The federal-state Medicaid program has been the bedrock of HIV/AIDS treatment and care since the beginning of the epidemic -- and like so many other effective, successful and humane government initiatives, President Trump and the GOP-controlled Congress want to destroy it.
The mechanism of destruction is "Medicaid block grants," which presidential adviser Kellyanne Conway said this week would be a key component of Trump's plan to replace the Affordable Care Act (ACA).
The rhetoric surrounding block grants sounds eminently reasonable. "[T]hose who are closest to the people in need are really administering it," Conway told NBC Sunday Today. "You really cut out the fraud, waste and abuse, and you get help directly to them."
What Conway didn't say is that block grants would eliminate the legal entitlement to medically necessary benefits and services that is the heart of Medicaid -- and of HIV/AIDS and disability care in America.
"Entitlement" is another word that's developed disturbing connotations for the public due to targeted, repeated attacks by conservative politicians and talking heads.
They suggest it's an unearned benefit enjoyed by undeserving people -- but the fact is that an entitlement is a legal right.
If you need a medication, treatment or service under Medicaid, you've got a legal right to get it. And, under the current program, the federal government pays at least 50% and up to 90% of the cost of needed care.
Of course, people living with HIV/AIDS had to fight to make this legal right a reality -- and it hasn't been easy.
But the demonstrations, lawsuits, lobbying campaigns and community mobilization that are the hallmark of the movement successfully fought state by state across the country to ensure that millions of Americans living with HIV/AIDS got essential care, lifesaving treatments when they became available, and the housing and supportive services necessary to live and thrive.
The legal right to care under Medicaid has often been the foundation of this fight for survival.
For homeless and low-income people living with HIV, for all people disabled by AIDS-related illnesses and comorbid conditions and particularly for people of color, the Medicaid entitlement has been the difference between life and death.
The expansion of Medicaid under the ACA was hampered by a deadly Supreme Court ruling that has allowed cruel governors and state legislatures to inflict suffering and death on low-income people living with HIV by refusing to increase access to care in some states. Nonetheless, the ACA has extended access to lifesaving HIV care in 32 states and the District of Columbia.
All of this goes away under block grants. The federal legal right to care disappears.
Without a legal right to care, state or local-level Medicaid administrators can ration services, impose new cutoffs on eligibility and create new hurdles or roadblocks to services.
And, without a continuing cost-sharing component, states won't be able to afford increasing expenses due to new medications, rapidly aging populations, new epidemics or other challenges. Moreover, many GOP block grant proposals actually cut Medicaid funding.
If Medicaid is cut and block-granted and the ACA is repealed, state budgets will explode with billion-dollar shortfalls.
At the same time, federal funding for public schools, housing and environmental programs will be slashed, opening new billion-dollar gaps.
State funding for AIDS care will compete with nursing homes for seniors, home care and independent living services for people with disabilities, and public school and university funding in an atmosphere one state capital lobbyist recently compared to that in Lord of the Flies.
In this atmosphere, many cynical and ruthless politicians will seek to divide and conquer, creating categories of "deserving" and "undeserving" people that will further demonize and marginalize people of color, trans people, drug users and LGBTQ folks -- as they've always done.
And, they'll be free to rob chunks of federal funding to replace existing state health care spending, then swap out that money for corporate subsidies and sports stadiums, just like they did in 1997 after Bill Clinton and the GOP Congress block-granted the federal welfare program for impoverished families with children.
It's a nightmare scenario -- but it's real.
It will only take 51 votes in the U.S. Senate to block grant Medicaid and move Americans living with HIV/AIDS into Lord of the Flies territory.
We've got to fight back in Congress -- and we've got to get ready to fight state by state if we lose.
Perhaps the only good news is that we're not alone: Millions of Americans from all backgrounds need lifesaving care funded by Medicaid.
Seniors in Nevada and Arizona, drug users in Indiana and coal miners in West Virginia all depend on a solid and well-funded Medicaid program for survival.
In the coming Medicaid Hunger Games, they should be our allies, not our opponents.
AIDS activists and advocates can and will build powerful cross-constituency alliances to build power quickly -- and there's not a moment to lose. Moreover, we will teach the direct action skills that built our movement and saved millions to a new set of health care warriors who will fight in Washington and in state capitals around the country for our lives and our democracy.
Michael Kink is executive director of the Strong Economy for All Coalition and served as senior staff attorney and legislative counsel for Housing Works from 1994 to 2008.