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> We have cities, but a lot of our major cities juet have nothing like the population of other nation's major cities.

I don’t think this is it. European cities aren’t that big compared to American ones. So Spokane is larger than Geneva. The problem is there isn’t much in terms of healthcare between Spokane, Boise, and Minneapolis.

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That's only if you look at the population of the named cities themselves rather than the population of the city plus the surrounding populates areas.

In Geneva's case, it is composed of several different named cities/towns/etc and those taken together are bigger than Spokane plus the municipalities that comprise its urban area.

Spokane metro is 579k. Geneva metro population is 633k. So Geneva metro has slightly more people than Spokane metro. Of course, the metro areas are wall to wall (so Geneva metro is adjacent to Lausanne metro) but they both have their own healthcare systems and aren’t gaining much more from scale than American metros.

And Spokane is a small case. There is nothing comparable to the Seattle metro in Switzerland. The closest you get is Paris in France or Milan in Italy.

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