Next week, the Pennsylvania state legislature is scheduled to vote on whether to continue funding a program that helps around 6,600 residents make ends meet. The program, called General Assistance, is being targeted by the majority-Republican legislature as part of its bigger plan to dismantle an array of programs that help struggling Pennsylvanians get by. If they succeed, General Assistance will be eliminated effective July 1 of this year.

While it serves a relatively small population, General Assistance is a meager but critical lifeline for its participants. The benefit amount — up to $205 per month for an individual — might not seem like much, but the majority of participants are single adults who cannot work or have no other income whatsoever. Around 90 percent have disabilities. Participants include individuals in substance use disorder treatment, survivors of domestic violence, and adults caring for nonrelative children. And, importantly, beneficiaries are often ineligible for other public benefit programs because they don’t have dependents.

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Many rely on General Assistance to serve as their only income while they await determinations on applications for Social Security disability benefits, which can take months and even years to process. Recipients indicate that they use the funds for essentials including rent, transportation, toiletries, and medical co-pays.

Recognizing the unique importance of General Assistance, Gov. Tom Wolf (D-PA) wants the program to continue to be funded at its current level of about $50 million — less than 2 percent of the state’s budget — in the coming fiscal year. But, predicting that the legislature will kill the program, he is also proposing to reinvest the money into the Pennsylvania Housing Affordability and Rehabilitation Enhancement Fund, or PHARE.

PHARE provides funding to build, rehabilitate, and support affordable housing throughout the state, some of which is allocated for households earning below 50 percent of area median income. Increasing housing affordability for low-income Pennsylvanians is extremely important, but Wolf’s office acknowledges that the two programs simply do not serve the same populations or purposes.

Eliminating General Assistance and reallocating its funds to PHARE will not mean that every current General Assistance participant receives access to affordable housing. A percentage would, but it would likely be a small one, based on the allocation of just $50 million and the fact that not all PHARE housing is for the lowest-income renters. Meanwhile, many of the General Assistance participants who don’t get housing would be left with no income.

Pitting these two essential programs against each other presents a false choice between basic necessities and housing development and affordability. Instead of robbing Peter to pay Paul, both programs should be adequately funded to help people meet housing and other basic needs.

Alas, there is good reason to expect the legislature will get its way. Six years ago, the Republican-controlled state legislature acted to eliminate General Assistance, but the Pennsylvania Supreme Court reinstated the program on a technicality, after finding that the legislature hadn’t followed certain required procedures. This time around, the legislature has learned from its mistake and knows exactly how to legally eliminate the program.

The Wolf administration still has time to push back. And for the well-being of the lowest-income Pennsylvanians, it should take up the fight.

“She was a single mom with a six-year-old son,” Rushka says, adding, “she was just coming out of an abusive relationship.” So Rushka decided to see if she could organize some of the folks who had offered to help her into helping this woman instead. She ended up with a minivan full of donations — some used, some new — of everything from clothes for mom to toys for her son. Rushka describes the people who met her as coming from a range of social classes, but notes that many were middle class or lower middle class. A lot of them, she says, commented that they were helping because they too had struggled. “The woman was crying when I met her,” Rushka recalls. “I told her honestly, I’m an addict in recovery and a lot of people have helped me out.”

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This kind of story doesn’t end up in the news as often as descriptions of dramatic convenience store robberies or violence-plagued low-income neighborhoods — but it’s a known, common thread within these communities. Poor people hold one another up. For decades, if not forever, poor communities have not been able to count on the government for support. SNAP (formerly known as “food stamps”) only provides about $1.40 per person per meal, and in the poorest states in the country, less than 4 percent of poor families receive TANF (Temporary Assistance for Needy Families, often referred to as “welfare”). Perhaps this lack of sufficient government assistance is why a 2010 study by researchers at University of California, Berkeley and University of Toronto discovered that lower-income people are more inclined toward thinking on a community level than people from other classes.

In the study, participants were told to gather as many points as possible. They were given an initial number of points and the option to keep the points for themselves or to give a portion of their points to an unseen partner. Anything they gave to their partner would be tripled, and then their partner would have the option to share a portion of their new, higher total of points with the study participant. Of course, there was no actual partner; the experiment was a measure of prosocial trust. Would participants trust their partner enough to share a sizable portion of their own points so they could both leave with a bigger total payout, or would they keep their points to themselves?

The results showed lower-class participants gave up more of their points in hopes that their partners would share a larger amount of their total, supporting an overall hypothesis that the increased generosity seen in low-income people results from intra-communal reliance. The lower-income participants needed a larger payout than they could get on their own, so they had to trust their partner to support them. As a result, need spurred generosity.

The tendency of low-income people to help others in need is something you can observe in the real world all the time, if you know where to look. You see it in the form of family hand-me-downs, diapers donated to a neighbor in need, or rideshares to the grocery store. Right now in Boston, the National Council for Incarcerated and Formerly Incarcerated Women and Girls is working to formalize this phenomenon by creating supportive microcommunities within vulnerable neighborhoods. “Our organizing motto is ‘block by block,'” says Executive Director Andrea James. She describes a system in which women reach out to neighbors to find out what they need in order to thrive, whether that’s a food pantry, a bail fund, a community garden, or a ride to the polls. It is a grassroots pushback against the government failure to provide, or at least provide enough, for its most vulnerable citizens. Led by women with criminal backgrounds — the exact kind of people often labeled “underprivileged” — this grassroots welfare project exemplifies that same generosity and trust observed by the researchers at Berkeley in 2010, and by Rushka last Christmas.

These community-focused habits are spreading outside of low-income communities, with mixed results. One of the better-known examples, The Buy Nothing Group, was specifically modeled after a poor community that the founders witnessed while working a relief mission in Nepal. In theory, the tenets of the Buy Nothing Project are simple: nothing is sold or traded. Each item is given freely, with no expectation of reward. Participation spans class, and at times, can work beautifully. I personally owe a lot to my local Buy Nothing Group: Members helped furnish my home, helped me with diapers for my daughters, and even provided food grown in backyard gardens.

It was a beautiful experience — but it was different from the giving and receiving that takes place within the confines of low-income communities. When people gave or received items in my Buy Nothing community, it was not often driven by need. Items are supposed to go to whomever the giver wishes, using whatever criteria she decides. Some people went so far as to state that they would not give to anyone who openly expressed needing something; they found that discussing need was distasteful.

That’s where the appropriation of low-income community tools became problematic.

Some people do need more than others. Pretending otherwise introduces an element of shame that doesn’t exist within low-income giving circles, in which everyone understands what they are providing and why. What’s worse, it introduces the idea that need is a weakness, rather than a normal and reciprocal part of human existence. The expectation that people can take when they need and give when they have plenty is essential to how societies work. If it’s been a long time since you needed something, it’s easy to forget that. But that’s not a luxury that most low-income people have.

Generosity is a beautiful human trait. It’s also a survival tactic. If economically stable communities are going to start implementing the survival tactics of the poor for other reasons — whether it’s to pass the time, meet their neighbors, or just get rid of stuff — they need to recognize that there are still people who rely on community resourcing. And they need to acknowledge that these neighborhood-sharing programs have their roots in low-income communities, whose members have been helping each other stay afloat long before it was trendy.

The HHS proposal would reinterpret Title IX, which bars “sex”-based discrimination in federally-funded education and is applied to a wide range of civil rights issues from campus sexual assault to affirming the rights of trans students. HHS intends to push other government agencies to adopt the same narrow and biologically inaccurate view of gender, according to the Times. The agency’s view is also not shared by the courts, which have ruled repeatedly that “sex” includes gender identity under Title IX and Title VII.

The news about HHS came just days before a report that the Department of Justice believes employers can discriminate against employees on the basis of gender identity or sexual orientation. Meanwhile, agencies such as the Department of Education and the Department of Justice have chosen to withdraw anti-discrimination guidance that protected transg people, while HHS quietly removed trans discrimination guidance from its website about health care discrimination. Massachusetts voters will decide on Election Day whether they wish to uphold a law banning gender discrimination in public accommodations.

This is an all-out assault on the transgender community in the United States, and it has sinister implications for other vulnerable groups as well. It will hit low-income trans people especially hard, amplifying already existing economic inequalities.

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“People with low or no income already struggle to acquire adequate representation to challenge their rights in court,” Harper Jean Tobin, director of policy at the National Center for Transgender Equality, said via email. “They could potentially be impacted by just the misinformation spread by this proposal. The proposal doesn’t actually rewrite laws, but it could embolden many employers or doctors or schools to disregard the rights of trans people. Those with resources enough to speak to a lawyer are more likely to know when their rights are being violated, while those who cannot might find themselves without much recourse.”

According to a 2015 report from the Movement Advancement Project and the Center for American Progress, trans people face a “financial penalty,” paying more to access health care and other services, from credit to fair housing, than their cis counterparts. They are more likely to live in poverty, with 15 percent of trans people making less than $10,000 annually in contrast with 4 percent of cis people. These numbers are even more stark for black (34 percent versus 9 percent) and Latinx (28 percent versus 5 percent) trans people.

The community overall experiences an unemployment rate double that of cis people. LGBQT people also rely more on threatened benefits programs such as the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families.

This state of economic precarity has a concrete impact on trans lives. For instance, the National Center for Transgender Equality has found that just 21 percent of trans people have changed over all their identification documents, due to high costs and regressive policies such as refusals to allow trans people to update identification or birth certificates without proof of surgery in some states. The lack of consistent and accurate identification can fuel discrimination, such as refusals to hire people when their identification outs them as transgender, or denial of benefits, with 16 percent of U.S. Transgender Survey respondents reporting benefits issues related to mismatching identification.

Financial instability also amplifies widespread housing, employment, education, and health care discrimination against trans people. 23 percent of trans people faced “some form of housing discrimination” in the previous year, according to the U.S. Trans Survey, while 67 percent reported being passed over for hiring, fired, or denied promotions because of their gender identity. One in four experienced problems with their health insurance. Low-income people may not be able to “go somewhere else” to access services, cannot afford alternative housing, and cannot fund litigation in cases of discrimination.

In a landscape without comprehensive and explicit civil rights protections, and with federal agencies not only refusing to enforce existing protections but actively promoting discrimination against the trans community, low-income trans people’s financial disadvantage will become much more glaring. The administration is already not enforcing Affordable Care Act protections barring discrimination on the basis of gender identity, making it challenging to access not only transition services but permitting other forms of health care discrimination; this kind of policy could make this problem even worse. Similarly, barriers to accessing identification could leave more trans people struggling to access benefits they need to thrive, such as subsidized housing, SNAP, and Medicaid.

Just as a flood of bathroom bills in 2015 and 2016 emboldened transphobic people and policymakers, moves like this fuel hatred and contribute to the distribution of misinformation about what it means to be transgender and how trans people interact with society. Legitimizing transphobia on the institutional level encourages harassment and abuse of trans people, which harms vulnerable trans populations such as sex workers, women of color, immigrants, disabled people, youth, and low-income people.

Targeting the trans community could also lay the groundwork for disrupting other civil rights, with the federal government’s pursuit of a “right to discriminate” becoming a blueprint for attacking groups such as those who are homeless on the streets of San Francisco, Native American and fighting for the right to vote in Utah, or lesbians who want to adopt a child.

By the time I learned I was pregnant, I knew abstinence didn’t work. I also knew I had to do something if I wanted to have a healthy baby. So, I enrolled in methadone maintenance treatment. My doctor insisted on it—he told me it would keep my body from going through withdrawal, which could have caused a miscarriage. But I almost couldn’t afford it. I was in Colorado, one of 17 states that did not cover methadone through Medicaid or state funds. Luckily, I was able to get my treatment paid for through grant money specifically designated for pregnant methadone patients.

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Because of that grant, I never had to worry about the cost of my treatment. I was able to stand to the side and watch while other patients came into the clinic, begging for an extra couple days to come up with their fee, only to receive the same response from the receptionist: “You could get together money for your drugs, why are you having a problem getting money for treatment?”

I lost count of how many times I heard her say that.

Approximately 2 million people in the United States are addicted to pharmaceutical opiates, and half a million to heroin. The latest report from the Centers for Disease Control and Prevention estimates more than 60,000 overdose deaths in the United States last year. Opioids are now more fatal than car crashes and gun violence. And those numbers don’t include the many people who survive but live with complications such as brain damage for the rest of their lives.

Despite the broad scope of the crisis, data compiled by Rockefeller University’s Addictive Diseases lab show that there are only about 350,000 Americans in methadone treatment, a long-acting opioid agonist An agonist is a chemical that binds to receptors and causes a biological response (in the case of opioids, that response is pain relief). Methadone is an opioid agonist that causes a similar biological reaction to opioids without the euphoric high, preventing the severe physical symptoms of withdrawal. that has historically been the gold standard of care for opioid addiction. Only about 75,000 are in buprenorphine treatment, a newer alternative that is similar to methadone in function and purpose.

There are some basic reasons that so few people receive treatment: More than 30 million people live in counties without a licensed provider of buprenorphine, and the daily process of receiving methadone maintenance treatment at a specialized clinic is incredibly time consuming.

And it’s expensive.

In addition to the limits on Medicaid funding, opioid treatment providers can decide whether or not to accept private insurance. Many decide against it, or contract with just one or two providers, because methadone treatment is difficult to translate into insurance billing terms. Every state provides coverage for buprenorphine/naloxone (naloxone is an additive that prevents abuse of the drug), but patients often have to find cash for treatment regardless of whether the medication itself is covered.

The National Institute on Drug Abuse estimates that the per-patient cost of methadone for providers is $4,700 yearly, but for-profit opioid treatment programs get to decide what they charge their patients. This means the actual cost to patients varies by clinic. Methadone patients I interviewed reported rates that ranged from $350 per month to $200 per week. Buprenorphine patients reported clinic costs between $100 and $300 per month, with medication costs broaching the thousands for those without insurance.

Zac Talbott owns two opioid treatment programs—one in Georgia and one in North Carolina—and is also a methadone patient (through a different provider). He explains to me over the phone that just because Medicaid covers methadone in a certain state, that does not mean the clinics actually accept it. Take Georgia, for example: Although Medicaid has covered methadone for several years, programs that were not directly affiliated with behavioral health entities could not bill Medicaid prior to 2016. Only two clinics met that standard, out of 62 in the state. The rules recently changed, and Talbott’s Georgia clinic, Counseling Solutions Treatment Centers, is now six months into the process of setting up Medicaid billing. He’s unsure how many other area clinics will actually take on the new insurance option.

“[Opioid treatment programs] don’t speak in insurance terms the way the rest of health care does. Insurance bills based on codes. There’s no code for a daily bundled rate,” he explains, referring to the daily or weekly flat-rate most clinics charge their patients.

“For a lot of the bigger corporate entities, it’s easier and more profitable to just take that cash, baby,” Talbott adds, punctuating his point with a morose chuckle.

Patients who struggle to find the money for treatment may live with the threat of an administrative detox hanging over their heads. This is a common technique practiced by many methadone clinics, in which a patient who is no longer able to pay is placed on a rapidly tapering dose to wean him off the medication. The length of these tapers varies by clinic, but they often mean going down by 10mg a day, usually with one- or two-month limits. That’s a far cry from the slow, medically supervised taper recommended for patients choosing to withdraw from treatment.

Medication-assisted treatment is designed for long-term use—sometimes even lifelong. Mary Jeanne Kreek, who was part of the team that developed methadone treatment, explains that methadone and buprenorphine help correct brain changes that may require years of maintenance.

“It’s just like treating depressive disorders. Most people on chronic antidepressants need those for a long time or life,” says Kreek.  “I think they’re very analogous.”

But even these administrative detoxes are less harsh than what patients face at clinics that simply cut them off. Because methadone is designed to remain stable in the body for long periods of time, withdrawal from a therapeutic dose may take up to a week to begin. Once it does, however, it is nearly unbearable. It’s not necessarily the sweats and cold chills, aching bones, diarrhea, racing heart, nausea, and restless legs that make it so difficult. It’s the fact that your brain thinks it’s dying without the drug. That is part of the reason relapse rates after opioid detoxification are so high—some estimates say 88 percent within three years, and up to 70 percent within six months.

Liz Hock Clark, a 59-year-old woman who has been on methadone for 34 years, says her clinic is one of many that simply ceases to dose patients who come in without payment in hand. She isn’t sure if it’s legal, but she’s seen it done, and she’s terrified it will happen to her.

Clark lives in a small apartment in West Virginia. She doesn’t have much furniture, and there’s no internet connection. If she needs to go online, she hops into her beat up 2000 Chevrolet Cavalier and drives to her cousin’s house. She picks up odd jobs, like house cleaning and dog walking, in order to pay for her medication. She does janitorial maintenance for her building in exchange for rent on the apartment. It’s tough on her body, but it allows her to put every penny she makes into methadone. Her clinic charges $15.50 a day. She says when she started methadone 34 years ago in Texas, it was $2 a day. She is terrified of the day when she doesn’t have the money for her clinic, which she fears will be soon.

“I’m not afraid of relapse,” she explains in her soft Southern drawl. “I’m afraid of dying. For someone my age, going cold turkey off 118 milligrams, I don’t know if I’d survive.”

Death from opioid withdrawal is rare, but because of her age, complications like cardiac arrest from a harsh detox are a credible fear.

“The thing is,” she adds wistfully, “I don’t want to get off methadone. I want to stay on it my whole life.”

How do we help patients like Clark access these essential medications without becoming enslaved by the exploitative tactics of some providers? For starters, the burden of methadone and buprenorphine regulations needs to fall on providers rather than patients. And we need to have a lot more payment options for low-income people, who are already more vulnerable to addiction in the first place.

The preliminary report offered by the White House opioid commission asks for expansion of access to medication-assisted treatment. It does not, however, express the need for a mandate on clinics to accept Medicaid, or for any kind of internal restructuring that will make accepting Medicaid and other forms of insurance more attractive to clinics. Trump’s attitude during his recent public health emergency declaration does not leave much hope that the commission’s advice will be followed—his $57,000 allocation will not come close to covering the cost gap. We’ll need to do a lot more if we are going to serve Clark and other patients like her—or like me—before it’s too late.