None of that is obvious to me, nor does it seem like it has to be a binary choice between two extremes. That only makes sense if you are thinking of insurance p

None of that is obvious to me, nor does it seem like it has to be a binary choice between two extremes. That only makes sense if you are thinking of insurance purely as a business proposition between the insurer and an individual (well, millions or billions of individuals). Insurance has a societal benefit, in the sense that it spreads risk around the population as equitably as it can. I'm not required to have car insurance to drive in California because the nanny state wants to protect me from myself. I'm not required to have car insurance to drive in California because some insurance company donated a bunch of money to the relevant politicians. Both of those things might be true, but that's not why I have to have car insurance. I have to have car insurance to protect everyone else from me, and vice versa. The alternative is a world in which many more people have accidents and go bankrupt or sue each other for damages, and that's a worse world for everyone, even the people who never get in an accident. Insurance is like a low-pass filter for tragedies. Health insurance is a similar situation. Access to preventative care, or just being able to see a doctor outside of an emergency room situation is a lot less expensive in the long run for everybody. Medicare and Medicaid costs (that all taxpayers eventually have to shoulder the burden of) scale with the health of the population on Medicare and Medicaid. Giving everyone the opportunity for health has a selfish reward as well as a humanitarian one, even if you don't care about poor people being able to see doctors when they have problems. It's much cheaper for everyone in the long run. This necessitates solutions in between the two extremes you presented.