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Current Affairs

A Magazine of Politics and Culture

A Way To Think Clearly About “Medicare For All” Debates

What if we talked about the fire department the way we talk about healthcare?

In the United States, if you call 911 and the fire department comes, you will pay nothing. If you call 911 and the ambulance comes, you could be charged $1,500 or more for a short ride. The fire department is a public service. It is “the government.” Ambulances and many hospitals are not.

Let us imagine for a moment that history went differently and today these services operate in the opposite manner: Ambulances are run by the city ambulance service and fire departments are still privatized and run by for-profit companies. If your house were to burn down, you would receive a bill from the fire company that showed up. These bills would be very high, in part because fire companies have trouble getting poor people to pay them. Because people do not want these bills, they often try to put out fires in their homes themselves, even when these fires become unmanageable. They’re financially disincentivized from dealing with an emergency well, because they’re thinking about money and trying desperately to make cost-benefit analyses in a moment of extreme stress rather than just thinking about how to get the fire put out quickly and safely.

Today, we have something like this situation. People beg not to be put in ambulances, or not to have ambulances called, in situations where they clearly need them. (Take, for example, this woman in Boston who got her leg caught between a subway train and the platform and who pleaded not to have an ambulance called because of the cost.) Instead of simply getting to ask the question “What do I need in order to be healthy?” people have to ask the question “How much health can I afford?”

In our alternate world, where fire services would operate like many medical services, we would see a “fire insurance industry” emerge. (This is insurance to pay for firefighting, not “fire insurance” for the property.) If you paid $100 a month, or perhaps far more, your insurance company would dispatch its fire trucks if your house caught fire, or it would reimburse you for whoever did put out your fire. There would probably be a giant “deductible,” so that having a fire put out would still be extremely costly, and even insured people would be reluctant to call the fire department because they’d know they’d have to pay $5,000 (reduced from an initial bill of $25,000).

Into this situation comes the left. Leftists say “This whole system is ludicrous. Let us just have a public fire service, like we do with ambulances and hospitals, where anyone gets their fires extinguished for free.” Having private insurance bureaucracies try to squeeze money out of people is making fire services more expensive. We should just establish a “fire department.”

Here’s what’s funny: All of the conservative arguments against left health care plans can be made against this scheme.

  • So you trust the government to put out your fires? You know that in England they have a public fire service and sometimes they do a bad job.
  • People deserve choice about how to finance extinguishing fires.
  • Many people say they are satisfied with their fire insurance. You want to take it away from them.
  • You are going to raise people’s taxes to pay for this “fire department.”
  • You are going to eliminate every job of every person who works in the private firefighting insurance industry. 

And of course, the centrists will say what they do today. Barack Obama would have proposed ObamaFire: Let’s have a public marketplace for fire extinguishing insurance, prohibit fire insurance companies from not giving plans to people whose houses have burned down before, and subsidize people’s purchase of the insurance if they fall below a certain income threshold. The more “progressive” types would say: No, we need a “public option.” We need a government fire insurance plan that is a reasonable price and anyone can buy. Pete Buttigieg would say: “We don’t want to force people off their existing firefighting insurance. Instead of just making everyone join a public plan, my plan is called Public Firefighting Insurance For All Who Want It.”

You will see how a lot of the arguments here are obvious bullshit. Saying it will “raise taxes” ignores all the money that is currently being spent on for-profit firefighting services and firefighting insurance. The fire department will cost everybody less! “Raise taxes” just assumes people are idiots who do not know how to look at the bottom line. “Taking away people’s firefighting insurance” is also disingenuous, because it implies people are losing something, when actually they’re not getting anything taken away, they’re just having an improved guarantee that when their house burns down someone will be there to fix it.

Now, you’ve probably already realized something interesting here: The “radical left plan” in the fire situation (a fire department) is not the equivalent of “Medicare for All.” Medicare For All does not establish government medical services. That would be “socialized medicine,” like the National Health Service in Britain. This, on the other hand, is “socialized insurance.”

So, the equivalent of Bernie Sanders in the fire scenario is saying: Look, let’s not have private fire financing. Let’s leave private firefighting companies, but let’s just pay for their services with taxes. And you won’t get a bill when they come to your house, and you won’t pay a monthly insurance premium, and when a fire breaks out you can just call them without worrying about how you’re going to pay for it. And because the government will be the “single payer,” it can negotiate better rates with firefighting companies. In fact, firefighting companies will probably ultimately do pretty well under this system, because they don’t have to worry about collecting payments and even though the rates they’ll receive might be slightly lower they’ll save a lot of bureaucracy and administration by just having one place to send a bill and having it be paid on time.

It is helpful to think about this analogy, because we can see that Medicare For All is hardly radical; it’s less radical and socialistic than the existence of a public fire department! It just socializes insurance, not the underlying services. Every time you hear an argument against Medicare For All, think about what its analogy would be in the fire scenario.

The left position is that basic services should not be things that are “commodified.” People should be thinking about their health when they go to the doctor and not about money, just as they should be thinking about books when they go to the library and stopping a fire when their house is burning down. Thinking about firefighting is informative because it shows us why government is such a useful institution. Ronald Reagan said that the scariest words in the English language were “I’m from the government and I’m here to help.” Clearly Reagan had never been trapped in a burning building, where those are the exact words that every single person wants to hear. The right has done a very good job convincing people not to think about public libraries, parks, and firefighting services when they think about government, and instead to think of welfare bureaucracies and the DMV. This is understandable, because these institutions are socialized, and public libraries, parks, and firefighters prove definitively that socialized institutions can work and aren’t evil.

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