[jval]

Politics is all about the money. Obviously administration is worse at scale too, but it comes down to political will in having the money to do it.

The way you keep a political union together without having it break apart is by limiting the amount of things the members of the union have to share. If you start taxing rich states and funnelling the money over to poor states, you give people a reason to want to break out of the union. Ultimately people only stay if they're getting a good deal.

Taxpayers in New York will definitely be happy if their money goes into the military, as having a New York rather than a US military wouldn't work. But to have all their money go into universal healthcare in Idaho would just piss them off, because people in Idaho can pay for that themselves. That's why healthcare is largely a state matter in the US - you'll find some states have great healthcare, others don't.

I'm not saying the US can't do it better (they clearly can), I'm just saying comparisons with other countries are useless because they don't take into account the unique political realities of the United States.

[hvidgaard]

New Yorkers aren't going to "pay for Idaho". NY may be paying more in tax for the entire state, but their budget would also be much larger. For obvious reasons NY can be more efficient, but that doesn't mean that they'll be paying a significant amount of the budget in Idaho.

[mcguire]

Well, actually, they would, for the same reasons that the postal service will make money in populated areas and lose money in less populated areas.

Say you need a trauma center within 1 hour of anywhere in the country. A trauma center in Manhattan is going to see a lot of traffic, while one in Clayton, NM, isn't. But the centers have the same basic cost in staff and gizmos.

[ThomPete]

It's not a once size fits all. You would of course look at the size of the area and the amount of traffic. So areas with higher traffic would get more resources allocated.

The real problem with healthcare is that you can never have enough. Even if everyone paid 100% in taxes it wouldn't be enough.

[DanBC]

> But the centers have the same basic cost in staff and gizmos.

Hang on: A busier unit is going to have more staff. Staff is not a trivial cost.

[mcguire]

In my simple model here, staff is per-capita; fixed costs like property, plant, and equipment are per-unit-area. Which wins in this case? I don't actually know, but I don't believe it is a trivial calculation. (Further, the medical events are not necessarily comparable in the two cases---rural means farming and resource extraction, etc., and that shit's dangerous, compared to white-collar work. And then there's transportation costs.)

I do know that in other similar situations, wealthier, more populated areas end up subsidizing poorer, less populated areas.

[rquantz]

New Yorkers are already paying for Idaho, and every other backwards, poor, uneducated, unpopulated state. And we talk about leaving the Union all the time, but that isn't why. It's because those same backwards, poor, uneducated, unpopulated states whose roads, schools, and healthcare we pay for keep blocking our attempts to turn the United States into a modern developed country.