Chanting “na na na na, na na na na, hey hey hey, goodbye!” Democrats taunted Republican members of the House who narrowly passed (by 1 vote) the American Health Care Act in response to GOP promises to “repeal and replace Obamacare.” After Republicans twice failed to bring together conservative members who favored a total repeal and moderate legislators who wanted to preserve various provisions of the Affordable Care Act (ACA), also known as Obamacare, House Republicans reworked their plan. While all 192 Democrats opposed the new bill and believe that for those who supported it this will be a death knell in the midterm elections, 20 Republicans also voted against the legislation. Some voiced concerns about what it will mean for millions of Americans who now may: 1) no longer be afforded protection in some states against small businesses opting out of mandatory health insurance for their employees; 2) no longer qualify for Medicaid; or 3) face increased premiums if they have preexisting conditions, among other revisions and restrictions (see below).

Conversely, some Republicans, such as Representative Rod Blum of Iowa, reluctantly voted for the latest version of the bill after refusing to support an earlier version because it did not go far enough in distancing itself from Obamacare. Whether they wanted to keep Obamacare or let it die, Blum faced incendiary crowds at a recent town hall meeting who shouted angrily at him as he struggled to explain why he voted for a plan that had been rushed through Congress (under pressure from President Trump to keep a promise during his roughly first 100 days in office) before it had been properly vetted by a committee or had received input from constituents. (Blum is a member of the conservative House Freedom Caucus who somewhat controversially prescreened the town hall attendees and only permitted residents of his district to attend the gathering. Even so, he was booed and yelled at.)

They say politics makes strange bedfellows, and in this rather rare case, it’s almost all hands on deck in voicing strong opposition to the GOP plan: more than 50 organizations including health insurance companies, organized medicine (hospitals, doctors, and nurses), and consumer advocates—even some small business groups, such as the Main Street Alliance. For example, the America’s Health Insurance Plans’ CEO stated, “AHIP believes that every American deserves coverage and care that is affordable and accessible, including those with pre-existing conditions. The American Health Care Act (AHCA) needs important improvements to better protect low- and moderate-income families who rely on Medicaid or buy their own coverage.”

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Others, including the American Association of Retired Persons (AARP), had a strongly worded opposition statement as well: “AARP opposes this legislation, as introduced, that would weaken Medicare, leaving the door open to a voucher program that shifts costs and risks to seniors. Before people even reach retirement age, big insurance companies could be allowed to charge them an age tax that adds up to thousands of dollars more per year. Older Americans need affordable healthcare services and prescriptions. This plan goes in the opposite direction, increasing insurance premiums for older Americans and not doing anything to lower drug costs. On top of the hefty premium increase for consumers, big drug companies and other special interests get a sweetheart deal. Finally, Medicaid cuts could impact people of all ages and put at risk the health and safety of 17.4 million children and adults with disabilities and seniors by eliminating much-needed services that allow individuals to live independently in their homes and communities. Although no one believes the current healthcare system is perfect, this harmful legislation would make health care less secure and less affordable.”

In a New York Times article, Michael J. Dowling, the chief executive of Northwell Health, a large integrated network of hospitals and healthcare providers in Long Island, New York, said, “Hospitals that serve low-income patients will just be drowning completely when this happens.” In a rally of over a thousand small business owners and their supporters, ReShonda Young of Iowa (a small business owner) said, “Who thinks it’s a good idea to cut health care for millions of people? Small business owners stand for health care for all.”

Kelly Conklin, a small business owner in New Jersey stated, “If the ACA is repealed, there will be a direct and devastating impact on small businesses.…The damage will touch every community, every resident, poor and wealthy alike.”

Perhaps the American Nurses Association (ANA) captured the concerns best in an opposition letter addressed to several key members of Congress, which stated, “The American Health Care Act threatens healthcare affordability, access, and delivery for individuals across the nation. In its current form, the bill changes Medicaid to a per capita cap funding model, eliminates the Prevention and Public Health Fund, restricts millions of women from access to critical health services, and repeals income-based subsidies that millions of people rely on. These changes in no way will improve care for the American people. ANA also remains troubled by the absence of testimony from non-partisan experts, such as the Congressional Budget Office (CBO), Medicaid and CHIP Payment and Access Commission (MACPAC), the Medicare Payment Advisory Committee (MedPAC), or the Government Accountability Office (GAO). Input from these and other non-partisan experts would shed light on the potential long-term economic and health consequences of the legislation. Any legislation that would fundamentally alter healthcare delivery and deeply impact patients and providers deserves thoughtful, deliberate and transparent consideration. ANA strongly urges Congress to allow opportunity for considered public and stakeholder feedback in the face of reforms that would have a far-reaching and personal impact on the lives of millions of people.”

What is everyone so upset about? Here are the Top Ten reasons that some are calling this new plan “Chumpcare”:

1. Expansion of Medicaid would be phased out by 2020 (freezing the ability to sign up new enrollees under the expansion effective January 1, 2020) and the program would be cut by $880 billion. This would profoundly affect low-income individuals who reside in the 32 states (including Washington, DC) that expanded Medicaid, under the ACA and are thus able to offer vital services to people who do not earn enough to afford coverage and/or who work in jobs that did not provide health insurance (eg, waitresses, freelancers, and home health aides). Going forward, states may opt to obtain block grants or per capita payments for each individual on Medicaid. Experience in Canada shows that block funding quickly becomes inadequate, and that may force states to deny coverage to needy individuals. Currently, Medicaid picks up the costs of covered patients’ medical bills without imposing a set limit, but under the per capita option, they would only get a fixed amount per patient. The bill also allows states to impose a work requirement for adults who are not disabled or pregnant, which will restrict access to health coverage.