it's expensive to keep people in the hospital. I think that's a hard topic for us to talk about like when we think about like what kind of Medicare for all policy do we really want, and what would it actually look like in a concrete way. I think we all get a little anxious about that because we're traumatized by neoliberal policies of like constant taking away. But having worked in a hospital, I think actually it's probably not good for people to have a system that incentivizes the hospital to keep you in a hospital bed. I think hospitals are a great place so you didn't really like go all the way there in the book but I'm imagining that you started thinking about like what kind of systems we should be looking at and I know you're a historian not an economist but I just, I wonder if you had more to say that didn't make it into the book about yeah definitely well you know it's interesting. In a certain way, I mean the health care system as we all know right it's it's kind of economic plumbing is so twisted in so many different ways, and parts of it work at odds with each other and really complicated ways. So, the, the, the sort of payment per day in the bed model. And the kind of payment platform doesn't really exist in the way that it used to so the kind of period of community hospitals that john was talking about those hospitals thrived on the kind of payment, you know per day type model and they really functioned and this is a big part of the book they really functioned, almost as kind of what I what I think of as medium term care. And, you know, I don't think it makes sense to romanticize, you know, that system or that time or whatever but the reason that people in communities like the place where john grew up or the places in the towns around Pittsburgh but I write about sort of love their hospitals was because you know, you had a baby you can stay for five days, you know, or, you know, if you know grand plus arthritis was acting up you can kind of just sort of check him in if he had good insurance which he probably did if he was a retiree in a steel town. And, you know, they could kind of keep an eye on it and make sure he was fed and whatever. And that was the kind of advantage of the payment by, you know, by the day in that way. And it let private hospitals to have community private nonprofit hospitals really kind of make a killing off of Medicare and off of collectively bargained health plans. And they grew and grew and grew off that. And that freaked out Congress and led to this change in 83 that I write about in the book. When Medicare moved to reimbursement by diagnosis and we still do this today. In terms of hospital reimbursement show like code but this is what medical coding is this for right and I'm sure folks here who work in hospitals know the term DRG diagnosis related group. Basically, in 1983, the Department of Health and Human Services came up with a list of 467 possible diagnosis you could have and said how much to pay a hospital for any of them, you know, with some adjustment by region and that kind of thing that basically they fixed the price to every possible diagnosis to come up with. And then the idea was that hospitals can go about this however they want to keep first for a day they keep person for a week and person for a month that's their problem they know how much money they're getting. They're incentivized on the one hand shorter stays for less acute patients. And on the other hand, hospital incentivize those hospitals that could afford it to invest in things like transplants spinal surgery cancer treatment. And that's really where the academic hospitals started to really diverge and do much much better than the community hospitals because they could afford those things. Doctor medical care that's a doctor's care which is a different accounting category and a different kind of economic stream from hospital care although obviously the overlap in practice remains on a fee for service basis. And so kind of, or often does. And so has this, you know, we have these kind of different kinds of systems and that encourages excess care in various ways we could talk about or more intensive interventions at times. None of that really directly answers the question but I think that's the kind of all the kind of context you want to know about thinking about this question. And it's true to me that I feel mixed about it I have to say I mean I think in thinking about Medicare for all. Right it's true that an important opportunity in Medicare for all is a kind of more rational use of our healthcare resources, and the most common way of thinking about this that I'm convincing is the idea of global budgeting basically for hospitals so rather than, you know, the insurer, the powerful public insurer saying, we're going to reimburse by the diagnosis. It's perfectly possible for the federal government to calculate what hospitals budget ought to be. And just sort of budget that for them in the totality of their operations. And that would remove some of the kind of incentives that you're talking about Felix. You know, I think at some level in terms of thinking about how to fight for Medicare for all that makes good sense. At the same time though, part of me, and I admit to being just torn about this I'll just be honest about it among friends and comrades. Part of me also thinks that there's an opportunity of sort of a political opportunity in the massive overgrowth of our healthcare system. And, you know, it's obviously takes this very perverted and kind of exploitative and grotesque form, right and it's grown so much because it has that form that it connects healthcare provision to capital accumulation. But that being said, we've sort of backed our way into this situation where we devote, you know one in four or $5 that we spend in this country to healthcare. And where we devote a huge amount of our kind of collective labor capacity to take taking care of sick and vulnerable people. And I don't actually think we want to be arguing against doing that. And I think instead maybe the argument is, or in this version right the argument is that what if we took this massive healthcare system that we've built for these fucked up reasons in this fucked up way, and turned it into something like what if your hospital was designed to be a place for homeless people for people in all kinds of need right what what if I mean they're kind of interesting experiments around things like trying to get Medicaid to fund housing and this kind of thing what if we actually did. Yeah, that's that is what it for, you know, and tried to kind of use the huge size of this institution, or this kind of system of institutions as a political lever. The very large size of its workforce makes it possible to start to imagine a constituency for doing some of that. But if you think those two analyses are somewhat at odds and they both make sense and I don't quite know how to, you know, work my way through that. I know that we're like talking about big things like Medicare for all. And as someone who's gone out there and like worked with my union and with political groups to try and advocate for Medicare for all. It feels like a lot of our, a lot of our discussion about Medicare for all is like winning a moral argument. And I've, and I'm concerned now that we've kind of like it feels like we kind of went through the Bernie Sanders moment that sort of thing. And that seems like that's passed and now we're back to square one where we might have been like five or six years ago with this sort of thing. And a big part of the book is talking about how union power was really crucial to fundamentally shaping like the politics of the country back, you know, in the, you know, the 40s and 50s. And I'm trying to think of like how do we, how do we get to a place where Medicare for all is actually back on the table, but because it's not a choice or a moral argument but because, you know, we have the power as workers to kind of like force that as like a thing. What are your thoughts about where we how we're going to like what are we going to have to do as union workers as union nurses to build a kind of labor power that like the US steel workers had like when, you know, 1954 and they went on strike the largest strike in the history of the country. What is your sense of our opportunities as healthcare workers in unions or who probably desperately want a union but don't even know what to do. Like, I don't know, maybe that's too vague but it feels like we're going to get these things like Medicare for all we need something very different from what we've been doing at this point. Well, I think the first the first thing to say this is, you know, I think it makes sense to campaign politically on it in certain moments and opportunities and whatever, but I don't think we're going to pass Medicare for all like a normal piece of legislation like oh you know we happen to have the right people in Congress right now let's get that through by one voter but it's not going to happen that way and I think we all know that. We're talking about ripping out an enormous industry, we're talking about Medicare for all, and it's just not you can't do it in that fashion right it depends on a much deeper level of social struggle. I think everyone here knows that but I really think it's worth saying. You know, I think it's helpful here to is a couple of sort of structural points about the healthcare industry and the way work is organized in the healthcare industry that I think are worth talking about one is a comparison to education. We don't think that we've totally figured out what bargaining for the common good and what that idea is supposed to mean education either right but I think there are unions like the LA teachers union Chicago teachers union that have pioneered that concept that organize groups of workers at the point of service right in the kind of public service industry can function as a kind of fulcrum of a larger coalition right in which their struggles and the struggles and needs of the communities that they work in can overlap to a significant extent not perfectly right but to a significant extent such that you know when CTU goes on strike here in Chicago right people and the ordinary people follow their lead. I think even there there's a problem. In terms of thinking about or a challenge I should say in terms of thinking about what participation in those struggles can look like for people who aren't teachers. And you know obviously they're simple versions of that like, you know voting for the people to see to you endorses and so on but I think it's a bigger organizational question. And, you know, then we can kind of take that comparison and think about health care what's different about health care. Well, public education is overwhelmingly public, or education is overwhelmingly public health care is overwhelmingly private. But it has a very large footprint of the public sector in it which I'm going to talk more about in a second because it's really important to this comparison. Education is occupationally more compact. I mean there is an occupational hierarchy in schools and in school systems, but it's not as large and it's not as stratified as the healthcare system right which runs from, you know, nursing assistants and you know people who work in the cafeteria up to doctors obviously who are PhD nurses and so on that's a much, much more stratified and graded occupational hierarchy which obviously makes unity harder to achieve and as we all know right that hierarchy maps on to race gender and citizen immigration status and a whole bunch of ways, which structures the difficulties of organization. I want to talk a bit more about the public private thing in health care which I think is sort of the key in thinking about this. I think the way we should see the health care industry is not just as a private industry, but rather as a, what labor law scholars like to call a fissured industry. So I think that that's developed in the labor law labor studies are the past couple decades, and like a good example of it is a franchise McDonald's. We all know it's hard to organize McDonald's because of the franchise arrangement, right in which the costs, born by the franchisee who owns the store are pretty fixed by the franchise contract that they have with McDonald's HQ. They don't do anything to not recognize the union right because they can't actually really change or control that much about how they runs the store. And that's sort of why you know $15 at a union kind of became just $15 right in the fast food campaign, a decade ago. And, you know, we all know the bosses lie about what they can and can't afford, but it's also true that behind the lies somewhere, the way are the way the capitalist economy is structured, right it is true that bosses actually can't always afford everything right and that is an important part of working class strategy is figuring out how to navigate that problem that competition and the economic pressure on employers is passed on to workers and we have to struggle around that. So in healthcare, I want to kind of argue to you all the healthcare is actually also a franchised industry, and the franchise or is the government in the form most of all Medicare and Medicaid, but also in a million other ways. There's a whole system of tax subsidy. There's the way that the government regulates private sector insurance and employment and private, you know, the way that employment generates private sector insurance. You know, as we kind of know from Obamacare but there's a whole history of this, going right back to the formation of the CIO and the first health plans that they won. So, the federal government hands and state government hands are really deep in the healthcare industry and really have given it its shape, but in very few places do they actually show right in the form of like public ownership and administration. And instead what they have are these franchisees who we know in the healthcare industry as bosses administrators who are the people who we have to deal with. And when healthcare was added to the National Labor Relations Act in the 70s. This was one of the first things that Unionists realized, you know, is that they would organize a hospital, and they would, you know, when you recognition and they would go to bargaining. And the administrator would say well we'd love to help you but you really have to take it up with Albany or Sacramento or whatever, with the state capital right which is basically determining our budget in various ways. And that's both probably a lie in many details and also fundamentally true at some, at some level. And I think this needs to be the starting point of a kind of political strategy to answer John's question. Since there is a structural institutional separation between workers and the real site of control, or the real site of power over the industry that determines working conditions. It's really, really clearly, especially in long term care and home care but it's true in hospitals too. Then what that means is that the problem is inevitably, I mean, the healthcare workers problems are inevitably political problems. And they have a fundamentally political character, because when the, when health policy is determining what happens in a hospital what happens in a nursing home what happens in a home care agency right what how many staff they're going to be on a floor or how many hours of staff member will spend with a worker, how many days people get to spend in the hospital or not or whatever. But they're, they're determining labor conditions health policy is always an everywhere labor market policy. And this is the kind of key point I try to make in the book. And so, what that means then I think is that there's this challenge for healthcare workers to figure out how their workplace struggles their industrial struggles can become political struggles. And that is a version of the question the CTU question right how can healthcare workers draw the real the very materially real connection between their need for better staffing higher wages, you know safer jobs everything the healthcare workers need. And the people who they take care of who also need those things, although they see those things in different form, right they don't see in this in under the same names, but they're the same needs. So in the case of the school system, not that this is perfect but I think often teachers unions are able to be recognizable to the parents and the children of the communities that they work in, as the obvious voice for those needs. And I don't think because of the fragmentation of the healthcare industry I don't think that we figured out how we could have such a recognizable voice and I also think. The relationships between healthcare workers and patients are shorter, typically, that's not always true right home care long term care but generally they're shorter, but on the other hand they're also more intense, because they occur in moments of need. And so, from my perspective, I think what that calls on us to think about is how to form organizations that healthcare workers are in some way again the fulcrum of the leadership of that their unions are kind of driving, but that people who rely on the healthcare system in some way as patients or as family of patients also have a role and a place in to both put a direct economic and industrial pressure on employers, and also to kind of contest the broader political field that is fundamental in healthcare working conditions. And I think is when we figure out how to build those kinds of organizations that we're going to be really cooking with gas and a different kind of way about about Medicare for all. Sorry, that was such a long answer. I think one thing you that also raised in my mind is, since I'm an SCI you this complicated thing that SCI you has done over the years where we represent care workers in the public sector. And so, institutionally we've ended up negotiating alongside the boss with the government with the payer. And it's become really confusing for members who have a militant point of view, because their parent union is saying is sending the message that we have a shared strategic interest with our boss. And I think that that's like, had a really negative impact on like rank about organizing for our members. I want to be curious along that lines. Gabe, do you have any, you know, things to live from the book about sort of the steelworkers and are there lessons to be learned from the ways they, you know, fought for, you know, the health care system we have now or that you know the ways that they handled change, you know, as a, as the industry started to the industrialize. I mean, I guess I'll try to take those questions in opposite order. You know, I think the interesting thing about the steelworkers was that as many interesting things about steelworkers but the kind of odd combination of quite intense militancy on one level. I mean as john said right the longest strike in US history is the is the 59 steel strike in terms of person hours I don't it's like, half a million workers for four months. And you know every contract in the in the steel industry had to get settled, literally everyone for the whole post war period by the president in the Oval Office pretty much, because it just generated such a big problem and the steelworkers went on strike, and they would do it, you know. And in combination with, you know, totally authoritarian bureaucracy, kind of ossified, you know, politics and all the many of the locals. You know intense internal racism as a whole civil rights struggle inside the steelworkers union in the 70s. You can go down the list like this. And so this is kind of paradox of economic militancy and ideological passivity basically that made them quite unprepared for the industrialization because the industrialization was not you couldn't beat it that way. If you were going to beat it. It had to be again political in some form. And, you know, whether that meant might have meant industrial policy and a kind of different government investment strategy, or, you know, there's a really interesting moment which is connected to the origins of labor notes right we said lousy campaign in the late 70s, which was this kind of rank and file democratic left wing insurgency in the union that probably did actually wouldn't have your questions stolen but we'll never know. And, you know said lousy. He had been the president he had been the president of the Chicago area district and when he was running for president of the whole union. He infamously gave this interview to penthouse, and we know we give us that separately. In which he said, you know, the last 10 years we've fallen from 400,000 to 300,000 steelworkers. Let's take it down to 100,000. No one wants to be doing this. He was an environmentalist and he was anti war. And his kind of beautiful thing he says in this interview he says you know all these guys who are spending their lives inhaling fumes and staring into the furnaces and, you know, boiling away and dying in injuries or poets and doctors or they could be right. And, right, that's actually an ideological and a political vision of the Union is something other than the kind of machines or when the economic gains although that's important and he agreed that that was important, but it was an idea that we could take the unions power while it still exists and try to renegotiate the larger class structure of the country in some way. And, you know, maybe that was a kind of pipe dream she certainly didn't get to do that. You know, it's instructive in thinking about this question of economic struggle and political political struggle and the relationship between them and political struggle can be broad right doesn't it. It means elections but it means a million other things too. But involves changing challenging transforming the state in some way. You know, I guess that kind of goes to Felix's question or Felix's point about some of the kind of contradictions that arise in these cross class collaborations that are part of the structure of the healthcare industry and the ways that collective marketing works in the healthcare industry. And I, you know, I don't have a great answer about it I mean I think you know there's an interesting story developing now I'm sure some folks know about it with SCI you in New York around home care. This is a big fight for, you know, better working conditions for home care workers which basically basically means a bigger Medicaid allocation right for all the reasons that we've been talking about. And SCI you and a lot of the providers are allies and Albany fighting for that. At the same time, as workers in New York City are saying that, you know, SCI that shops that have contracted SCI you are engaged in wage theft, and, you know, you know, contract violations and overwork and various things. And the union's response, and as well as the provider's response is sorry take it up with the governor. And I think one of these kind of challenging contradictions because on the one hand, of course, of course workers are right and to that matter patients are right to fight with the union leadership and with, you know, with a provider obviously about negligent abusive and exploitative conditions and they have to do that. At the same time as the problem really ultimately actually is an Albany, or rather the problem actually is in the structure of the healthcare system and how money is allocated. And so I think the challenge is one of these things where you kind of have to hold both hold both ends at the same time in your mind right. The challenge is like, how to kind of maximize the militancy of our struggles on the ground in workplaces, where union bureaucracy is collaborating with management, even though actually we also want that collaboration to work and kind of on some things in a day to day way. And I don't think that that's an impossible task I just think it's difficult and challenge, you know, a delicate one. And, you know, obviously the better organized shops are the more it's possible to be possible to make sense of that among workers. Kind of building off of what you're saying gave one of the things that I was thinking, as we're kind of reading those anecdotes about, you know, what would a future look like, you know, nursing and being like a bedside like healthcare worker is really like a dangerous, violent hard thing and we're always talking about burnout as like an issue. You know, my friends in the emergency room are like dealing with 30% turnover every year. It's just, it really is intense like I put in six and a half years and then medical ICU it's, they took part of my soul, and thinking about how we could get out of the German steel workers were in the news like a couple years ago for negotiating less work for similar but being able to maintain the same pay. And, and one of the things that we're fighting for here in Illinois is like a nurse patient ratio bill which is very similar to what they've passed in California. And that we, it feels like one of those fights what's going to be enormous and it doesn't feel like we're quite there with the understanding with how big that fight is going to be. And that's kind of like a step in that direction right, forcing the work or forcing employers to hire the amount of nurses that it takes to actually be safe, right at work. So, I don't know if you've got any insight or any thoughts about those sorts of arrangements where it's like, you know, union nurses and regular nurses who aren't in union have been able to like to do that work of forcing safe kind of working conditions because you know we I get paid enough I'm not concerned about my money. I know coworkers that are but I'm fine. If our nurse patient ratios were actually normal or like something closer to safe maybe I'd go back in the critical care. It's just like, I don't know what are you thinking about what are your thoughts on that. It goes to this earlier thing about, you know, the way like the ways that our system, we think about it as being so inefficient and sort of bloated and in one way it is that but also it's not big enough, right. And I think it's a sense of actually how many people there are to do the work. And, you know, I think that it makes a ton of sense to have kind of immediate struggles over staffing levels both through collective bargaining and through, you know, ultra politics where that's where that's viable which is obviously not everywhere. But once you have that right you have to fight constantly to enforce and enforce those regulations and to try to keep them from being eroded in various ways, and it's obviously management is a million ways of doing that. But you know I think that, like, as a kind of immediate site of struggle is a good one, because it does go centrally to the issue of how the working conditions and the way that the healthcare system takes care of the whole society are connected to each other. That being said, you know what I also think you know among socialists it makes sense for us to be thinking about what would it actually mean to have a society where nursing was, you know, and all kinds of care work were rewarding and sustainable, and, you know, plentiful, all at the same time. And, you know, I think from that perspective, once you start to ask that question it takes you pretty quickly I think to a place where you have to imagine caregiving is something that implicates all of us much much more, right. You know, one story that the book tells is how work that was performed by women for free in the family got sucked into the healthcare system basically right I mean we all know that a large portion of kind of low level healthcare. So caretaking is always done inside the family and you know that in a kind of patriarchal, you know, world of like Fortist industrial cities. That was that was women's job, almost exclusively. And you know part of the transition of the industrialization and the growth of the healthcare industry was the transition of some of that work into kind of formalized settings, as women themselves increasingly went into formalized ways of being wives to being nursing assistants. But I think, you know, without wanting to romanticize or saying anything about the range of the family is good. I think again we can extract something from it right which is the idea of a society where you know ordinary people think of it as their job to take care of each other more and how the help the formal healthcare system could be a hub of that in a different kind of way. And you know this is kind of pushing in a more utopian direction than we're going to you know with in Springfield this year with JB Pritzker or something like that. But I do think that it's possible to imagine if we want a bunch of staffing fights, and the healthcare system started to get larger right in terms of its footprint and new jobs started to get more sustainable. And then there was less burnout and less stress that people would maybe want to work fewer hours, right, as you're saying John, and as people want to work fewer hours you didn't want to start to ask a question of like okay what would it mean to work. Not 40 hours but 30, what would it mean to work 10 what would we need to work five. Right and not for everyone right but maybe it should be my job as a college professor to do my you know 30 hours a week as a professor and five hours a week of caregiving at the hospital down the block. And again this is you know I think going beyond the kind of normal questions that we need to be asking about in everyday class struggle. But I think it's actually important in thinking about what a genuinely democratic healthcare system would look like. It would implicate all us because the need is so immense, and it's actually what it means to be a society at some level is to take care of one another and you know from my own perspective that it's very hard to imagine a genuine socialism, where we are not all responsible for like looking after the disabled folks and old folks on our block and that kind of thing. And I think that is the ultimate direction in which shorter hours points and that's what's very exciting about that as a kind of line of struggle even though I think it also goes through the different important ways. I'm sorry I'm sorry to kind of drag this back down to a more terrestrial place. I like this. But I do. Yeah, I like where this is going. But we do have some questions that have some some more concrete questions so I hope this is in the same at least kind of, you know, on the on the path to that. And Sean asked a question actually that I think is interesting you sort of hinted up below and maybe we can have you speak more to which is the question about. Do you think healthcare workers have a similar degree of economic and political power in the modern economy, because of these developments in the way that auto and steel used to be central, for instance. And I think that also, I also wonder, and I can, I'm going to throw in one more question and you can decide how you want to answer. But Russell asked, is it a detrimental detriment that in many cases our nurses unions are not the same unions as behavioral health home health long term care. I work for a nurses union lack of members and care settings other than hospitals seem to potentially hurt our analysis and our campaign building horizons. So I guess thinking about these questions of sort of like what do our current structures look like and and do we have power and you know what what does that mean for us. Yeah, yeah those are great questions I mean, no, what the answer is that healthcare workers do not have the kind of power auto and steel workers used to have, I think is worth thinking about what they could but how they could we have to think about that but it's not going to be in exactly the same way. For all the reasons that we've been talking about about public and private and, you know, the kind of, you know, profit structure of healthcare and these kinds of things, and also, you know, the very basic level that this, I mean, the structure of economic leverage is different. The CIO unions arose because relatively small groups of workers could paralyze huge amounts of capital. And, you know, then they got large numbers of workers to participate. But it doesn't it doesn't work in the same I mean the strike power doesn't work in the same way in healthcare. And that's why, you know, I think, having even an equivalently large sector of the workforce, even an equally angry and militant one, you know, for in people's own internal experiences I'm sure doesn't translate directly into the same kind of power. Now does that mean that it cannot possibly. I hope not I wrote the book to kind of argue not but I think that healthcare workers power. arises from the same thing that limits it. And that's to say, the political is the kind of fragmented and featured structure of the healthcare industry and the ways that it's a kind of politic that it's fundamentally shaped by political processes by public policy, but the healthcare workers can't access that that's the core of why help is hard for healthcare workers to wield economic power, but it's also the potential source of enormous political power right and we have seen when social reproduction or care workers do behave in militant ways and you know do engage in struggle that their communities care about that their communities do sometimes follow them. And that I think is a potentially enormous amount of power if we can find the organizational form for it. And I don't think that's that's not as in the clouds is my like little communist feel a minute ago. I think that's something that we can really, you know, we actually see small forms of all of the time. You know, we haven't figured out how to do it in a large and sustained way. But you know, I mean, it's quite common that communities actually do kind of rally around healthcare workers unions in important ways that do bring genuine political pressure to bear on them in in struggles. The question is how to expand and deepen that. And that I think it will be the form of healthcare workers power that is equivalent to the form that steel workers auto workers once had, and it is more political and less economic at some level. I think to this other question about fragmentation I mean yeah you know I mean I look. There's no union that should be the right union for that is the problem. And I, I think the difficulties of organizing a genuinely industrial healthcare workers union would be very large. You know again given the degree of stratification and that all the social forms that it takes. But I think we're not really trying enough to figure it out. I mean it's easy for me to say it's not my job. I'll say you know john started this discussion with an analogy to of the university where we both work to you know a big integrated steel mill or auto plant. And that's really that that I had that same thought when I was starting this book which is, you know, because I was at do my PhD at Yale, which is a, you know, New Haven as a company town the industrialized place that we're now the university that will dominate employment, and where all the workers at the university are in united here together. And my day to day life much more than writing, researching already my dissertation was like organizing and trying to figure out how to make that nominal unity real right to kind of convince astronomy graduate students that actually like they should do what the custodial workers union says. And how to also take that message into the kind of surrounding community and organize a community politically against the university and against the hospital, because it, you know, if the company in the company town, and it was extremely difficult to do that, but it was possible and there were moments where you can really see that it was possible. These these these massive institutions, although they don't have economic choke points in the way that older industrial institutions or current logistics companies do. They do touch everyone's lives around them in pretty intense ways and this is something I discovered as my kind of union activity thrust me into like local political local political work in various ways. You can knock on any door in New Haven. And, you know, I would I had this experience so many times you'd see people think like oh we're white yell kid want something from me great. And I realized you could get past that if you could figure out what, in what way yell would fuck this person. And if I can communicate I'm here because he was fucking me over in various ways. And I actually can make that transparent to you pretty straightforwardly you know I'm a teaching assistant at the bottom of the ladder. So if you're organizing union or union is involved in your city council election. How is he'll fuck you over. Oh as your landlord, their cops arrested your kid, you're in debt to their hospital. I mean you can go down the list right. And they're pushing you out of your neighborhood. And I do think that these big anchor service institutions. The hospitals are really the prime example and especially academic hospitals. They just sweep up people in their wake in a huge in huge numbers and we ought to be thinking much more about how to organize those people into the same spaces as workers and figuring out what what issues connect them. And I think that would be easier to do where we have more industrial organization. And that would create the kind of organizing resources in a different kind of way. And because it will make much clearer why a person in debt the University of Chicago hospital ought to identify with the organization of workers there because if you're asking them to or to identify with the tech workers union or the dietary union, or whatever that's way harder. And it's like the workers at the hospital want to ally with the people who the hospital, who depends on the hospital and are exploited by it to that's a much more straightforward thing to figure out organized. You're, you're kind of making me think about well the parallels and differences between steel workers and healthcare workers and another. Well something you talk about in the book is how the worker power in the steel industry led to the healthcare economy through various like large social pressures and economic pressures. But what you didn't explore as much directly is like also house the steel industry itself made people sick and have a need for healthcare. And in a way, there's a contradiction in being a steel worker fighting to maintain the steel industry because you're harming yourself at the same time. And I think in healthcare, we are experiencing very directly now that like our work makes us sick and we're healthcare providers and it's, it's a very, it's a moment of contradiction where we can't ignore that because it's just so obvious right now. And it feels like, you know, as you're kind of talking about and people are talking about staffing ratios in the chat. There's more opportunities now, in our context of healthcare to think to bargain and fight, maybe not just bargain but to have fights that are about transforming systems. While also like improving our immediate quality of life and so maybe this is, this is a question if either of you want to address it and also I just kind of thought, maybe if people have stuff they want to put in the chat of examples of what they're doing in their healthcare workplace that's, that's bringing in something that's a little bigger than just these like direct workplace improvements to their lives, given these opportunities we have right now. Do you want to respond? My brain was kind of a little bit off so why don't you respond and if I've got anything to add I'll add. Yeah, I mean I think it's a really, you know, it's a, it's an important question. It's a hard one. I mean it's connected obviously to the questions around staffing and around, you know, ultimately less intense workload. From my perspective, you know, the more workers in healthcare workplaces have power to enforce, I mean both there's winning those kind of rules, right, and then the more workers have the power to enforce those rules themselves or together with their immediate coworkers. The more I think they're also going to be in a position to, not just in a position, they're organically going to find themselves and I think you hear these stories healthcare workers all the time, making decisions about their own well-being and the well-being of their patients in a kind of qualitative way. And I think those things are really deeply connected to each other in the fabric of daily life, you know, on a hospital floor in a nursing home. I think like I, I did an interview with a, with a CNA in a nursing home from Illinois, I guess two years ago now, a nursing home in a ton of early COVID deaths. And Illinois has, you know, past two years ago, a tighter staffing regulation for nursing homes, which mandates two and a half care hours per day I think is the number per patient. And you know this nursing home like never has that has that many staff working I mean it's constantly in violation of law. And this person is a shop steward in SCIU. And, you know, it described to me in this interview, the ways that, you know, just the way like the way that she keeps on her boss about how they're constantly in violation of this law how she's constantly reporting him, how she like knows the person who should be in the hospital at you know the Illinois Medicaid whatever nursing home quality office, and like has a has a number on her cell phone, which I'm sure it doesn't work that well right but like is, you know, on the one hand is kind of like model how shops do which would be obviously, but at the same time also she I remember she described it to me. She described it to me in terms of her own safety. And you know her, I think she had a kid who is invulnerable or you know compromise in some way, and the way that she was trying to navigate that. And the way that she would bring that into her confrontation with her boss, and also obviously the safety of the patients. And, you know, this was someone who seemed to take great pleasure in the way that labor notes would hope in, you know, being a kind of militant shop steward. And I don't know I haven't been there in person I'll just talk to her right but I, but she really described to me kind of creating a kind of like bubble around herself and her coat you know the coworkers who kind of followed her of not just militancy but kind of qualitative, a different kind of qualitative workplace culture both about their own safety and about their patient safety, because they had developed a practice of like, never fucking putting up with it right and that really meant something about that patient who's 98 and you know has a respiratory condition that worker who lives with her mom, and it was really deeply embedded in those very human level realities, and I feel like it seems sort of been out to say I guess but I think when we're figuring out a fight over these questions on the shop floor in a day to day way. It's really important that those things actually be really present because like bosses in the healthcare industry what to dehumanize care that's like what they're trying to do all the time. And you all know this obviously but to make it to make the kind of accounting decisions that they that are good for them to make that make workers and patients vanish as people. And I really think there's a kind of almost a kind of cultural question about how we think and talk and relate to each other about the kind of humanity of what we're struggling over that is, I don't know if it's not a very good answer but I think that's sort of what I think about in response to that. And kind of like building off that like thinking to my experiences where we've been like in, you know, the ICU or critical care areas where you see a patient or you see a staffing decision be made where people literally die and that like and then your patients going through that is really kind of a real sizing thing to go through as a nurse because they hammer in your head like this is on you this is always on you that's like part of the discipline of like nursing school is that you are responsible for the patient outcome right and thinking like the times when I've seen the management move fastest to resolve a staffing issue is when one of my co workers said we're not taking report tonight until or today until we get more staff, and all of us agreeing that that was what we were going to do and it's kind of like the sort of thing like some of my, you know union staff people a little nervous but thinking about when we all went on strike in 2019 we were the first union hospital to go on strike for nurses to go on strike in decades, and then watching that kind of ripple out into other first it was us, then it was INA nurses, then it was Cook County nurses and like nurse like hospitals kind of like watching what happened where we were able to pull it off, and we got wins out of it and then all of a sudden, like, there's like this weird thing where, when you're start talking with staff and they're like you're going to talk with other nurses about joining union but don't talk about strikes because everyone's afraid of strikes and, but watching the opposite thing happened where people seeing that your union can support people going on strikes and your union does and we go on strike was the thing that lit up, you know, it seemed like it brought more people to our union than anything we've ever done before, and just thinking about there's like this, this old, this essay that I read a long time ago called the stopwatch and the wooden shoe and thinking about the militancy of CIO stewards where you would have the whistle stop strike, and thinking about like, how do like, what is the healthcare equivalent of the whistle strike, you know, and how do we like encourage that, but at the same time, where do we get like, you know, strap the spine on to some of our union staff where it's like don't freak out that we're doing this, because this is the only way we're going to win I don't know like I'm just thinking about how is it that strikes build power of all of us together, like, nurses that aren't in unions have higher wages because my union went on strike in Chicago, and just thinking about, I don't know like, do you have some thoughts about how that's worked out historically, and then how maybe you see that in other areas with like healthcare. Yeah, I mean I think, you know, I think that one of the big kind of early discoveries for me as I first started to kind of learn my own organizing learning trajectories that you know it's not that workers don't want to fight it's that they don't want to lose. Right. And it's really easy to mistake, not wanting to lose not wanting to fight, because people mainly think that they're going to lose and they're maybe right. And so, you know, obviously, as you're saying John successful struggle has, you know, has these ripple effects because people realize that they may not have read their situation in the only way that you can read it they may be other options for them. And I think, you know, a real I mean what you're saying about how to kind of do that in a day to day way on the shop floor I think is a really important question. And again I think that healthcare workers have both a challenge and an advantage in the way that their patients lives are on the line in some form. It's a challenge because obviously management wields that over you to keep you in line. You know, whether if you don't do what we say, right you're in someone betraying the needs and you know, harming the patients. But at the same time you all are the people who know better, right. Are the ones who are actually making care functional in a dysfunctional situation. And I do think that that sets up the real possibility of you know whether it's like you're saying john, or you know like the shop steward I was describing a minute ago, sets up the possibility of you know, just amping up the level of friction on the shop floor. That kind of all the time and you know it's not possible to do everywhere obviously the way you have organization and it can be when you do that, you know, recklessly can make it harder to organize obviously. But where there is organization or where there's a possibility of kind of cohering strong organization soon that can be really important. I always tell students and labor history classes that in 19th century workshops, like especially very skilled workshops. It was very common for there to be a norm that workers would not work, if management was looking at them. That you know you like if you were being observed, but say nothing of time and measured and, you know, sped up but you're being observed you put down your tools. And, you know that obviously that comes out of different material situation in a different moment in the history of the working class movement and various things like that. But I think in that, you know, thinking about the relationship between yourselves in the hospital and the patients you're taking as the kind of core productive function of the hospital. And, you know, your administrator on duty and their supervisor and their supervisor as interwoping parasites which is what they are. Then I think you know there there is something in, in that principle like excuse me I'm trying to take care of this person would you back the fuck off please that I think is a, like actually an important principle to, I see, I've got to swear this company I assume that's okay. That I think like is actually something we should probably try to think about how to build into our organizing more. And I think that you know that it's that feeling and that kind of center that sentiment, and that kind of demand that is how healthcare workers can take their responsibility for patients, which is used as a weapon over you and burden on you and turn it into a source of power. That's hard because you know also that there's a kind of Superman quality Superman nurse kind of quality in that the it's not we shouldn't be your job to manifest all the time but I do you know and I think that's that opens up a whole other can of words which we've been talking about obviously, but I do think that is your source of power in the day to day. I want to jump in. There's a question in the Q&A that I think is relevant but it also makes me think back to the labor notes and said lousy Pittsburgh example of, of knowing that both we have these unions that are not coordinating with each other for one, so we have you know we don't just have the United Steel Workers we have even just on this call there's like four to five different international healthcare unions. I mean I was like eight bargaining units. Oh yeah I mean it's, you know there's there's there's no coordination that we saw this during the pandemic if ever there was going to be a time when healthcare unions would like band together for a set of demands. You know you would think maybe that would be it but we didn't see that. And of course our labor notes perspective is is changing our unions has to come from, you know from the shop floor has to come from Democratic rank and file action. But it also makes which you know it's the last key of course also that but that's my tired. Dennis has a question in the Q&A about, I think an industry shift that is weighing on a lot of people's minds which is this question of agency nurses. And I think there's a real, you know I think there's been some like doom and gloom forecasting that there's like a real this could really be the precipice of like a different way that hospitals are trying to do healthcare, like in a in a wide scale union busting way. And I wonder if our unions are up to the task of tackling, you know the question of agency nurses so Dennis asked. It's been a great cost of hospitals it can be divisive in some workplaces. It's got all these things what's your sense of sort of agency nurses and my question then is like do you think this represents the kind of industrial change that our unions are not in front of. You can do to doom and gloom, you can tell me I'm like, no I mean I thought a lot about it I can't say I have great answers about it I mean, it's pretty hard for me to see how, I mean it's obvious why they would want to do nursing. But given that the model is depends on overpayment. I mean, you know obviously no workers overpaid but relatively other nurses, given that the model depends on overpayment is different for the moment from, you know, classic forms of subcontracting. And in that way, it's pretty hard for me to see how, you know, our ends at large could be kind of displaced in this way. You know, I mean I know that there's a. There's an effort right now which I can't imagine will pass but I guess you never know in California to to put through an initiative like the same people who did. And the same law firm is behind is, you know, kind of doing the legal work on it they did the prop. I can't forget the number of the Uber 22 Thank you. An initiative to legislatively reclassify web based agency nurses because you know there's a lot of like web systems for doing this now. So Uber for nurses to reclassify them as independent contractors. And, you know, it's sort of hard to imagine that will pass. And they have various legal problems that might get thrown out in court even if it did pass. But, you know, short of something like that. It's difficult for me to see how that that could bring about a kind of large scale. You know, disruption as I would say, to the industry in a direct way just because, you know, it, what it consists of hospitals overpaying in order to hire fewer people. And they can, they can't, they can only go so far doing that. That being said, obviously it. It is serving as a device to disorganize nurses, you know, industrially, and to avoid giving in, you know, to resist staffing demands and to, to, you know, try to generate forms of division among, you know, healthcare workers, and, you know, it costs them some money to do that but it's worth it to them that it would seem. And, you know, I think that that then creates a budgetary crunch for hospitals that they will then use to, you know, bring the hammer down on other workers right they'll say well we you know we're, we're already operating in the red. And again when they say that it's at one level true even though it's also a situation they've engineered. So I think you know in that way it's important to resist it, although obviously you know one doesn't necessarily want to turn agency nurses themselves into the antagonist and that kind of thing so it's tricky and I don't know exactly where it goes. I think you know, one thing, the other thing I'll say about it is that I'm sure you all know there was this kind of proposed bill federal legislation to cap nurse wages in response to this, which is just like incredible to see like that. I think that would be the only example of federal law having any workers wages and it would be nurses. And, you know, again I think that kind of goes right to this point that like the relationship between you and your boss in a hospital is fundamentally political. Such that when they kind of get a skew and out of whack because of an emergency, like suddenly Congress is implicated. But you know that I would actually, if I worked in a hospital and if I were a steward or an organizer I would be talking about that in those terms as well as isn't this crazy and bad, because it actually indicates your importance and power. I have one last question, and then I'll be quiet, because I think it's a thing that has been kind of brought up a little bit advanced around where we're talking about these management and administration kind of inserting themselves into this process that fundamentally workers are like really have a lot more control of over than in say like the average car factory or something like that. And as you know good socialists who are in the union movement, a thing that I don't hear enough about is the idea that nurses and healthcare workers are equipped in a way maybe that we haven't seen workers in a long time to actually like you know society owns a thing but that we could also control it and nurses and healthcare workers owning and controlling at least you know how healthcare is delivered feels like something that's way more achievable because my boss is a nurse her boss is a nurse nurses run hospitals and I we're helping nurses down in southeast Kentucky that are working in a former union owned hospital and thinking about how union power could be used to begin to kind of take these things back from private industry that just doesn't seem to be interested in like where's the value at it for those people. All right, and I'll be the last thing I got to say. Yeah, I mean, right, you know the, the, I don't know folks, I imagine folks made me know the story also the Lincoln hospital occupation and the Bronx and by the young lords. But you know I think your point is, is, you know, I think even if we don't want to kind of go to a utopian vision of what you know our egalitarian society would look like right I think again it's important in the course of every day of organizing that you all have the skills necessary to operate the institution and the skills that your bosses have the skills that your bosses have are about maximizing reimbursement, as opposed to allocating care in a, you know, equal and humane way. And I just think, you know, every day, every like every you know all the this is a daily cycle of your shift in your hospital generates 1000 pieces of evidence of that. And, you know, I think, like, that would be if I, you know if I were one of you and if I were working in, in organizing in, in, in a healthcare workplace. I sometimes tell, tell, like when I'm done organized trainings in the past and sometimes tell, tell people like keep a notebook, not necessarily for evidence, though that can be good too. But just like as a way of accumulating for yourself and clarifying your own thoughts about all the ways that you actually have material knowledge and power in your situation. And I think that can be a really useful thing to do with other workers who you're trying to kind of agitate also right is asking them to think to just try to keep track in some way of all the moments in your day. Over the course of your week, where you think something should happen one way, and management for reasons that are presumably about accounting that are not totally transparent to you and said, is causing it to have another way, and if you actually want to keep a notebook like that or keep track like that. I think that could be a very useful organizing device. And you can imagine many other versions of that kind of thing you could do right in meetings and you know in and in discussion and so on. The other thing I'll say on the kind of policy side. I talked about this briefly in the book, but you know as anxiety about healthcare costs started to become a kind of political problem in the 1970s. It created these things called health systems agencies, which don't really mainly exist in the same form anymore today, but they did generate a process that we often still have today called the certificate of need process. When a hospital you know you want to build a new wing in a hospital or do a big any big capital project in healthcare depends on the state, how exactly it works but there's often a process called certificate of need in which the person, the entity wanting to do this has to kind of make the case to some regulatory body about why it's necessary. And then there's a kind of back and forth and a process and a discussion. It's pretty toothless it doesn't, you know, it's pretty opaque no one really pays attention to it except like lawyers and so on. But in the 70s when this first was developed. I spent a long time just reading the kind of certificate of need applications in the healthcare health systems agency of Southwestern Pennsylvania just read their files from the 70s. And this is a period of rapid expansion in the industry so there's a lot of files there's a lot of proposals going through. And the book the actual board of this agency that reviews these proposals, but consisted of some kind of academic experts of different kinds some local elected officials some kind of consumer representatives you know maybe the head of the local AMA people like that kind of medic medicine adjacent sort of city father type people. And what would happen, almost always would be they would get a proposal, they would review it, and someone would say, you know this is more of a money making scheme than a, you know, necessary scheming, or at least in the form that is designed we should reject this or ask them to modify it. There would be a political uproar, and they would get overruled by the State Health Secretary and that's basically how these things always went. And the State Health Secretary said, look, if you want this to go differently if you actually want to have someone other than healthcare administrators and their bankers deciding about what healthcare literally what our healthcare institutions are going to look like, in terms of the actual capital the actual plants and machinery, then you would need these bodies that are reviewing these proposals to be democratically elected. That would be the only way that you could have legitimate sort of publicly legit democratically legitimate review. And this was a Republican saying this in the 70s. And I say all that not to say okay let's just do that, but that. Again, because the power of those agencies came because if they rejected a proposal they, they had the power to cut off a hospital for Medicare and Medicaid, which very rarely happened that they could do it. And again, the public political presence in the industry does create all these opportunities, potentially anyway, both within the everyday life of the worker and the workplace and the patient, and within the kind of political and economic institutional structure of the industry to assert democratic values and power. And I would say in my time in New Haven, again, because we were a large cluster of organized workers in the, you know, we were the biggest such cluster in the state basically, we were sometimes able to get state legislators to do stuff. And we got the legislature to pass various things that basically made the certificate of need process much more difficult for Yale New Haven hospital as it was acquiring other hospitals along the Connecticut shoreline. And we did that in hopes of then leveraging that process, but I shouldn't say this like this, in the hopes of accumulating political power that the hospital would have to think about as it weighed how we wanted to engage in industrial relations. And, you know, it was genuinely like good policy also I think in various ways hospital monopoly is bad for various reasons. That's why I think we were able to kind of make a case for it to legislators and you know to the public. But I think, you know, both at the political level, as well as in other words as well as at the, or thinking about you know the health of the hours, you know, legislation that this nursing home worker is able to actually mobilize in her day to day life and the way I was describing earlier, as well as kind of an everyday moments of organizing and class struggle. So this kind of paradox of a privatized public service, I think really generates these opportunities and we need to just be alert for them all the time. Okay, it is 9pm Eastern time so I'm going to wrap us up but I actually thought that that was, you just basically said all the sort of sort of wrap up things I wanted to say so I think that's actually perfect. The book is the next shift. If anyone hasn't read it and is interested. I just couldn't agree more. And I thought it was so interesting the way you lay out the opportunities for organizing and I think what is such a powerful reminder for us as as workers and unionists and activists that systems didn't come up this you know they didn't pop out of nowhere into these like fully formed hegemonic, you know, institutions that, you know, it wasn't always this way and it won't always be this way and I think that in some ways that's like the most hopeful thing we can do sometimes is just be able to like have historians peer through all those documents so we see how these things came about and where their weaknesses are. Thank you so much for that. I, sorry if your question didn't get answered. You can always contact me and I'll make sure questions get to Gabe, and I will make a plug for the conference. If you liked this conversation and you want to talk and learn more about organizing and healthcare. We'll see you in Chicago June 17 through 19 2022 you can register here early bird registration ends May 1, I think. Thank you so much to john and Felix for pulling this together thanks for our network folks who joined us tonight and if you're interested in joining to be an email. And I just think if there's any way that we're going to support each other and learn how to tackle these huge institutions together it's going to be folks like you all working across unions and across this country so please join join the join the group. Thank you so much. Thank you so much. Have a great night. Good night.