WASHINGTON, D.C., USA — If the budget bill supported by President Donald Trump, which was approved by the House of Representatives on Thursday, becomes law, the U.S. social safety net could experience significant changes.

This bill includes introducing work requirements for low-income adults to qualify for Medicaid health insurance. It also proposes stricter work requirements for food assistance and plans to reduce funding for services such as birth control provided by the nation’s largest abortion provider.

Supporters of the bill say the moves will save money, root out waste and encourage personal responsibility.

The Congressional Budget Office, a nonpartisan group, has preliminarily estimated that these proposals could lead to 8.6 million fewer people having healthcare coverage over the next ten years.

The measure, which also includes tax cuts, passed the House by one vote and could have provisions reworked again as it heads to the Senate.

Here’s a look at the potential impact.

Starting next year, many able-bodied Medicaid enrollees under 65 would be required to show that they work, volunteer or go to school in exchange for the health insurance coverage.

Some people who receive Medicaid were worried Thursday that they could see their coverage end, even if it is not immediately clear whether they might be covered by an exception.

Raquel Vasquez, a former cook who is battling two types of cancer and has diabetes, said she believes she could be affected because she has not been able to qualify for Social Security disability benefits. “I cannot even afford this life now because of my disabilities,” said the 41-year-old Bakersfield, California, resident. “But my country won’t even help me.”

About 92% of people enrolled in Medicaid are already working, caregiving, attending school or disabled. That leaves about 8% of 71 million adult enrollees who would need to meet the new requirement. An estimated 5 million people are likely to lose coverage altogether, according to previous estimates of the bill from the Congressional Budget Office.

Only Arkansas has had a work requirement that kicks people off for noncompliance. More than 18,000 lost coverage after it kicked in 2018, and the program was later blocked by federal courts.

“The people of Arkansas are generous and we want to help those who cannot help themselves, but we have no interest in helping those who are unwilling to help themselves,” said Arkansas Senate President Pro Tempore Bart Hester, a Republican. “I’m glad the federal government is starting to align with our thinking.”

Increased eligibility checks and red tape related to work requirements may result in some people wrongly getting booted off, said Eduardo Conrado, the president of Ascension, a health care system that operates hospitals across 10 states.

That could spell trouble for rural hospitals, in particular, who will see their small pool of patients go from paying for their emergency care with Medicaid coverage to not paying anything at all. Hospitals could have to eat their costs.

“Adding work requirements is not just a policy change, it’s a shift away from the purpose of the program,” Conrado said of the rule.

That is also a concern for Sandy Heller, of Marion, Massachusetts.

Her 37-year-old son, Craig, has Down syndrome and other complicated medical needs.

She worries the changes would make it harder for hospitals in out-of-the-way places like hers to stay afloat and offer the services he could need.

If they don’t, he would have to travel about 90 minutes for care.

“It could mean life and death for my son if he needed that medical care,” Heller said.

The Supplemental Nutrition Assistance Program, formerly known as food stamps, already requires work for some of its roughly 42 million recipients. Adults ages 18-54 who are physically and mentally able and don’t have dependents must work, volunteer or participate in training programs for at least 80 hours a month, or else be limited to just three months of benefits in a three-year period.

The legislation passed by the House would raise the work requirement to age 65 and also extend it to parents without children younger than age 7. The bill also would limit the ability to waive work requirements in areas with high unemployment rates.

The combination of those changes could put 6 million adults at risk of losing SNAP benefits, according to the liberal-leaning Center on Budget and Policy Priorities.

Like work requirements for Medicaid, those for SNAP tend to cause a decrease in participation without increasing employment, according to an April report by the Brookings Institution’s Hamilton Project.

Under the bill, the federal government would punish states that use their own state dollars to provide Medicaid-covered services to immigrants lacking legal status or to provide subsidies to help them buy health insurance.

Some states that provide that sort of coverage extend it only to children.

Those states would see federal funding for the Medicaid expansion population — typically low-income adults — drop from 90% to 80%.

That could mean states pull back that Medicaid coverage to avoid the federal penalty, said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

KFF said the provision could affect 14 states that cover children regardless of their immigration status.

This month the Democratic governor of one of them — California’s Gavin Newsom — announced a plan to freeze new enrollments of adults in state-funded health care for immigrants who do not have legal status as a budget-balancing measure.

Planned Parenthood says a provision barring it from receiving Medicaid funds could lead to about one-third of its health centers closing.

The group said about 200 centers are at risk — most of them in states where abortion is legal. In those states, the number of Planned Parenthood centers could be cut in half.

Planned Parenthood, the nation’s largest abortion provider, also offers other health services, including birth control and cancer screening.

Federal money was already barred from paying for abortion, but state Medicaid funds in some states now cover it.

“We’re in a fight for survival — not just for Planned Parenthood, but for the ability of everyone to get high-quality, non-judgmental health care,” Planned Parenthood President and CEO Alexis McGill Johnson said in a statement.

Susan B. Anthony Pro-Life America celebrated the provision, saying “Congress took a big step toward stopping taxpayer funding of the Big Abortion industry.”

Medicaid would stop covering gender-affirming care for people of all ages in 2027 under one provision.

Further, coverage of the treatments could not be required on insurance plans sold through the exchanges under the Affordable Care Act.

Trump has targeted transgender people, who make up around 1% of the U.S. population, since returning to office, including declaring that the U.S. won’t spend taxpayer money on gender-affirming medical care for transgender people under 19. The care includes puberty blockers, hormone therapy and surgeries.

The bill would expand that to all ages, at least when it comes to Medicaid.

Some states already block the coverage, and some require it. It’s unclear how much Medicaid has spent on providing gender-affirming care, which has only been recently added to some coverage plans in some states.

Associated Press reporters Devna Bose in Jackson, Mississippi; Andrew DeMillo in Little Rock, Arkansas; Susan Haigh in Hartford, Connecticut; Marc Levy in Harrisburg, Pennsylvania; Amanda Seitz in Washington; and Leah Willingham in Boston contributed to this article.

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