> Under such a system, if your choice is not to have insurance, what should happen if you step in a hole and shatter your ankle in a way that requires complex surgery to repair?

In this hypothetical, I clearly wouldn't be able to afford the complex surgery, so either I would do without it or make use of any non-profit foundations/charities set up to give people in my position money.

It's worth noting that the cost, while still significant, would be FAR lower in a world with no regulation/licensure whatsoever. It's hard to understate how much cost (nominally expressed in dollars but the cost is so much more than that, to be clear) is introduced by all the layers of red tape.

And actually, now's a great time to mention that this problem occurs in our current US system, except it's way worse because (well, at least pre-Trump) you will get fined for not having insurance in addition to all the fun that comes with not having insurance. The obvious counterpoint here is to argue that if we had a single-payer system, where there's not actually private insurance companies at all (or at best they exist for people who aren't satisfied with single-payer and so those individuals both pay taxes for the single payer system and also pay for their own private insurance in parallel), that this problem wouldn't exist because it's impossible to not have insurance since the government already has it. That part is true, although you run into the classic problem that when everyone has government insurance, the client of a doctor/physician/etc is the state and not the individual, and therefore incentives are aligned against you right off the bat. Then factor in that you don't get to make decisions about your medical care - or rather, you can reject treatments but you can't decide to take a treatment that the government has decided you can't take, etc etc.

> And if the response is to simply pay the cost out of pocket, what if that "choice" not to have insurance was made because you're working at a minimum wage job?

I already implicitly answered this with my answer to the first question because I didn't shy away from saying that if you can't afford the surgery then you can't get the surgery without a benefactor. If I had tried to pretend that magically you would always be able to get the surgery then this would be more of a "gotcha" than it is.

While we're here though, this is a good time to mention that minimum wage shouldn't exist either. (Doesn't change your point, to be clear, but I can't help but mention that the whole concept of minimum wage is regressive policy masquerading as progressive policy)

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So, to conclude: resource scarcity is a thing and always will be a thing, and the best way to address is that to utilize our resources as efficiently as possible and maximize innovation, both of which require regulations to not be a thing. Regulations are always sold as "this will make things more efficient/safe/etc because the market dynamics aren't properly addressing this", but the reality is that regardless of your philosophical views on regulations, the actual utilitarian result is to make things more expensive with no increase in safety. And it of course makes things more inefficient.