> 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.