And don't forget to keep in mind that in many countries with "single payer" healthcare systems, that the healthcare system itself is often run on a state/provincial level, which makes the "scale" argument completely irrelevant. Canada does not have a national health care system, despite what you may have read elsewhere. Every province does it's own thing. All the Feds do is provide some of the funding, and set the overall requirements. So wee little PEI with a population of 140k has it's own healthcare system, as does Ontario, population 13m.