The problem with "small and local" is that the smaller your coverage-pool is, the less leverage you have in negotiating payments.
I read an interesting article, recently. My first thought, at the end of reading it was, "when you represent 10% of the households in a given jurisdiction — 20% when you consider the typical percentage of people covered by insurance — you're going to have leverage to work against the extortionate practices of for-profit hospitals, pharmaceuticals, etc."
Bargaining-leverage is directly proportionate to how much money you control. It's why Centers for Medicare & Medicaid Services can pretty much dictate pricing. It's also why (prior to ACA), so many employers reduced or dissolved their coverage for employees with each passing year. Arguing for "small and local" really only makes sense if all of the bargaining players are "small and local". Pharmaceutical companies are neither small nor local. Fewer and fewer hospitals are "small and local".
While, like most people that have grown up in post WWII America I have a near-reflexive aversion to things labeled "socialism", I'm also pragmatic. As such, I'm able to recongnize that single-payer style systems at least create a degree of peerage among the negotiating parties (service-providers, pharmaceuticals, and representatives of the medical consumers). You can see this illustrated in many places:
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