> We are better in some areas, worse in others, but overall outcomes are roughly the same, at a much higher cost per person

What if you limit yourself to Americans with health insurance?

First, it wouldn't be an apples to apples comparison because the Americans without insurance are not randomly selected, so you'd be carving out a population with other confounding variables. And second, if doing so showed better outcomes here than elsewhere, we'd be saying "we have the best care, but 10% of the country doesn't get to have it. Tough luck!". Third, our overall spending is so much higher, we'd be admitting that we spend way more money to not even cover everyone.

I do agree that US costs are much higher per person.

It is not true that countries with our scale (population) are at or above our healthcare quality (scale matters).

For reference, here are the countries I am talking about: India, China, Indonesia, Pakistan, Nigeria, Brazil, Bangladesh, Russia, Mexico.

Those are the Top-10 most populous countries (with US at number 3, after China). Mexico at #10 has 200M fewer persons, so calling that the same scale is generous.

I have no doubt that Norway or Singapore has better healthcare than the US.

I feel like it's apparent why comparing healthcare in the US with healthcare in, well, any of the aforementioned countries, is problematic. If you look at Western Europe (a bit less populous than the US) or the EU as a whole (a bit more population than the US) they have functional healthcare at much more reasonable rates than the US. Scale matters, but scale is also a matter of division. If a single system can't serve 300+ million people then it can be broken down into regional systems or state systems. That being said medicare already serves something like 60 million people. I'd argue that scaling a system to support 5x the number it currently serves is significantly more doable than scaling anything from zero.

The US is not comparable to W Europe or the EU on this topic, since neither of those are political units responsible for a healthcare system. However, that brings us to your next point

>scale is also a matter of division...

This is a great point. However, for whatever reason, we have never seen a successful single-payer system in a US state. Even very blue, wealthy states have not achieved this.

>scaling a system to support 5x...

Again, the data does not support this. I don't have a reason why, just observing that it's not supported by real life.

Hm, with regards to the difficulty of scaling these systems specifically and really the whole topic at hand more generally I don't know that there is sufficient domain specific data to justify a viewpoint either way. I mean how many examples of scaling a national healthcare system (public, private, or otherwise) to support 300+ million people do we have? Literally three, right? The US, China, and India. Each of which has such significantly different circumstances that comparing them is less apples to oranges than it is apples to giraffes to glaciers. That being the case I feel like it's only reasonable to draw upon non-domain specific data wherein so far as I'm aware and in my experience we see a pattern of scaling existing systems being simpler than originating new ones.

You're right that we only have a handful of countries operating at this scale (~150M+ populations) so it's not exactly "data" in the common tech-sense of that word.

I want to get back to my original point: it's not "astoundingly clear" that the US should have a single-payer system (not your words, I know). My own thoughts are that this is mostly a scale problem as well as an inability to properly assess the performance of other systems (e.g. I would call both Canada and UK healthcare broken, but others see those as successful).

I agree that the US system seems broken from both an "Outcomes vs Cost" and a "Cost over Time" perspective. I just disagree that nationalizing healthcare, either through a single-payer system or the current Obamacare system is the answer.

Scale does not matter. If anything scale makes it easier. Those countries are not peers with the US when it comes to wealth and resources.

>scale does not matter

The actual data seems to indicate the exact opposite. Countries with large populations aren't able to provide inexpensive healthcare, while countries with smaller populations achieve better outcomes at a lower cost

edit: I've read some of your other comments on this post and I really enjoy the deep level of understanding you're bringing on the actual article's topic. I just think you're wrong about the specific scale thing that I'm talking about

I would argue that the quality of governance of those countries and the strength of their economies relative to the US dramatically outweigh looking at size alone. Size makes things easier. The more scale the more predictable the costs.

We have a single payer system for everyone 65+, because we had the political will to do it, and it remains funded and functional because it is an important and powerful political bloc. A lot of people make a lot of money from the dysfunction of the system for everyone else and they fight tooth and nail to keep that gravy train flowing.

We also have an unhealthier society because we have different jobs, standards of living sedentary lifestyles, etc. For example we have more obesity. So depending on how you are measuring overall outcomes it could be that the US system is in fact better, but is just dealing with patients with a different initial health level.