You're going to the extreme case of catastrophic coverage. For the majority of common conditions such as appendicitis, broken bones, even some types of heart d

You're going to the extreme case of catastrophic coverage. For the majority of common conditions such as appendicitis, broken bones, even some types of heart disease, this type of plan worked quite well. It's true that a catastrophic case could blow through the lifetime cap, but then there was something else called catastrophic coverage for not that much more. I chose not to get it, but maybe should have. I suspect it's not so much that the coverage was prohibitive but that people simply didn't, and don't, understand the economics. A lot of people were knowingly going "bare", i.e. foregoing coverage altogether. Even today, people are consciously choosing to pay the personal penalty. Your claim that "you could reject everyone" pre-ACA is completely false. In fact, insurance companies were required to carry a certain percentage of high liability customers. It varied from state to state, though. Finally it's also worth mentioning that even for people with no coverage whatsoever, hospitals were (and are) required to care for them. If you stumble into the ER with any condition, they are required to provide care, or at least transport you quickly to a place that can. The poorest among us will get excellent care albeit they may not have the wherewithal and knowledge to actually go seek out that care. The ACA sought to rationalize this fragmented and confused system and deploy a universal system throughout the country. It will be a subject of debate for decades to come whether this law would have worked.