On September 8, 2006, the Scottish Medicines Consortium told patients with advanced stomach cancer to go home and die. On June 8, 2007, it said the same thing to people with advanced kidney cancer. Even though the U.S. Food and Drug Administration had granted sunitinib accelerated approval for the treatment of advanced stomach and kidney cancer in January 2006, the National Health Service (NHS) Scotland said no. “In uncontrolled trials,” it opined, “sunitinib has been associated with tumour responses in patients who have metastatic renal cell cancer. However, the economic case has not been demonstrated.”

When it comes to medical care, people in the United Kingdom are docile subjects. They do what they are told. And since politicians control the health service, money for health care flows to areas of concern to politicians. In the United States, where roughly half of spending is still controlled by patients, the money flows to areas of concern to patients.

An August 25, 2007 editorial in the BMJ highlights the difference: “An advantage of the way in which the United Kingdom funds the NHS," it opined, "is that its patients do not have to judge whether or not the health benefits of their treatment are worth its costs.”

Whether treatment is worth the cost depends on one’s perspective. The “economic case” made by NHS Scotland for kidney cancer patients was a comparison of sunitinib treatment with the best “supportive care.” Supportive care means that the government pays to make your death less unpleasant.

The government estimated that the cost of providing sunitinib would be £34,000 to £81,000 per quality-adjusted life-year (QALY). In Britain, the unofficial National Institute for Health and Clinical Effectiveness (NICE) threshold is that new treatments must be below £20,000 to £30,000 per QALY. Never mind that QALY estimates are anything but transparent, that they can vary considerably depending on the method used to measure preferences, or that they do not reflect what people are willing to pay.

In the U.S., where patients still control half of health care spending, sunitinib is available in private Medicare formularies and in the formularies of private health plans such as Kaiser-Permanente, Cigna, Aetna, Anthem, and Humana. It is also included in the formulary for the Federal Bureau of Prisons. When the private sector benchmarks medical care, even felons have better access to new drugs than the bureaucratically burdened Scots.