At first glance, HIV advocates were profoundly troubled by the provisions of the American Health Care Act (AHCA) and its implications for people living with chronic conditions like HIV. AIDS United firmly opposes the bill, calling it “a hack job ” that places tax cuts for the wealthy above the health needs of everyone else. And that it “directly undermine[s] the goals of providing treatment and care for people living with HIV as well as the goal of ending the epidemic.”

As more analysis has been done on the impact of American Health Care Act, our initial misgivings about this legislation are continually exceeded by the empirically grounded projections of the damage it would inflict on the American people. We knew it would be bad, but were still surprised at how bad it wound up being.

We were shocked when the Congressional Budget Office projected that 24 million people would lose their insurance coverage in 10 years under this legislation. The legislation would gut the Medicaid program by implementing per capita spending caps that would reduce federal contributions to the program by an estimated $880 billion over 10 years. This would force state Medicaid programs to make very tough decisions on what services and populations to cover, a move that would be devastating to people living with HIV and other chronic conditions. This is absolutely unacceptable, and we must ensure that these drastic proposed changes to the Medicaid funding are never implemented.

It was widely expected that any plan to replace the Affordable Care Act (ACA, or Obamacare) coming out of the House would reduce the quality and accessibility of mental health and substance use disorder care, but that expectation did not blunt our disappointment upon learning that the GOP’s American Health Care Act would roll back Medicaid expansion and remove the requirement that Medicaid expansion plans cover mental health and substance use disorder treatment for nearly 1.3 million people.

However, while the repulsive nature of the American Health Care Act has been eye-opening, so has the strident opposition to the bill. It is not terribly surprising to see Democratic members of Congress coming out and railing against a Republican health care bill, but it’s remarkable that both Republican moderates and conservatives have been uniting in opposition to the American Health Care Act, albeit for markedly different reasons.

Last week, three Republicans on the House Budget Committee—Reps. Dave Brat (R-VA), Gary Palmer (R-AL) and Mark Sanford (R-SC)—voted with Democrats in an unsuccessful bid to prevent the American Health Care Act from moving to the House floor. The trio of dissenting Republicans are all members of the House Freedom Caucus and, amazingly enough, were voting against their own party’s bill because they thought it too generous in its dispensation of tax credits. Like many in the more conservative wing of the Republican Party, they view the American Health Care Act as “Obamacare Lite” and won’t support it until the tax credits included in the plan are removed and the implementation of Medicaid expansion repeal is moved up.

On the other side of the Republican spectrum, moderate GOP Senator Susan Collins (R-ME) declared that she would vote against the American Health Care Act in its current form, saying that “this bill doesn’t come close to achieving the goal of allowing low-income seniors to purchase health insurance.” Collins, who co-sponsored her own partial ACA replacement legislation with Senator Bill Cassidy (R-LA) that would have allowed individual states to continue operating under the ACA if they chose, is representative of a group of Republican Senators like Lisa Murkowski (R-AK), Rob Portman (R-OH), and Shelley Moore Capito (R-WV) whose moderate ideological leanings or reliance upon Medicaid expansion have made them hard sells for the American Health Care Act.

Essentially, Speaker of the House Paul Ryan (R-WI) and, to a lesser extent, President Trump are stuck between the devil and the deep blue sea when it comes to health care reform. They can’t move the American Health Care Act through the House without appeasing the Freedom Caucus and conservative hardliners who are clamoring for a clean repeal, and they can’t get the American Health Care Act through the Senate without winning over moderates like Senators Collins, Capito, and Murkowski who are all very protective of Medicaid expansion and don’t want to alienate low income and older voters who would be devastated by the bill.

Now, more than ever, HIV advocates should speak up and make their voices heard in the halls of Congress. Support for the American Health Care Act has yet to gain momentum, and members of Congress from both parties should be made aware how wildly unpopular it is among their constituents. Go to AIDS United’s Policy Action Center to take action and let your representatives in Washington know that any health care reform that provides tax cuts to the rich at the expense of the old, the infirm and the poor is unacceptable.