Around and around we go with health care. I believe we need another ap-proach in the discussions. Our health care debate is missing at least one critical issue, and one clarification. First, we are always mixing the health care delivery system with the financing (insurance, in particular) of said system. Our delivery system works fairly well, albeit with some built-in rationing created by the financing part of the picture. It’s our financing system that is seriously broken, which in turn creates access problems.

The issue that receives no debate at all and is presumed to be a given is whether the insurance industry should be in the business of providing “health insurance” at all. Let me explain by providing a brief primer on what insurance is all about. Knowing this information can help with an enlightened discussion of this subject, I believe, and generate more incentive to enter the forbidden territory of private enterprise.

Insurance has been a service provided since cargoes were insured in the days of the ancient Phoenicians on the Mediterranean Sea. Also insured in more recent times have been insurance on premature deaths of people, protection of our property from fire and natural disasters and collisions, insurance on business partners, and so on. Three basic principles govern whether a risk (i.e., a life, a car or boat, etc.) is insurable:

1. the risk must be of a type that is shared by large numbers of people (the Law of Large Numbers) and is capable of causing a catastrophic loss;

2. the risk must not be something that is predictable or under control of the party insured or the beneficiary (a premature death, or accident, or loss);

3. the risk must be one where the cost-sharing can be spread sufficiently to make for an affordable premium.

For instance: Homes are insured at usually reasonable premiums because it is not very likely that they will burn down or become damaged by floods, etc. Vehicles have higher premiums because it is a little more likely that they will incur a loss, due to the nature of driving today. When you live in a large city, the auto premiums are much higher, due to the higher risk. We don’t usually insure trivial matters which are so commonplace as to not be worth the overhead costs. (There are exceptions to these rules for a few special risks which small numbers of people chose to pay hefty premiums for, such as the hands of a concert pianist.)

In my opinion, health insurance no longer meets the criteria for acceptable risks. Yes, the “law of large numbers” criterion is met, though even that has been impacted by the increasing numbers of uninsurable people. (Fewer insured people share in paying the higher premiums for the large number of anticipated claims.) But the other two criteria now place it outside the purview of insurability. We can now often influence whether we incur a loss (whether we go to a doctor or hospital, or choose to have an elective procedure). As to cost, the risk has become unaffordable for large numbers of people.

Where does this leave us, and why do we still have medical or health insurance? We still have this sort of insurance because there is a vast bureaucracy in place that no one wants to even consider abandoning. Dozens or hundreds of insurance carriers, thousands of peripheral services, and even tens of thousands of medical office staff people would be affected if we changed how we finance medical care. So what do we do then?

Dr. Richard Dillihunt, a recently retired Portland surgeon, suggests socialized medicine or “Universal Medicare.” He’s probably right. Whatever system we put in place must deal with several important issues, among them are incentives to live a healthy lifestyle and for preventive medicine, to have excellence in medical care, to contain excessive profit-making and inflation, to find a satisfactory method of delivering health care fairly to all yet containing overuse-abuse from any “free” system, and to also come to grips with some difficult ethical issues on withholding extraordinary care for certain small segments of our population, a la Oregon.

As others have, I recall the debates about Medicare in the 1960s. I was sitting at my seventh-floor desk in Hartford, Conn., when the insurance industry was opposing any government intervention. It was easy to buy the industry’s arguments then; it is absurd to buy them now when they’ve had nearly 40 years to address the problems and have failed to do so. It’s the financing that is broken. Too much energy is being expended on shifting costs, medical care decisions being made by people who have no business making them, doctors and nurses deciding it isn’t worth the aggravation to stay in the business, and many patients getting inadequate care.

We patients also need to acknowledge our part in contributing to the problems. Often we have demanded to be kept alive at all costs, more miracle drugs to take care of our unhealthy living habits, and expecting all of it at little cost.

The solutions may still rely on the insurance industry providing some part of the backbone of a new system, as they do now with the Medicare system. After all, trusting the federal government to solve a problem isn’t a desirable solution. But I think it is now clear that there is enough dissatisfaction with what we have, that a solution must be found soon. A new system will not be a cure-all. We will not like everything that it brings, but I suspect it may be better than what we have endured in recent years.

Patricia I. Felton of Ellsworth is the author of “Through This Window: Views on Traumatic Brain Injury,” and had a 25-year career in the insurance industry.