When you add up all the changes to health care in the House GOP reform bill, they look like a not-so-veiled attack on women’s health.

The Affordable Care Act was a big leap forward for women in the US. The law expanded contraceptive access, finally required private small-group insurers to cover maternity care, and broadened the number of people who could access Medicaid — which pays for half of all births in this country.

These advances mattered to public health when you think about how poorly American women fare compared with women in other rich countries. (We have some of the worst maternal health and mortality outcomes in the developed world.) They also gave women some relief from worry about accessing very basic health services they will at some time or another need.

Now the GOP’s health reform bill, the American Health Care Act, looks like a big step backward, doctors and reproductive health advocates are saying. Today, the bill passed with a narrow 217-213 vote. Here are the five key ways this bill (and a related executive order from President Trump) could undermine the health of women in this country if it passes through the Senate and turns into law.

1) The bill overhauls and dramatically cuts Medicaid — which covers half of all US births

Medicaid is incredibly important for reproductive health in this country: The program pays for half of all births, including two-thirds of unplanned births. Three-quarters of the public dollars spent on family planning are Medicaid dollars, and in 17 states, Medicaid programs also cover abortion with state dollars.

The latest version of the AHCA would cut Medicaid, and phase out Medicaid expansion (which made more people eligible for the program).

“Fewer people eligible [for] and enrolled in Medicaid means fewer people with access to coverage for the reproductive health services they need,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, a research and policy organization for sexual and reproductive health and rights. “That’s the big overarching assault [on women’s health] in the bill.”

2) The bill defunds Planned Parenthood (without naming it)

If you search the latest draft of the bill and its amendments for language about Planned Parenthood, you won’t find it. But provisions about “prohibited entities” are basically attempts to defund Planned Parenthood.

In essence, these sections of the bill say groups that are primarily engaged in family planning services, reproductive health, and providing abortions (other than abortions that are medically necessary or responses to cases of incest or rape) — and whose Medicaid receipts exceeded $350 million in fiscal year 2014 — are barred from receiving federal dollars through several health programs, most importantly Medicaid.

“You add that all together and it means Planned Parenthood,” said Sonfield.

Here’s what the change would look like: If a woman has Medicaid as her health insurance plan, she can’t go to Planned Parenthood for her health care and get those services covered. Planned Parenthood would not longer be able to be reimbursed for these services.

"The American Health Care Act is the worst bill for women’s health in a generation,” said Erica Sackin, the political communications director for the Planned Parenthood Federation of America.

Without receiving Medicaid dollars, it’ll be difficult for clinics to stay afloat, since three-quarters of the public dollars spent on family planning in this country are Medicaid dollars. And right now, 2.5 million people rely on Planned Parenthood for a range of health care services, like birth control and cancer screenings.

“That takes Planned Parenthood off the table as a health care provider for people with Medicaid,” said Diane Horvath-Cosper, an OB-GYN and reproductive health advocacy fellow with Physicians for Reproductive Health, “and we know from looking at the accessibility of other clinics that there are not enough places to take up the slack and provide care for those people who will be shut out of Planned Parenthood.”

3) It makes essential health benefits, which ensure maternity coverage, optional

In an attempt to make the insurance marketplace fairer and more viable, the Affordable Care Act required insurance plans sold on the individual market, the fully insured small-group market, and through Medicaid expansion to cover a list of 10 “essential health benefits.” The 10 included pretty basic medical care — like pregnancy and maternity care, as well as mental health and addiction treatment, and lab tests.

Republicans in Congress have consistently tried to scrap this part of the law. And with their latest proposal, they’ll have another shot at the EHBs. In a push to win support from the more conservative Freedom Caucus, lawmakers want to make the EHB requirement optional for states.

Before the ACA, only 11 states required maternity coverage on the individual and small-group markets. And this is what we may be looking at if the GOP gets its way on health care reform. If the AHCA passes, “[t]his means that plans in the individual market could once again decide not to cover maternity care — like 88 percent of plans did before the Affordable Care Act passed,” Vox’s Sarah Kliff explained.

4) It cuts access to private insurance coverage of abortion

The latest AHCA draft also resurrects a longstanding effort to keep people from using federal tax credits to purchase private insurance that includes abortion services.

Before the ACA went into place, an anti-abortion faction of Congress wanted to make sure federal tax credits to help people buy private insurance on the Obamacare exchanges couldn’t be used to pay for plans that provided abortions. (This was called the Stupak–Pitts Amendment — and it didn’t pass.)

The AHCA is trying to fight this battle again. If it passes this time, women who want to buy private plans that include abortion services would not be allowed to use tax credits to pay for them.

Creating this kind of financial disincentive for plans to cover abortion could be devastating. “This provision would likely eliminate abortion coverage in the individual insurance market because there would be essentially no consumers who would be able to buy a plan that includes abortion coverage,” explained Sonfield.

5) A separate executive order could make contraception coverage optional for employers

Hours before the House passed the AHCA today, Trump signed a “religious freedom” executive order. It’s expected to give “regulatory relief” to people who objected to the Obama-era requirement that contraception be covered as part of health plans for religious reasons, among other changes.

This would potentially expand the number of organizations, employers, and individuals who could get an exemption from the birth control benefit. But health advocates say this would mean stripping it from women who desperately need it. “The contraceptive benefit has been so beneficial to women’s health, and to let companies just say they don’t have to cover it is devastating,” said Horvath-Cosper.

She went on: “This just compounds this administration’s efforts to roll back progress on reproductive health care.”