A recently proposed amendment to the Republican health-care bill that passed in the U.S. House of Representatives yesterday effectively allows health insurance providers to raise premiums on the basis of pre-existing conditions. Among the many people affected by this amendment, sexual assault survivors would be disproportionately harmed, as they often need both acute and preventive medical care in the aftermath of their trauma.

The bill—the second recent attempt by House Republicans to “repeal and replace” Obamacare, also known as the Affordable Care Act (ACA)—includes an amendment proposed by Reps. Tom MacArthur (R-NJ) and Mark Meadows (R-NC) allowing states to waive the nationwide ban the ACA created preventing insurance companies from charging people with pre-existing conditions more for their coverage. This could mean that if a survivor of sexual assault undergoes certain medical treatments, they could later be charged a higher premium because those treatments would alter their “health status.” For many people, a higher premium would mean going without insurance coverage they can no longer afford.

Further, the bill would allow states to waive coverage of preventive health services, such as antibiotics, gynecological screenings, counseling, substance use disorder assistance, and mammograms. These “essential health benefits” (as the ACA calls them) are crucial to many, including survivors of sexual violence, who may need services related to sexually transmitted infections, mental health, or pregnancy in the wake of their sexual trauma.

Gina Scaramella, executive director of the Boston Area Rape Crisis Center, is one of the many concerned advocates speaking out against the bill. She points out in an interview with Rewire, “Years of evidence have shown us the kinds of health and mental health impacts sexual assault can have.” These effects can include physical trauma, gynecological injuries, and long-standing psychiatric disorders. In her work, she has seen that “people [who have experienced sexual violence] do really well when they have the services that they need, both preventative and intervention. They do well when they can access the services they need, when they need them.”

The list of pre-existing conditions may vary from one state to the next, but a forensic medical exam (sometimes referred to as a rape kit), HIV medication, pregnancy prophylaxis, and therapy are all courses of treatment that Scaramella says could raise a red flag for health insurance companies under the proposed law.

Taking control of decisions about whether to waive preventive services and the protection for pre-existing conditions from a federal mandate and granting it to the states is particularly concerning for advocates, especially given the myths and stigma surrounding sexual violence. “It would be concerning in states that tend to, for example, reduce access to reproductive health, to think that those same states could determine access for rape survivors,” said Scaramella.

One example demonstrating that stigma is a recent interview with Rep. Mo Brooks (R-AL), who voted for the bill. The representative said that “people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy” would pay less under the ACHA, implying that those with pre-existing conditions, such as those who are pregnant or survivors of sexual assault or domestic violence, have not lead “good lives” and are not healthy. Brooks went on to say, “Now, in fairness, a lot of these people with pre-existing conditions, they have those conditions through no fault of their own. And I think our society under those circumstances needs to help.” However, that still leaves the door open for some people who need health-care services to be considered at fault, and doesn’t change the stigma associated with identifying some people as leading “good lives,” but not others.

For many, this amendment feels like a step backwards after the ACA put these protections in place. “Before Obamacare, we had survivors who were very concerned about getting HIV tested or doing anything that would show in their medical record that they had a pre-existing condition,” Scaramella shared.

The legislation would also cut funding to Planned Parenthood, further limiting the accessible, low-cost options for survivors of sexual assault and others to access essential health-care services.

Estimates put the rate of sexual assault in the United States at 1 in 6 women and 1 in 33 men. Notably, sexual violence disproportionately affects people of color, LGBTQ folks, and persons with disabilities, among others. As survivors of sexual assault attempt to determine how the proposed legislation could affect them, opponents of the bill warn of a potential chilling effect on reports of sexual assault, an already-underreported crime.

The consequences of the legislation are not limited to survivors of sexual violence. Cesarean sections, post-partum depression, and domestic violence could also be considered pre-existing conditions. As a result, this provision disproportionately affects women, LGBTQ people, low-income individuals, and persons with disabilities.

The amendment states, “Nothing in this Act shall be construed as permitting health insurance issuers to discriminate in rates for health insurance coverage by gender.” Back in 2010, before the Affordable Care Act was passed, HuffPost reported that a representative for America’s Health Insurance Plans, the largest trade group for the health insurance industry, said, “I think it’s important to point out that health plans are not denying coverage based on the fact that someone was raped.” But, the spokesperson added, “PTSD could be a factor in denied coverage.” Many are unconvinced.

The ramifications go beyond the 24 million individuals many advocates say could lose coverage by the year 2026, based on the nonpartisan Congressional Budget Office’s March 23 estimates of an earlier iteration of the bill. “It’s extremely short-sighted not to be taking care of people in that way, from a prevention and cost-saving perspective,” said Scaramella.

Of course, the executive director feels there is also a moral imperative. “It’s another burden placed on survivors [of sexual violence]. We have a societal responsibility to address that, as long as the crime exists.”

The bill is now being considered by the Senate, where several Republicans have already rejected it, with the intention of drafting their own version. Still, the New York Times reports that at least one senator “might borrow ideas,” from the House bill.

What can opponents like Scaramella do in the meantime? “Speak up.” Her goal, and the goal of many sexual assault survivors and other opponents of the legislation, is to make sure the bill and its impact remain visible.