By DAVID A. LIEB and GEOFF MULVIHILL

JEFFERSON CITY, Mo. (AP) — Supporters of the sweeping tax and spending legislation that Congress has sent to President Donald Trump say the changes to Medicaid, food aid and other programs will encourage personal responsibility and halt those scamming the system.

Critics of the bill, given final congressional approval Thursday, say the requirements will upend lives.

Here’s a look at what people are saying about the bill.

Work requirements added for accessing more federal benefits

To enroll and stay on Medicaid, many ages 19 through 64 would be required to work, go to school or perform at least 80 hours of community service a month.

The Medicaid work requirement would apply to people in 40 states who are enrolled through expanded access that states agreed to put in place since 2014. Ten states, including Texas and Florida, did not expand the program.

For the Supplemental Nutrition Assistance Program, or SNAP, which already requires adults ages 18 to 55 to work, working would become mandatory for many until they turn 65.

For both benefits, there would be exceptions, including for parents who are caregivers to children under age 14.

Most people covered by Medicaid already meet the work requirement or qualify for an exception.

The requirements are sparking worry for some enrollees

Theresa Gibbs, who lost her job as a school bus driver, is enrolled in both Medicaid and SNAP. She likely would be exempt from the work mandate because she has three children under age 14. But Gibbs said she is applying for jobs anyway.

“I don’t think people should just live off the state if they’re perfectly capable to work,” said Gibbs, 34, of Jefferson City, Missouri.

But the changes worry others.

Amanda Hinton, 39, of St. Martins, Missouri, receives Medicaid and SNAP benefits. She puts in enough hours at a part-time gas station job to likely meet the new requirements but is concerned should her fibromyalgia, which causes pain and fatigue, keep her from working for a time.

“I’m panicked. I mean I have some chronic health conditions that are not curable, and I rely on my medication to help me just get through the day,” she said. “And without my Medicaid, I couldn’t afford these.”

Brittany Phillips, 32, of Greensboro, North Carolina, said being on Medicaid has helped her stay afloat both financially and health-wise while she works a temporary, remote medical services job paying about $600 weekly.

“I do believe that Medicaid should be available for everyone regardless of who they are — regardless of capacity, faculty — everyone should have Medicaid,” she said.

It’s not just the work requirement; it’s also the paperwork

The nonpartisan Congressional Budget Office estimates that 11.8 million fewer people could have health insurance by 2034 because of the changes, which also include booting off non-citizens who are not in the U.S. permanently and legally. And that doesn’t include those who could lose coverage for other reasons.

Advocates say that even people who are covered by exceptions to the work requirement could lose their Medicaid coverage. One major reason is a requirement that people’s eligibility would be assessed at least every six months.

“Every additional paper someone has to submit separately from their application,” said Deborah Steinberg, a senior health policy analyst at the Legal Action Center, “you lose people.”

Julia Bennker, who runs an in-home daycare in Eau Claire, Wisconsin, relies on SNAP and Medicaid and has had paperwork issues under existing Medicaid requirements. She said that earlier this year, she didn’t have health coverage for a month after she was told her forms were late — though she believes she submitted them on time.

That meant going a month without therapy and needing to reschedule another appointment with a prescriber.

Some of the conditions that would trigger exceptions — mental illness or substance use disorder — are not currently tallied in Medicaid computer systems.

“It’s not like you wave a magic wand and everyone who should be exempt is exempt,” said Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness.

States will face pressure – and deadlines – to revamp their programs

State health care and social services agencies will have to rework their computer systems to account for the various changes while also dealing with federal funding reductions. That’s cause for concern for some health care advocates.

The legislation requires all states to shoulder more of the administrative costs of SNAP starting in 2027 and, for the first time, could force some states to pay for a portion of food assistance benefits starting in 2028.

States also must implement the Medicaid work requirement by 2027.

“It will be a very tight and difficult timeline for many of these states,” said Sophia Tripoli, senior health policy director at Families USA, a health care advocacy organization. “There’s a huge cost burden on states from the administrative side just to stand up these systems.”

Julieanne Taylor, a lawyer at the Charlotte Center for Legal Advocacy in North Carolina, said her organization’s clients already face delays in verifications for the food program.

“To add more to them, it’s going to be a disaster,” she said. “It’s going to cause people to drop off because they’re like, ‘I don’t want to have to do this every year or every six months.’”

Rural hospitals could face financial struggles

The bill could also put rural hospitals at financial risk, experts say, because it seeks to cap the taxes that states impose on hospitals and other health care providers in a way that boosts Medicaid funding.

The nonprofit KFF, which studies health care issues, estimates that Medicaid spending in rural areas would decrease by $155 billion over the next decade under the bill.

“While there are already a number of small and rural hospitals that are vulnerable,” said R. Kyle Kramer, CEO of Day Kimball Hospital in Putnam, Connecticut, “it’s going to lead to a lot of closures.”

The bill includes a $50 billion fund to partially offset those reductions.

Planned Parenthood would lose federal money

Federal taxpayer money is already barred from paying for abortions in most cases.

The bill would also ban federal funds going to Planned Parenthood, the nation’s largest abortion provider, for other purposes like family planning programs and cancer screenings.

The group says that one-third of its roughly 600 clinics across the U.S. could face closure as a result of the legislation, and that states where abortion is legal would be hardest hit.

At least one other group says it also stands to lose funding because of the provision. Maine Family Planning has 19 sites and subcontracts with other health care organizations, including Planned Parenthood, to provide services at other locations across the rural state.

Mulvihill reported from Cherry Hill, New Jersey. Susan Haigh in Hartford, Connecticut, and Gary D. Robertson in Raleigh, North Carolina, contributed to this report.