> Others can do R&D in their own ways, including very significantly University research besides Nationally funded research.

They can, but do they? In other words, is the amount of research done per capita in Europe more than the amount done in the US, counting both government and private sector in both cases?

> Pure commercial health research is problematically burdened by interest in profitability of potential treatments.

In principle this is just a measure of how important something is to people. A cure for cancer when you have cancer is worth a lot more than a cure for restless leg syndrome or whatever. Then that gets multiplied by the number of people who have that condition and it actually is a pretty good measure of how much we should be spending to cure something.

Sometimes you get seemingly silly results like a lot of money going into things like baldness cures, but it's because there are a very large number of people with that condition, and small importance times large volume actually justifies a significant amount of research investment.

It doesn't work that well for things that generally only poor people get, but that doesn't mean it can't work for the major killers like heart disease and cancer that get everybody. And charities are actually doing a pretty good job with the exceptions like malaria. You don't have to solve every problem the same way.

> Its unfortunate that in this age we are to assume international competitiveness in health and all important technologies as given and unavoidable, over cooperation. Cooperation is what we do with people we care enough for.

It's not really a matter of cooperation. It's not as if the US develops a cure for a given condition and then keeps it to themselves and doesn't let Europe have it.

The issue is that if there are 100,000 patients world-wide and it takes a billion dollars in revenue to justify the development, the average patient has to pay ten thousand dollars. If a country declares they'll only pay $8000, taking that much is still better than having to amortize the same costs over fewer patients, but then they have to charge more than $10,000 to patients somewhere else.

Naturally every country has the incentive to do that, but the more of them that do the more drugs never get developed to begin with because the remaining countries couldn't make up the difference.

> The doctors quite rarely don't have most expensive treatment option available and can advise that one is available for private purchase occasionally.

It's not just a matter of not having the treatment option available.

Consider that math again from the perspective of the drug company. They need a billion dollars in revenue which is $10,000/patient on average.

Now they go to the NHS in the UK which offers to pay no more than $8000. The actual manufacturing cost is only $100 and the rest of it is going toward fixed costs like R&D and interest on the money borrowed to do R&D. Getting $7900 to put toward those costs isn't sufficient on average, but it's more than zero.

Meanwhile if the company refuses that price, they get nothing from the UK, because NHS does cover the existing alternative. Which means that if the company refuses the government's terms, a patient's price in that country is $10,000 more than the alternative, because the NHS is paying $6500 for the existing drug but nothing for yours. Then even though yours is $5000 better and only costs $3500 more, from the patient's perspective it costs $10,000 more because the alternative is "free" but yours is full price. So if you don't accept the governments terms you get approximately zero customers in that country.

So the company takes the government's $8000 because it's better than the nothing they get in the alternative, and then the drug is "available" there. But that's not enough to sustain the research when everybody does it. The more countries do that the less research we get.