> As a result it is very transparent what is sacrificed - e.g. you can find NICE [1] documentation on evaluations of individual drugs and treatments and their benefits, and documentation of the decision making processes of the NHS trusts, so they can be debated and used as a basis for deciding funding, or you're free to sign on to additional private cover if the exemptions worry you.

The decisions that NICE makes are not fundamentally different from the decisions that insurers make when deciding which medications and treatments are covered for various conditions, and in fact, you can find analogous documentation of these decisions from every major insurer.

> The difference is that those systems goes to great lengths to ensure that the decision is done based on clinical needs and objective measures of what achieves the most patient benefit for the available money.

Emphasis mine.

NICE is not operating in some magical world where "revenue" and "costs" are somehow not intrinsically linked with clinical decisions. They're doing the same thing that insurers do - make decisions about treatments based on objective measures of clinical outcomes, subject to a finite budget.

Ironically, this entire thread is about HIV, and HIV treatment and prevention are one area in which the NHS falls drastically short of what's available in the US both to people on private insurance and to people without insurance coverage whatsoever.

The point is not that NICE is perfect, but that these limitations are subject to democratic control - if people feel that the NHS treatments are inadequate based e.g. on the NHS being unable to fund treatments that are recommended by NICE, the government has a direct and immediate ability to control the funding. It happens quite regularly that public debate over NHS funding of specific treatments leads to concrete change in policy.

And, as pointed out, people additionally have the option of taking out additional coverage, which as it happens also provide us with a good idea of to what extent people feel the NHS is sufficient. Typically only around 10% take up private insurance, mostly as a perk offered by some employers.

The availability of that as a (quite cheap) "escape hatch" is quite interesting in that respect. Especially given that the average person in the UK pay far less towards the NHS than the average American pay for healthcare via taxes and health insurance - you can sign up for high end private insurance in the UK and still end up paying less.

> They're doing the same thing that insurers do - make decisions about treatments based on objective measures of clinical outcomes, subject to a finite budget.

NICE's recommendations are not subject to the NHS budget. They are independent for a reason. Cost efficiency of a treatment enters into their assessments, but they do not have final say on which treatments are offered. They make recommendations based on the clinical need and document efficacy, outcomes and costs. It's up to the NHS to then allocate funds accordingly.

> Ironically, this entire thread is about HIV, and HIV treatment and prevention are one area in which the NHS falls drastically short of what's available in the US

I don't know the details of this, but find it curious given that some quick searches indicate that the HIV/AIDS death rate in the US per 100,000 is a larger factor above the UK than the prevalence rate.

Of course that could be for other reasons than treatment.

I know there's been some debate over funding of preventative treatments (with the NHS finally deciding to fund trials), but that was over responsibility largely (preventative measures is in general a council responsibility), but if anything the fact that the NHS decided to start trials after public debate seems to me a pretty good demonstration of what I'm saying.

The system is not perfect, but it's open, transparent and subject to democratic control.

> And, as pointed out, people additionally have the option of taking out additional coverage,

That's like saying "people additionally have the option of paying out-of-pocket". Remember, by definition, the expected monetary value of insurance is negative, so unless the private insurance is being subsidized by taxpayer dollars (defeating the whole point), this is equivalent to saying that people are still free to pay for treatments themselves.

> NICE's recommendations are not subject to the NHS budget. They are independent for a reason. Cost efficiency of a treatment enters into their assessments, but they do not have final say on which treatments are offered. They make recommendations based on the clinical need and document efficacy, outcomes and costs. It's up to the NHS to then allocate funds accordingly.

You can't escape the fact that, at the end of the day, the process still amounts to the same thing. Given a finite budget, decisions are made on how to allocate that funding based on clinical data, resulting in some people not receiving treatment, even though they would otherwise benefit clinically from it. What the NHS does is not fundamentally different from what insurance companies do.

Saying that it's subject to "democratic control" doesn't really mean a whole lot, except that the process ends up being a lot slower, and it becomes a political battle. (Notice that PrEP has been available in the US for five years at zero cost to patients, and it's still not available in the UK. Or, notice that the cure for HCV is generally accessible on private insurance in the US, but almost nobody in the UK is able to receive it through the NHS.)

> That's like saying "people additionally have the option of paying out-of-pocket".

No, that's pointing out that in the UK, we have an insurance system that is so cheap that for the very few that feels it's insufficient, it is still cheaper if they buy supplementary insurance on top, and they do have the option of have both private and socialised insurance.

> What the NHS does is not fundamentally different from what insurance companies do.

It does result in fundamentally better coverage for far less money. Somehow that seems "fundamentally different" to me. We pay on average about half as much, and for that everyone gets covered, and those that aren't satisfied can pay - still less - to get far more extensive cover.

The pigheaded insistence on defending the US system is to me utterly bizarre given that it's more expensive even if you choose to go private on top of the socialised systems in most of Europe. Especially given the kind of stories in this thread - from a European perspective they're the kind of horror-stories that makes at least me want to never consider living in the US.

> Saying that it's subject to "democratic control" doesn't really mean a whole lot

It does mean a whole lot when there are a number of examples of how it results in actual change.

> (Notice that PrEP has been available in the US for five years at zero cost to patients, and it's still not available in the UK.

Firstly, you can not consider the UK as a whole as one entity, as the NHS is not a single system, and control of NHS Scotland is devolved. Scotland started NHS funding of PrEP in April 2016.

This is an issue of speed of approvals of new treatments, which frankly says little about the respective systems - the reverse is often true too; drugs coming out of Europe often take years to get approved for use in the US.

Secondly, PrEP has been available to people in the UK from online pharmacies since 2016. It's not available on the NHS outside of a trial, but the flexibility of UK drug import rules means that buying PrEP in the UK is possible for around $50/month.

Also while it may have been technically available for 5 years in the US, wide insurance cover does not appear to have been present nearly that long.

Saying it is zero cost to patients in the US also seems like cherry-picking. The pages I find all say that outside of various programs targeting specific groups you can expect to pay your normal insurance co-pay, which for many will be more than the full cost of buying these drugs for UK patients outside of insurance.

In any case this boils down to the usual process of approvals varying country by country irrespective of the system - in most of the world PrEP is not yet approved, irrespective of budgets.

If you want to a meaningful comparison of this you'd need to do a wide comparison of time to approvals. Otherwise you need to look at availability of drugs post-approval.

> Or, notice that the cure for HCV is generally accessible on private insurance in the US, but almost nobody in the UK is able to receive it through the NHS.)

I believe that's at least two years out of date - as far as I can see expanded funding was approved in 2015, and an example of how policy was changed within weeks after a charity made the public aware of it. Given that the drug in question was rolled out in 2013/14 that does not seem unreasonable to me.

Same issue as above in any case, where looking at the newest drugs says little about long term availability of care.

> The pigheaded insistence on defending the US system

While I could respond to the rest of your points - including a couple of the statements which are factually incorrect - if this is the way you're going to talk to someone who's having a conversation with you in good faith, there's not much point in me spending any more time on the matter here tonight.