Politics & Policy

For Fun: A Small-Town-Diner View of Medicare for All

photo by P. A. Jensen

“I’ll have the country-fried steak breakfast scramble.” (Waiter scribbles.) “With a side of pancakes.” (Waiter scribbles again.) “And an extra egg.” (Waiter scribbles, then reaches into apron to grab another pen—the first one has gone dry.)

“And a side of country gravy.” (“Sir, it comes with gravy.”) “Yeah, but do you have a little bowl, though?” (Waiter blinks several times, wondering if this is a dream. And if he can carry all of this.) “And a Coke. No—make it Diet Coke.” (Oh good—I was thinking he might overdo it.)

As someone who has worked in a family-style restaurant in rural America, I can say that obesity is not an accident. You can peg someone’s order, and therefore someone’s calorie intake, within seconds of walking through the door.

Or doors, in some cases.

For example, if you see someone who looks like he could try out for the Packers, and just maybe could make the team as long as he didn’t have to, you know, move or anything, you can count on two things: he’ll want to be seated at a table, because he literally can’t fit into a booth, and the kitchen staff won’t be reaching for the lettuce anytime soon.

Better fire up the fryer, Enrique.*

With obesity labeled as one of the biggest healthcare problems of our time, overeating becomes a political issue, and, ahem, a big one. Also, with one of our political parties flirting with quasi-socialism and Medicare-for-all-style healthcare, we should consider what it means to be footing the bill for what people eat at family-style restaurants like the one where I worked.

And not just at restaurants, either. Every dive bar where people tickle their tongues and pickle their livers will be the scene of a crime—of knowingly stealing from the state when that liver gives out. And if you don’t believe me, consider that obesity and alcohol abuse are not uncommon in rural areas, to put it mildly, despite the fact that neither trait, last I checked, was on the Wish List for Healthy Bodies when you took Health in eighth grade. Nor was the smoking that people do while huddled in the parking lot of the dive bar, just outside the door, at least in the winter. The little white warning label on that pack of cigarettes—news to no one, perhaps ever, but for sure now—didn’t seem to stop them from braving the cold to have a smoke. Or getting lung cancer, as it turns out.

So, Americans overeat. And drink too much. And smoke. Oh, and they don’t exercise, either—some of them at all. Somewhat literally.

And we want to publicly fund healthcare? In this country? With the family-restaurant, dive-bar, sedentary crowd?


It’s informative, and a bit entertaining, to read articles about healthcare from left-leaning magazines and websites. The story inevitably starts with someone who is deep in a financial hole because of healthcare costs, but the root medical problem is often blameless: a kid got leukemia, or an adult has a rare genetic disorder. The article then goes on to build a compassionate, often compelling, case for healthcare as a human right, or as the product of a just society.

Maybe. But why doesn’t the protagonist ever have lung cancer from smoking, or Type-2 diabetes from eating way too much sugar? Or the Type-7 diabetes, or whatever, that the customer highlighted above was going to get? (By the way, that customer interaction above was real, even if the quotes were paraphrased—I didn’t have a recorder on me.) These stories that advocate for healthcare-for-all don’t talk about the underbelly of medicine, the unpopular parts of medicine: the preventable stuff. The Saturday-night emergency rooms full of drunks, whether accident-prone or detoxing. Or, the joints that need replacing in 400-pound people at age forty, and not 400-pound people who played offensive line, though I suppose that wouldn’t be much better.

Or, other elective procedures that people supposedly “need.” We could list many of them here, but now I’ll focus on the most common, and most expensive, and most preventable one: childbirth. That’s right. Childbirth is an elective procedure—one that can be prevented, at least at the point of intercourse. My wife does epidurals as part of her job, and she routinely gets called in in the middle of the night just to get bitched at by a lady who’s having her third, or seventh, or tenth kid. You’d think she’d see a pattern by now. And like it or not, chances are that lady—or girl, too often—is not paying for any of it: the government already funds about half of the births in this country.

This can’t be a good idea.

That having too many kids is a choice and a problem becomes apparent at the family restaurant, too. When there are one or two kids, they’re often polite and say “please” and “thank you,” and, you know, use a napkin. When there are five or six kids, though, napkins are typically for cleaning up spills. Of which there are many. Honey, that two-dollar tip won’t cover what your little Picasso of pickles did over there. Or what your little Kahlo made with cracker crumbs and ketchup, either. It’s totally, totally baffling why they were hyper, too, with the sodas and the platter of fried foods and the pancakes with whatever they’re calling “fruit syrup” in the back. Which is now on the carpet. And maybe the ceiling.

Also, it’s too bad you couldn’t fit in a booth, which might have contained the food fight, including the Shamu-style splash zone of Kool-Aid.

Yeah, I don’t want to pay for any of that.

Left-leaning politicians, and sometimes even economists, routinely say that it’s absurd to think of healthcare like just another good or service, because no one would voluntarily increase their consumption of it. I disagree, at least in an indirect sense. Because Americans often voluntarily consume whatever goes into their bodies—and over-consume whatever goes into their bodies, many times—they do indeed voluntarily increase their consumption of healthcare, at least indirectly. For many “ailments,” the cause was indeed voluntary, even if only long before the patient entered the hospital.

A Medicare-for-all system puts taxpayers on the hook for all of that, voluntary or not. And as long as Americans keep going to the trough at family-style restaurants, or at the bar, they would “need” to keep going back to the government trough for healthcare. And the rest of us would “need” to keep filling that trough.

With sausage gravy, probably.

This type of thinking is especially apparent in small towns. As I’ve written before, the general sense of accountability is different in small towns than in large cities, largely because everyone knows everyone else, and can therefore keep track of things like whether someone parks it at the bar every night. In fact, many people would just recognize your pickup sitting there without going in themselves.

When you’re more accountable for your actions, your behavior changes, it turns out. Or, you at least own the consequences.

In a small town, you wouldn’t ask the city to pay for your healthcare, in no small part because they might be less likely to be empathetic if your hospital visit were preventable, which they would surely figure out. You’d need to be pretty shameless to demand that your neighbors pay for your knee replacement, especially face-to-face at a city council meeting, if you weighed 400 pounds but no one had ever seen you exercise, but had seen you at the family restaurant, eating country-fried steak with extra gravy, for example.

But as long as the money keeps coming from the Magical Anonymous Money Tree that some people call “The Government,” people will keep plucking the fruit from that tree. Without shame. Again, and again, and again. They might even feel entitled to it. Anonymity breeds abuse in this sense.

To be sure, as far as medical problems go, obesity-related conditions are different than childhood leukemia. And childhood leukemia is different than helping someone have their thirteenth kid after they’ve lost custody of most of their others. (Which, according to my wife, who has to deal with this stuff and some of the paperwork, is more common than we’d think.) Also, helping the person who was hit by a drunk driver is fundamentally different than treating the drunk driver who was in the same crash.

Sure, some of these medical problems are accidents of life that might deserve compassion, and perhaps—perhaps—there is a role for government in dispersing (and disbursing) that aid. But like it or not, some of these things are choices, and people don’t like paying for other people’s choices. A healthcare system that would treat all of these expenses as just “medicine,” regardless of cause, and would hand out the funds anonymously, with no consequences, would violate some basic rules of accountability and human nature, it would seem.

And in small towns, where almost nothing is anonymous, that lack of accountability rubs people the wrong way.

So, before we start talking about “Medicare for all” as if all medicine always resembles the type featured in left-leaning articles, let’s take a step back. Let’s take a step back and ask if there could, or maybe should, be more accountability, the kind we see in small towns. Let’s take a step back and realize that there might be a middle ground, and maybe that middle ground can be found in the middle of the country.

And while we’re at it, let’s take a step back from the buffet of consumption. Our health—both personal and fiscal—depends on it.

*Yep, the head cook at the restaurant where I work was named “Enrique.” Or “Ricky,” for short.




P. A. Jensen is editor of RuralityCheck.com.

He lives in northern Minnesota with his wife and son.

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