I’m Gay and I Want Medicare for All

I support Medicare for All because it’s for everyone — but it’s especially important for gay and transgender people. It should be a central demand of the movement for our liberation.

ACT-UP New York protesting the pharmaceutical company Gilead for its price gouging of HIV-prevention drug PrEP. ACT-UP NY / Twitter

I’m gay and I want Medicare for All.

The main reason I want Medicare for All is that, like all people, I have a body that requires maintenance. The vast majority of the reasons I go to the doctor have nothing to do with being gay. Sometimes I have a bad cough or want my teeth cleaned. One time I needed an ambulance, and while it’s true that on that occasion I was coming home from a gay DJ night, what happened wasn’t gay-specific: I swerved to avoid an opening car door and was thrown from my bike, which could happen to anyone.

I had health insurance then, but the ordeal still cost me several hundred bucks. These kinds of costs are why people in the United States are afraid to call ambulances or hesitant to seek the routine health care we need.

Medicare for All would replace private insurance companies with a single, universal health insurance program, publicly administered and paid for by progressive taxes. It would eliminate copays, premiums, and deductibles, making all health care free at the point of service. It would cover everyone, and everything that requires a medical professional, including prescriptions, dental, vision, and mental health care. Unlike the market-based solutions pushed by liberals, it would actually make the dream of “universal health care access” a reality.

Most of the health care gay and transgender people seek is connected to the fact that we have bones, blood, and organs, just like everyone else. But there are some specific health-related issues that disproportionately impact us. Medicare for All would make addressing those issues far easier for individuals and whole communities. It’s a universal demand, not targeted at any particular group, but it’s also a demand that could be liberating and life-changing for millions of queer people. It should therefore be a leading demand of the contemporary gay and transgender political movements.

Take access to HIV prevention medication. Since 1980, hundreds of thousands of gay men in the United States have died from AIDS, and even today male-to-male sexual contact accounts for 68 percent of new HIV infections. Meanwhile, an estimated 14 percent of transgender women are HIV positive. For politically conscious gay and transgender people, ending the AIDS epidemic is a defining struggle of our time.

After decades of devastation, we are now incredibly lucky to live in a world with PrEP, or Pre-Exposure Prophylaxis medication, which goes by the brand name Truvada. By blocking an enzyme that the HIV virus needs to reproduce, Truvada is at least 99 percent effective in preventing infection — a true medical miracle.

But the list price for Truvada is nearly $2,000 a month, and the pharmaceutical company Gilead keeps raising the price. The drug was developed with public grant money, but because of the cost it remains inaccessible to many members of the same public that funded its existence. Gilead made $3 billion in profit in 2018 alone.

For people who don’t have insurance, their options are to either pay for Truvada out of pocket or forgo it entirely. Paying upfront for a drug that expensive is unfeasible for just about everybody. Since uninsured people are usually poorer, the poorest members of groups at risk for HIV transmission are the ones least likely to access the miracle drug that could prevent it.

For those who do have insurance, it usually doesn’t cover the entire cost of the drug. The higher prices soar, the more insurers — which, like Gilead, are private corporations that exist to turn a profit — are incentivized to shift the cost burden onto patients, causing out-of-pocket expenses to skyrocket. Gilead offers copay coupons to help with access, but profit-driven insurers increasingly refuse to honor them.

The spillover costs lead even people who are insured to pass on PrEP simply because they can’t afford it. There are publicly funded programs that try to fill in the cost gap for prospective PrEP-takers, but as the prices skyrocket, those programs find they don’t have the resources to keep up.

We could put an end to all of this through Medicare for All. Public health insurance would cover everyone — no more uninsurance whatsoever — and would cover all prescriptions, including PrEP. Done, solved.

As for the list price, Medicare for All would allow the government, as the powerful single payer for all prescriptions, to negotiate pharmaceutical prices down. (In France, which has a single-payer system, PrEP is off-patent and the monthly cost is only 176 euros; patients themselves pay nothing.) Everyone in the United States would get access to this potentially life-saving drug, and Gilead would no longer be allowed to make obscene amounts of money off people’s desperation here, selling a drug that the public paid to develop.

Another area where Medicare for All would be a game-changer is in hormone replacement therapy and gender reassignment surgery for transgender people. Without coverage, transition-related health services can cost over $100,000 in some cases, making it completely prohibitive to the vast majority of the uninsured population. Due in large part to discrimination in employment, transgender people are more likely to be uninsured than the general populace.

Some private insurers cover transition services, but most don’t, and in any case most people have little choice about the insurance company that covers them; that’s usually decided by employers. The Affordable Care Act tried to do away with gender identity discrimination in private insurance, but insurers — motivated by profit, not public wellbeing — have been busy finding ways around the provisions. “Insurance companies are making up their own rules as they go along,” says Anand Kalra of the Transgender Law Center.

You know what insurance program does cover transition services? Medicare. If we build a movement that can fight to make sure there are no concessions, Medicare for All would generalize this coverage to every member of the populace, not just senior citizens. If we truly want transgender people to be able to take advantage of our society’s stunning medical advances to lead happier and freer lives, we should demand Medicare for All.

Finally there’s the issue of mental health. This one impacts the largest swath of the queer populace. Gay and transgender people are twice as likely to struggle with substance abuse. Gay and lesbian people report considering suicide at twice the rate of heterosexual cisgender people; for transgender people, the incidence is over ten times as high  41 percent of transgender adults say they have attempted suicide.

When it comes to accepting homosexuality and transgender identity, we’ve come a long way in a short amount of time. But queer people still experience prejudice and discrimination, which can take a major toll on mental health. Because many of the same conditions responsible for deteriorating mental health — family rejection, community ostracization, substance abuse, unemployment, homelessness — are intimately bound to poverty and inability to afford care, the gay and transgender people who need mental health care the most are the least likely to have access to it.

The single person most responsible for advancing the demand for Medicare for All is Bernie Sanders, and he has been adamant for years that mental health services should be fully covered by a Medicare for All program. In the United States we not only have a high rate of uninsurance, but we also have gaps in mental health care coverage for insured people, as well as an overall shortage of mental health providers. Medicare for All is the best means available to address all of these problems on a large scale.

Medicare for All would be revolutionary for the millions of Americans who struggle with mental wellbeing. A disproportionate share of that benefit would fall to gay and transgender people — from youth who are grappling with their identities or are being harrassed by peers; to adults who are discriminated against on the job market, struggle with substance abuse, or have lost touch with their families of origin.

Medicare for All is for everyone. As the longtime single-payer crusader Quentin Young used to say, its guiding principle is “Everybody in, nobody out.” The beauty of the program lies in its universality: because the need for health care is a point of unity, the demand can bring people together across lines of difference in a coalition large and powerful enough to override the will of the profit-motivated insurance and pharmaceutical companies.

When we have Medicare for All, everyone — gay and straight, cisgender and transgender — will be able to get the drugs and services they need to flourish and lead better lives. If we change the rules overnight, whoever is most boxed out by the current system will find their circumstances most dramatically changed. That includes many gay and transgender people, particularly the poorest among us, making Medicare for All a necessary demand of queer politics in the twenty-first century.