Universal Health Care Discussion split off from Poz Tops and guys on PReP

[Cutedelicategay]

14 hours ago, BootmanLA said:

Yes, you're missing something (a lot of somethings, actually), and unlike Cosmaz above, I'm willing to spell them out for you.

1. It's probably true that relative to the overall population in the world, or in the US, or even just among gay men, gifters and chasers are a relatively small community (though I would not say "miniscule". That said, there are plenty of them who are not on this site. 

2. You find it "hard to believe" there are lots of guys who are negative but not on PrEP. You live in Canada, a place which has universal health care. Until this year's determination in the U.S. that PrEP is a recommended preventative measure (and thus must be covered without copay by insurance under the terms of the ACA), many insurance companies did not cover PrEP, and those that did frequently had a large copay (sometimes hundreds of dollars per month). And of course, there are still plenty of people in the United States who (a) live in places where the state has not expanded Medicaid and (b) they make too much for traditional Medicaid, and (c) work for an employer who doesn't offer health benefits or who has them priced so high they're not affordable.

Millions of people in the United States still lack any health insurance coverage at all - somewhere between 25 and 30 million people, the vast majority of whom are adults. If we guess that 5% of those are LGBT people (I'd wager it's higher, as we tend to be overrepresented in marginal occupations in the service industry) - that would still be over a million LGBT people at a minimum with no insurance coverage. Those people are far less likely to be on PrEP strictly due to cost concerns.

Your Canada-induced myopia is perhaps keeping you from seeing what your large neighbor to the south experiences.

Beyond that, a certain number of people prefer condoms over bareback sex, even PrEP-protected bareback sex, because condoms offer additional protection to other STI's. Not to all of them, and not in every case, but still - it's their call to make and they make it that way. What you or I or anyone else thinks about the desirability of bareback sex over condom sex, a lot of people are still making that decision every day.

And beyond THAT - if an undetectable-poz top bareback fucks a bottom who's not on PrEP, he's almost certainly not going to infect the bottom. That means that in sharp contrast from our community experience in the 1990s - where fucking assorted guys bareback was almost a guarantee towards getting pozzed, eventually - in 2021 as long as one of the two participants is undetectable OR on PrEP, the chances of transmission are negligible. While I think it's still crazy to roll the dice that way, the odds of getting pozzed have gone way, way down (as evidenced by the frustration of so many chasers on this site).

3. Once a person recovers from the initial "fuck flu" - if he experiences that - health complications from HIV take a pretty long time to develop for most guys. Some don't want even the minor complications that HIV treatment regimens can produce. And even in later stages of infection, when HIV begins multiplying rapidly in the system, opting into treatment at that point is frequently successful at reversing the effects of years of not being treated, although such a patient has fewer options for "med holidays". So yes, it's entirely possible to believe some people would rather wait until it's absolutely necessary to begin treatment.

Beyond that, there are some guys who figure "Live hard, die young" and take that seriously - they don't want to be 80 years old with joint problems, unable to walk up a flight of stairs and unable to remember what they had for lunch yesterday. They would rather live a shorter but fuller life, and that's their choice to make.

4. What *you* believe is "criminal" and what actually *is* criminal are highly likely to be two different things, so let's make sure we define our terms.

Canadian law - which covers where you are - is somewhat murky in that exposure to HIV is covered under general sexual assault law. "Criminal exposure to HIV" is defined as a "realistic possibility of transmission" of HIV during sexual intercourse. "Realistic possibility" is not spelled out in Canadian statutes, but the Supreme Court of Canada has held that it does not include sex with a condom OR sex where the infected person has a sufficiently low viral load. There are proposals floating around that would codify "no realistic possibility of transmission" to cover four situations: when the infected person is undetectable, when condoms are used, when the non-infected person is on PrEP, or when the particular sex act (e.g. oral sex) is itself very low-risk - but those proposals haven't been adopted into legislation yet.

In some (not all) jurisdictions in the United States, by contrast, you have 50 different sets of laws, because this is a state, not federal, matter, and while the laws in one state may resemble those in another, none are identical. In some states there is no specific criminal provision at all.

Now, if you mean "morally wrong" and not "criminal", that's a different kettle of fish entirely. But in that case, you shouldn't use words like "criminal" that have a very specific meaning, especially not tossed around willy-nilly with no understanding of what is actually criminal and what isn't.

That is a well thought out reply. Possibly a myopic view however I disagree with you on the concept of universal health care system. That system is a total waste of money and resources. I do not and will never agree with the fact that the entire society is responsible for the health of every individual. To certain aspect yes but entire health absolutely no. We had one of the strictest lockdowns and that too was not to save lives but to protect the ever failing universal health care system. People who cannot afford health care should evaluate themselves and their profession as to why cant they work better jobs when many of us are really working hard to earn and afford luxuries of life. Thats another debate for another time. However I really liked your reply. 

[BootmanLA]

7 hours ago, Cutedelicategay said:

I do not and will never agree with the fact that the entire society is responsible for the health of every individual. To certain aspect yes but entire health absolutely no. 

If you can't define what that "certain aspect" includes, then your point is useless. But I'm more curious as to why you think this. The "entire society" is responsible (via our laws, legal system, regulations, etc.) for providing clean air and water as essentials for life. We don't tell the people who live downstream from a chemical plant that they're responsible for taxing themselves enough to keep the chemical plant under control.

The U.S., unlike Canada, primarily uses the private sector as a means of paying for health care. Result: despite spending more than twice per capita what Canada does, we have somewhere around 10% of our population with no coverage whatsoever, and with a considerable number of the rest getting substandard - that is, far below the level you get in Canada - care.

7 hours ago, Cutedelicategay said:

We had one of the strictest lockdowns and that too was not to save lives but to protect the ever failing universal health care system.

Join the club. We had just as strict a lockdown early on, and longer ones in many places, and that, too, was to protect our health care system. So our private system fared no better than your universal one, AND it fails to deliver care to millions on top of that.

 

7 hours ago, Cutedelicategay said:

People who cannot afford health care should evaluate themselves and their profession as to why cant they work better jobs when many of us are really working hard to earn and afford luxuries of life.

The idea that you consider health care a "luxury of life" tells me all I need to know about your outlook, and it's not a pretty picture.

[Guest PigBruderChi]

On 9/3/2021 at 10:41 AM, Cutedelicategay said:

That is a well thought out reply. Possibly a myopic view however I disagree with you on the concept of universal health care system. That system is a total waste of money and resources. I do not and will never agree with the fact that the entire society is responsible for the health of every individual. To certain aspect yes but entire health absolutely no. We had one of the strictest lockdowns and that too was not to save lives but to protect the ever failing universal health care system. People who cannot afford health care should evaluate themselves and their profession as to why cant they work better jobs when many of us are really working hard to earn and afford luxuries of life. Thats another debate for another time. However I really liked your reply. 

um you know how that insurance work right, when you pay for it you're also paying for some else health care. lol... thats how the industry works. 

[Sfmike64]

On 9/3/2021 at 10:41 AM, Cutedelicategay said:

That is a well thought out reply. Possibly a myopic view however I disagree with you on the concept of universal health care system. That system is a total waste of money and resources. I do not and will never agree with the fact that the entire society is responsible for the health of every individual. To certain aspect yes but entire health absolutely no. We had one of the strictest lockdowns and that too was not to save lives but to protect the ever failing universal health care system. People who cannot afford health care should evaluate themselves and their profession as to why cant they work better jobs when many of us are really working hard to earn and afford luxuries of life. Thats another debate for another time. However I really liked your reply. 

Wait until you, like me, are diagnosed with cancer that you didn’t know you had and the treatment costs $65,000.
 

Unless you don’t plan on reaching an old age, universal healthcare is the best thing for everyone. 

[Cutedelicategay]

On 9/3/2021 at 7:12 PM, raw773 said:

You honestly just can't avoid the drive-by nastiness towards others. I have you set to ignore, but it's not enough because I want to follow conversations and wind up reading you anyway.

Why can't you just be nice to people? You've been called out by several people. We get it: you think you're smarter than everyone else. But please. You can make your points without being a jerk.

The issue with virtue signalers is that they say think and do differently. They lack consistency. Most don't even agree to disagree. I have my views on universal health care and I believe that health care should be available for a cost. Just because health care and other social nets are available people have misused that system in such a way that it has become a burden to people who pay their taxes to feed the lazy ones who sit on their asses and collect free money. Social systems are nothing but a breeding ground for a beggar society without self respect. That's what Canada is anyways. I do stand by my statements and people who think free health care is must just reflect how deep rooted lack of meritocracy is in them. I try to be nice to people so a discussion can be done with disagreement in a mature manner but some have this in built character of stupidity in them. Indeed reflects a lot about them too. 

Edited September 9, 2021 by Cutedelicategay

[BootmanLA]

8 hours ago, Cutedelicategay said:

The issue with virtue signalers is that they say think and do differently. They lack consistency. Most don't even agree to disagree. I have my views on universal health care and I believe that health care should be available for a cost. Just because health care and other social nets are available people have misused that system in such a way that it has become a burden to people who pay their taxes to feed the lazy ones who sit on their asses and collect free money. Social systems are nothing but a breeding ground for a beggar society without self respect. That's what Canada is anyways. I do stand by my statements and people who think free health care is must just reflect how deep rooted lack of meritocracy is in them. I try to be nice to people so a discussion can be done with disagreement in a mature manner but some have this in built character of stupidity in them. Indeed reflects a lot about them too. 

I think the contempt you feel for those less fortunate than you are shines through loudly and clearly here. You can deflect by calling it "virtue signaling", but I'm not sure what you would call advocating for a system where if you're poor and can't afford health care, you die.

And I love how people use "meritocracy" to mean "people who have more money than others", as though more wealth automatically means a better person. Some of the shittiest human beings I know are exceptionally rich materially, through no effort whatsoever of their own other than being born to wealthy parents, who themselves were born to wealthy parents.

And best of all is the attribution of "stupidity" to people who disagree with any of these positions you've taken. 

[fskn]

On 9/2/2021 at 6:19 PM, BootmanLA said:

2. You find it "hard to believe" there are lots of guys who are negative but not on PrEP. You live in Canada, a place which has universal health care.

...

Your Canada-induced myopia is perhaps keeping you from seeing what your large neighbor to the south experiences.

A correction, relevant to PrEP and other pharmaceutical interventions:

Many Americans don't know the details of Canada's single-payer health system. The provincial health insurance plans that comprise the system do not cover prescription drugs.

There is no government-funded prescription drug coverage in Canada unless you are a senior citizen or a low income earner (if you are curious, you can look up ODB/Ontario Drug Benefit, the largest such program in Canada) or you have one of a small number of high-cost conditions for which exceptional government help has been legislated.

Canadians rely on employer-provided supplemental health plans for prescription coverage. There is no individual health insurance market to speak of in Canada, and supplemental plans are generally offered to employees high up on the economic totem pole (full-time, white-collar professionals who work for large employers).

The lack of government-funded prescription drug coverage has significantly held back PrEP adoption Canada.

For a similar example, even though medical (pill-based) abortion has been routinely available in Europe and the US for years, and was finally approved in Canada, it didn't become routinely available there until a year or two ago, and there are still access gaps. The provincial health plans cover services, so they will pay for surgical abortion, but because they do not cover outpatient prescriptions, they initially refused to cover the medication needed for medical abortion. This was the height of economic irrationality: surgical abortion was much more expensive for the provincial health plans!

One small consolation is that Canada, at the federal level, regulates prescription drug prices. (Note that health is largely a provincial responsibility in Canada. The federal government retains regulatory authority and, because it reimburses the provinces for a [declining] share of the cost of their health plans, it can use this financial lever to set rudimentary standards for the provincial health plans.) But even with federal price caps, the out-of-pocket cost of brand-name Truvada remains out of reach for ordinary people in Canada.

In the US, generic Truvada, particularly from Aurobindo (Teva's first-to-market generic was nearly full-price) is at once helping and harming PrEP access.

Uninsured Americans could potentially afford to pay out-of-pocket for the Aurobindo product (just over $1 per daily pill), but the company does not sponsor a patient assistance program. Gilead covered thousands of dollars a year in out-of-pocket costs for Truvada for any privately-insured or uninsured American who asked and, given proof of income, the entire cost for low income earners. (This wasn't a matter of generosity; it was simply redistribution of a fraction of the revenues that Gilead received from private and public insurers, which paid full-price. For Americans, this kind of redistribution is more palatable than actually correcting inequities in healthcare access.)

Now that the preventive health care designation is in place, and that most PrEP patients receive generic Truvada, getting health insurance (whether through basic Medicaid eligibility in red states, expanded Medicaid eligibility in blue states, or subsidized ACA plans in all states — note that federal subsidies have been increased for a few years) is the way for low-income Americans to get access to PrEP.

In Canada, low-priced generic Truvada will only improve PrEP access. Gilead did not offer patient assistance in Canada. For the large number of Canadians without supplemental health insurance to cover prescriptions, the prospect of paying just over $1 per daily tablet brings the drug cost within reach.

A more substantial consolation is that the provincial health plans in Canada — unlike Gilead's patient assistance programs in the US — do cover office visits and lab tests.

Edited September 10, 2021 by fskn

[BootmanLA]

3 minutes ago, fskn said:

Now that the preventive health care designation is in place, and that most PrEP patients receive generic Truvada, getting health insurance (whether through basic Medicaid eligibility in red states, expanded Medicaid eligibility in blue states, or subsidized ACA plans in all states — note that federal subsidies have been increased for a few years) is the way for low-income Americans to get access to PrEP.

The only correction I'd note to your excellent post: in most of the states that did not expand Medicaid, "basic Medicaid" frequently doesn't cover most people who would need/use PrEP. 

For instance, in Texas, in addition to meeting the "low income" threshold, you must be one of the following:

--Pregnant, or

--Be responsible for a child 18 years of age or younger, or

--Blind, or

--Have a disability or a family member in your household with a disability.

--Be 65 years of age or older.

None of those applies to the vast majority of sexually active people, men or women, gay or bi or straight.

And those are typical of the limits of non-expanded Medicaid. For the 12 states that have not expanded Medicaid, virtually none offer any benefits of use to an otherwise healthy working-age person.

[Guest]

This thread has gone off topic from the OP. 

Perhaps move the last part to a new one about the pro's and con's of universal (which is not 'free') healthcare?

 

Having said that:

On 9/4/2021 at 7:58 PM, PigBruderChi said:

um you know how that insurance work right, when you pay for it you're also paying for some else health care. lol... thats how the industry works. 

As an industry the aim would be profit-driven by collecting more money than the industry pays for healthcare. Logically that would lead to higher costs for anyone participating that ads to the wealth of the management and owners of the industry.

 

Another way to frase and see this, is that when you have universal health-care / -insurance is that you pay your premium so your own medical costs won't bankrupt you when you need it to stay healthy and/or alive.

And when you don't need it yourself you can consider yourself VERY lucky and it might sound a bit selfish you don't want to be pay a premium, taxes or another contribution for people who have become ill.

 

[raw773]

21 hours ago, fskn said:

Uninsured Americans could potentially afford to pay out-of-pocket for the Aurobindo product (just over $1 per daily pill), but the company does not sponsor a patient assistance program.

I'm not following this one... If it sells for $1 a pill (news to me), that's already very cheap. What's the profit? 10 cents? So where does Aurobindo get the money for a patient assistance program?

I mean they'd basically be losing money on it.

To me? I'm not troubled that PrEP costs money. It's a lifestyle drug. Let's be honest. Going bare is a choice. Unless you're being raped, nobody makes you do it. I think those of us making that choice ought to have some skin in the game, and I'm uncomfortable dumping the cost of PrEP on the rest of society.

[fskn]

5 hours ago, raw773 said:

I'm not following this one... If it sells for $1 a pill (news to me), that's already very cheap. What's the profit? 10 cents? So where does Aurobindo get the money for a patient assistance program?

I never said low-price generic drug manufacturers should fund patient assistance. I explained that the shift from high-priced, brand-name Truvada to a low-priced generic changed the landscape for low-income US PrEP patients. Where they might have been able to get by with a patient assistance program before, they now need to pay something out of pocket, or obtain insurance (@BootmanLA notes the difficulty of qualifying, in states that have not expanded Medicaid eligibility) and rely on the new preventive care designation for PrEP (which, as pointed out by @BergenGuy in a different thread, is being litigated by the same religious conservatives who oppose birth control).

You should be able to tell from my explanation of how patient assistance programs are paid for that I don't view patient assistance ( = hidden revenue transfer) as a solution.

5 hours ago, raw773 said:

To me? I'm not troubled that PrEP costs money. It's a lifestyle drug. Let's be honest. Going bare is a choice. Unless you're being raped, nobody makes you do it. I think those of us making that choice ought to have some skin in the game, and I'm uncomfortable dumping the cost of PrEP on the rest of society.

Emprical data don't support this position.

Large randomized controlled trials (the gold standard in medical research) have established that daily Truvada, 2-1-1 intermittent Truvada, daily Descovy, and also 2-month injectable Cabotegravir (already approved in the US for HIV treatment, with approval for prevention pending) are nearly 100% effective in preventing HIV infection when used as directed. Even in actual use (a subset of the patient population fails to take some  Truvada or Descovy doses), efficacy is quite high: a substantial percentage of infections are avoided.

The lone exception in PrEP efficacy research is in heterosexual women in Africa. You claim that "going bare is a choice", but this is not true for straight women in patriarchal societies where, to make matters worse, the rate of existing HIV infections ("prevalence") is very high, treatment is limited, and HIV remains a major cause of disability and early death.

African women's male partners generally refuse to allow condoms. African women also reported having to keep their use of Truvada secret from their male partners. Some women signed up for PrEP studies because they were so poor that they needed the compensation or the general health care offered to study participants, but had no intention of taking Truvada. Not surprisingly, the efficacy of Truvada for PrEP among heterosexual women in Africa was low, because adherence was very low. Adherence might be better with injectables or implants, which are currently being studied. These alternatives are more discreet than a daily pill, and they last a long time.

Returning to our comparatively simple, American universe, we know from birth control studies that there's a difference in the effectiveness of condoms in perfect versus actual use. Just as PrEP users miss doses sometimes, couples who rely on condoms sometimes don't use them. No matter our intentions as individuals, we are not perfect!

So, another source of evidence of PrEP's value is epidemiological data. Even in San Francisco, a city with a large, long-term, sustained investment in HIV prevention and HIV treatment, and relatively low rates of new HIV infections  ("incidence") to show for it, existing interventions had peaked. Condoms — and a big intervention that you left out, Treatment as Prevention (the fact that HIV-positive people with an undetectable viral load do not transmit HIV) — were not enough. For the first half of the 2010s, there was still more than one new HIV infection in San Francisco per day, on average. The infection rate was no longer going down.

It started dropping again only after Truvada was approved for PrEP, access barriers were reduced, and PrEP usage became widespread locally. PrEP makes a difference, at the whole-population level, even in places like San Francisco that already did a good job with HIV prevention. Think of the difference it could make in less advanced locales!

As for economics, PrEP was never intended for everyone. CDC guidelines indicate that it is for people who are at high risk of HIV infection. When it is made available to high-risk people, with minimal access barriers, the rate of new HIV infections goes down. Health economists could well weigh the cost of PrEP (which continues to drop) against the cost of HIV treatment (or lost economic output due to disability and early death, in places where treatment is not readily available) for the extra people who would become infected if PrEP were not accessible.

In the US, PrEP isn't yet reaching the people at highest risk of getting HIV. As far as sexual transmission goes, new HIV infections in the US are overwhelmingly among low-income people, people of color, young people, and trans people. These groups have trouble accessing PrEP, believe that they would have trouble, or simply don't know it's an option. There is a big demographic (and also geographic) mismatch between Americans who readily access PrEP and Americans who are newly infected with HIV.

When we expand our perspective to Africa, the mismatch is even worse.

You want more, not less, PrEP access for people who are otherwise likely to get HIV!

Edited September 11, 2021 by fskn
Looked up user name to @mention

[raw773]

6 minutes ago, fskn said:

You want more, not less, PrEP access for people who are otherwise likely to get HIV!

Sure. At the population level, it certainly works and it's probably saving lives. At the micro, individual level, though, it's needed because people make selfish choices (I want to have sex with anyone I want and without a condom). Let's be honest with ourselves.

[fskn]

1 minute ago, raw773 said:

At the micro, individual level, though, it's needed because people make selfish choices (I want to have sex with anyone I want and without a condom). Let's be honest with ourselves.

Tell that to a heterosexual woman in South Africa, where 17% of adults have HIV, not everyone has access to testing and treatment, and her husband beats her (or has threatened to abandon her) if she insists that he use a condom.

Even in the US, there is no "micro, individual level" to speak of when we are talking about health. Blaming individuals is not useful for health policy (which necessarily deals with entire populations) and it's not effective at changing individual behavior!

If it were that simple, problems like drug and alcohol addiction; lung cancer from smoking; sexual transmission of HIV; frequent COVID-19 transmission among unmasked, unvaccinated people; and so on would all have been solved long ago.

I don't think you read what I wrote, or understood what I was trying to say. I hope you'll spend a day shadowing an HIV prevention counselor or a family planning counselor to understand that there's no easy way to control individual behavior, and then spend an hour with a researcher at an HIV Prevention Trials Network (HPTN) site to understand why it's important to continue working on PrEP methods, adherence and access.

[Guest]

Aaaand we're back - or almost - on Topic. 🤗

Thanks to the administrators though for splitting the thread.

[Guest]

10 hours ago, raw773 said:

To me? I'm not troubled that PrEP costs money. It's a lifestyle drug. Let's be honest. Going bare is a choice. Unless you're being raped, nobody makes you do it. I think those of us making that choice ought to have some skin in the game, and I'm uncomfortable dumping the cost of PrEP on the rest of society.

Good for you if you want to pay for your own protection by PrEP. 
Not everyone has the same financial means to do the same though or are downright (financially) poor. Also it's not just the cost of the drugs used in PrEP, which are dropping, but also the cost for the regular testing, guidance and coaching when you go on PrEP which add up.

In the long run it's estimated that the cost of PrEP (including the guidance etc.) is payed back because of less HIV-infections and life-long drug-treatment to manage the disease. As far as I know, there's a plus when comparing purely the medical costs of prevention by PrEP vs. treatment.

 

4 hours ago, fskn said:

Blaming individuals is not useful for health policy (which necessarily deals with entire populations) and it's not effective at changing individual behavior!

If it were that simple, problems like drug and alcohol addiction; lung cancer from smoking; sexual transmission of HIV; frequent COVID-19 transmission among unmasked, unvaccinated people; and so on would all have been solved long ago.

This.
Medical doctors generally adhere to the practice of treating every patient, regardless of the cause of the disease. And I feel that's a good thing. It feels like the humane thing to do. Offering guidance quit smoking, have a more healthy life-style or offering PrEP to keep people healthy is probably a lot more effective and certainly a lot more friendly than blaming for their so called 'life style choices'.

 

Which brings me back to where I started this response:
I don't necessarily disagree with @raw773's statement about going bare being a choice. I do think it's oversimplifying the seriousness of both a very serious global Pandemic (HIV) and the beautiful complexity and sensuality of (male) human sexuality.

I'm also not comfortable with the word 'lifestyle' in any relation to being gay or how te put that into practice. I've gotten enough of that from the extreme (christian) far-right in my life thank you very much.