How do you account for the free rider problem? Suppose you live in a small town how do they collectively pay for expensive medical services if one member of the small community gets an illness that requires lots of resources to treat? Isn't it better to distribute the burden over a larger population? Wouldn't there be a massive amount of administrative overlap if all services truly were done at the community level? How do you prevent the race to the bottom mentality if everything is done at the community level?