Paul Ryan kept his promise: House Republicans overwhelmingly voted to gut the Affordable Care Act and replace it with a dangerous, inhumane healthcare plan that could leave millions of Americans uninsured. Among those who stand to lose their insurance if the American Health Care Act, aka Trumpcare, is signed into law are people with pre-existing conditions—a catchall term that includes cancer survivors, women who have given birth and now, victims of rape.

This isn’t an exaggeration. Insurers are looking out for their bottom line and will take any opportunity to charge people more money for medical care. In the pre-Obamacare years, pre-existing condition was such a broad term it included those who sought treatment for sexual violence.

Chris Turner, a health insurance agent from Florida, was raped while she was on a business trip in 2002. She was later denied insurance because her doctor had prescribed her anti-HIV medication to prevent her from becoming HIV-positive, yet another pre-existing condition. Turner presented her story hypothetically to several insurers, most of which told her an applicant who had previously been prescribed anti-HIV medication after being raped would have to wait years to receive coverage.

If you’ve been raped and you know reporting it could cost you your insurance down the line, would you report it?

Under the AHCA, sexual assault survivors like Turner could once again be denied coverage for reporting their rapes and receiving appropriate treatment. This raises an important question: If you’ve been raped and you know reporting it could cost you your insurance down the line, would you report it?

“There are many, many barriers to not reporting rape,” Rachel Easter, an attorney with the National Women’s Law Center tells me. “Women don’t report rapes for a huge variety of horrific reasons. The fact that they could later lose insurance coverage as a result of coming forward could be a reason.”

And if a woman—or anyone else—without insurance does report their rape, receiving treatment could cost them a fortune. In 2012, an anonymous woman posted the bill she received after being given a rape kit in a “major city in the U.S.” The total cost? Just over $4,500.

Rape survivors aren’t the only ones targeted by this bill: victims of domestic violence, people with mental illnesses and people who experience gender dysphoria are also targets, since all of these things can be warped to fit into the “pre-existing condition” category. So are women who give birth or have heavy periods and any woman who uses Planned Parenthood for preventative services.

I hate to give Paul Ryan credit of any kind, but his Republican cronies weren’t explicitly trying to fuck women over with this bill—the AHCA is primarily an assault on the poor—but its harmful effects on women are surely an added bonus for a party whose members have a history of making rape jokes and saying that if abortion is legal, men should be able to rape women. This bill wasn’t intended solely to punish women, but it seems like the logical course of action for a government that preaches individual liberty while blaming women for being abused. What else should we expect from a country that is being led by a man who has been accused of sexual assault by multiple women—and who defends himself against these allegations by saying his accusers aren’t attractive enough to get raped in the first place?

The AHCA bill didn’t get enough votes the first time around because apparently, that version simply wasn’t cruel enough. The ultra-conservative and ultra-white House Freedom Caucus refused to support the first iteration of the bill because, among other things, it required insurers to cover maternity leave, mental health services and to provide coverage for “high risk” patients with pre-existing conditions. Late last month, New Jersey congressman Tim MacArthur introduced an amendment giving states the right to discriminate based on patients’ medical history. In other words, insurers can deny coverage—or charge more—to anyone with a litany of pre-existing conditions.

Republicans are institutionalizing their ideology in a system that literally determines life or death.

Republicans are framing this as a way of leaving the decision of who does or does not deserve insurance up to the states, just like they’ve done with reproductive rights. If Zombie Trumpcare is signed into law, which states will let insurers deny coverage to a huge swath of their populations? Probably the same conservative states that are shuttering their last abortion clinics and forcing women to undergo ultrasounds, mandatory waiting periods and “crisis counseling” before they can abort their pregnancies.

One in six women has been a victim of attempted or completed rape, according to statistics from the Rape Abuse and Incest National Network. Trans women are at an even higher risk than the national average: RAINN estimates that 18 percent of trans women have been sexually assaulted. And although rape and sexual assault primarily affect women, men are victims as well; 10 percent of all rape victims are male.

“This bill and other things this administration and Congress have done are a full-on assault on women’s access to healthcare,” Easter says. “It’s broader than that: they want to punish anyone who does not fit into their narrow worldview of what is acceptable, and that has to do with your gender identity, your sexual orientation, when you can have sex or have birth control.”

Before Trump was elected, it seemed as if the conservative war on sex was over. The United States Supreme Court had legalized gay marriage nationwide and battles to defund Planned Parenthood and reverse Roe v. Wade burned out as quickly as Ted Cruz’s presidential campaign. But even though moderate Republicans are more likely to be pro-choice and stay out of our bedrooms, a president who so casually dismisses the existence of sexual assault has given enough conservative dinosaurs the fuel to reignite their decades-old war on sex—and on women.

While we’ve won these battles before, Republicans are now institutionalizing their ideology in a system that literally determines life or death. Such severe grandstanding for the sake of one’s own pride hasn’t occurred since, well, Trump’s last rally. One can only imagine that if this bill passes, provisions to increase insurance for patients who’ve contracted a curable STD could too be introduced in an effort to punish non-monogamous lifestyles. Transgender people won’t be able to afford sex-reassignment surgery, and gay men might have to forego PrEP prescriptions to avoid higher premiums. Rape victims who don’t want to lose coverage will be effectively silenced.

Lest women stop getting raped or bearing children, an untold number of Americans will stand to suffer if the AHCA passes, in addition to those low-income and minority people who will already suffer from Medicaid cuts. We don’t know how many, though, since House Republicans voted for the bill without letting the Congressional Budget Office analyze it. Most House Republicans who voted yay didn’t even bother reading the bill, but honestly, who cares? Congress, their staff and their families are exempt from losing their insurance, and that’s all House Republicans needed to know in order to vote to slowly kill the poor, the infirm,\ and the people who suffer most in Trump’s America. Meanwhile, the president plans his next rally.