Several years ago, when contemplating the re-election of George W. Bush, I expressed my disgust with both major candidates, calling them utterly clueless on domestic issues. I then offered "Ten Simple (?) Reforms" on health care. And one of my Internet interlocutors challenged me:

[Y]ou seem to object to governmment spending. [Y]ou seem to say it's better to let the insurance companies have the money instead. [A]nd how do you propose individuals buy *BUY* health insurance on a non-living (aka minimal) wage???

In an email response, I took the last point first (what follows is my original email, now belatedly posted):

I don't. People who can't afford insurance won't get insurance.

They should be helped directly, either through charity, or via government.

But we shouldn't pretend that either charity or government spending on the poor is insurance, because it isn't. And regulating insurance to make it behave more like government hand-outs is disastrous, and leads to terrible consequences. Constructing government handouts to mimic insurance may make some sense, but when this is done, adding regulations upon regulations to non-handout methods — or, in the case of America's Medicare systems, making competing private systems virtually illegal (which is precisely what has been done to senior citizens) — also makes no sense.

Insurance is a special contract. It is only one way of paying for some things we want. There are other ways. Pretending that insurance can be fiddled with to grant us everything is idiotic.

And trying to get everything is idiotic, too. You can't. That's simply the case. In countries like Britain and Canada, where the state takes care of most or all medical transactions, rationing by procrastination becomes the norm, and many people die waiting to get treatment.

There is the terrible truth that, in modern times, the bulk of a person's medical expenditures occur in the last year of life — indeed, the last six months of life — and that many of these expenditures (expecially those in the last week of life) don't even help the patient. This is a fact that activists and reformers on all sides tend to ignore. (I'll try not to, in my writing about medical reform.)

By the way, your line that you seem to say it's better to let the insurance companies have the money instead strikes me as extremely peculiar. I think insurance companies, with minimal regulation (and that mainly against various forms of fraud), would provide better help to most individuals regarding health care than will government-run systems. But I don't think people should rely only on insurance only. That's borderline insane. Most insurance programs, in the wake of the wage-and-price-control work-around from WWII, have tried to do too much, have tried to insure things that shouldn't be paid for by this method. I'm speaking mainly of routine doctors visits, which should be paid for out of savings. One should plan on spending some of one's own income on routine check-ups, etc.

The problem of medical economics is that the bulk of all transactions, public and private, are paid for by third parties, that is, not by the patients (or the families of patients) themselves. This means that very little economizing gets done.

In short, many medical services get over-used.

Example? OK, here's one from personal experience. I was at a friend's house a few years ago, and his son stubbed his toe. He bawled and bawled. Now, the 7- or 8-year-old boy had just stubbed is toe. I knew it, my friend knew it. But my friend's wife insisted that the lad be taken to the emergency room. So off we went, fearing the wrath of that notoriously irrational mother.

Well, by the time we got there, the poor kid was getting control of himself. And the doctor basically gave the standard advice, after an hour or so of the kid being sent from nurse to doctor and back again. An amazing waste of time and money.

Now, why would any rational person send their kid immediately to ER for a stubbed toe?

Why, because she didn't have to pay for it, that's why! My friend is poor, on disability, and all his family's medical expenses are taken care of by the state. Whereas that trip would've cost me about $400, it cost him — and, more importantly, his nutball wife — nothing.

I'm quite happy that my friend's being taken care of so well. He's a rational individual (except, I think, when it comes to choosing sexual partners), and tries to minimize his contact with the doctor, though his condition doesn't allow him to avoid the doctors entirely. But even if his wife were a rational individual, she'd be likely to over-use the system, because she doesn't have to pay a dime for it.

This happens with full coverage insurance program users, too. The less they have to pay for any single use (that is, the lower the deductible), the less sense they put into using the system.

And since many people do not even have a choice of economic coverage — they get their insurance through their employment, of all goofy things, and some never even see a bill — little economic rationality can be put into action.

Hence my desire to get insurance entirely out of the employment contract negotiation sector of the economy. To allow a little more consumer choice, which can rein in some costs.

Now, I understand that many people cannot afford to obtain any medical insurance. But I also realize that some of this is the result of current government regulation. For instance, a few years ago Washington state added some major regulations and requirements to health care insurance. And within a year or two, the bulk of the major players left the state, and the Big Blues went bankrupt. There's a real and obvious causal connection here, but one is not supposed to mention this.

Further, I know from my own weird life that many people who can afford medical insurance don't get it, because they want to buy other stuff instead. That was me for many years. I just recently bought a good policy. And today I went to the doctor for a surgical procedure that is not covered by my insurance. I knew it when I bought the insurance. So I'll have to pay for the procedure out of pocket. Though I'm not rich, I'll just do without some things.

And doing without is something I'm learning. Not perfectly, but I am learning to prioritize, even this late in life.

The biggest trouble in America regarding health care, other than government policy, is an individual failing, all-too-widespread. Too many women bring babies to term without being able to provide for them. Too many couples beget children without being able to pay for basic care, much less medical care. Obviously, a new level of social control - cultural, not political — should be added to our current lenience: obloquy against procreation without some level of wealth.

Of course, those who — through no or little fault of their own — become poor after a period of solvency should not be treated with disdain. They should be helped. And in a decent society, and where people aren't trying to remake everything by government edict, they most likely would be helped. And find their way back on their feet more quickly than is often the case today.