That is to say, we've reached a scale where we absolutely can start thinking and acting like a nation state. That doesn't mean that smaller, poorer, and weaker states can simply copy what we do directly, one-by-one. But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.

(This is true, incidentally, because in large part NZ's low costs come from just buying less stuff. Fewer fancy drugs, fewer fancy machines, smaller and older hospitals, and lower salaries for doctors and nurses. Works great, but this is politically infeasible in the US, to say the least, which is probably why California isn't even dreaming about trying it.)

Yes, California has 38 million people or whatever, but other large groups of in the US can't get good deals (be that insurers like Aetna or Kaiser, or government programs like Medicare). They're not larger than Medicare, so that's out. Are they going to be greedier that Aetna? Really? Or is the famously dysfunctional and lobbyist dominated government in Sacremento going to make some hard choices and piss off the voters?

> But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.

I'm a very strong proponent of federalism and the states as laboratories of democracy and all that. But... What California is proposing to do is not really new or untested. It's an expansion of a system that already exists in the US, and closely replicates systems from other countries. Yes, it works great if costs are low, and will bankrupt the state if costs are high. Costs are currently high. How do you square that circle?

Hospitals and pharmaceutical companies then negotiate directly with the state. And as far as what they can be expected to accept without going out of business themselves goes, we can get a pretty good idea from the expenditures of every other OECD country.