This is a fight over Obamacare, again

• Many of the changes in play are directed at the people who've gained insurance under the ACA's Medicaid expansion, which helped drive the dramatic reduction in the share of Americans who are uninsured.

The big picture: The White House and some congressional Republicans are trying to recast Medicaid as a welfare benefit meant only for certain groups.

• "The increased share of welfare spending dedicated to able-bodied working-age adults distracts from what should be the focus of these programs: the truly needy," Health and Human Services Secretary Robert F. Kennedy Jr. and other Cabinet officials wrote in a recent New York Times op-ed.
• "President Trump and Republicans are protecting and preserving Medicaid for the Americans who the program was intended to be a lifeline for: pregnant women, children, disabled individuals, and seniors," White House spokesperson Kush Desai tells Axios.

Between the lines: That leaves out poor working-age adults without children who gained Medicaid coverage under Obamacare.

• Republicans have been pushing back against the expansion of federal health spending for this group from the beginning — though efforts to repeal the law have failed multiple times.

Yes, but: The White House argues that Medicaid was originally meant to be a welfare program, and when it was expanded under Obamacare that wasn't where the growth in the insured rate was supposed to come from — the expectation was that the ACA insurance exchanges, where Americans buy individual coverage, would be how more folks got covered.

• "Any attempts to recast historical facts and claim that Medicaid was actually intended to be a welfare program for illegal immigrants and fraudsters is not just incorrect, but borderline Orwellian," says Desai.

What they're saying: "It's a very concerted effort right now to redefine Medicaid as welfare, and not health insurance," says Joan Alker, executive director of Georgetown University's Center for Children and Families.

• But since the Affordable Care Act, Medicaid has become a critical component of the health insurance system, she says.

Between the lines: There are Republicans who see it that way, too, most prominently Sen. Josh Hawley (R-Mo.).

Reality check: Earlier drafts of the reconciliation bill being debated in the House included some provisions that would've hit at the expansion even harder. Those appear to be missing from this latest version.

Zoom in: However, the hit to Medicaid is still massive. The new work requirements will lead to millions losing coverage, and a likely accelerated timeline would put even more people's care at risk, as Axios' Victoria Knight and Peter Sullivan write.

• And, the bill would require folks who are covered under the expansion to renew their eligibility twice a year — instead of annually.

• That's a complicated process that can lead people to fall off the program's rolls — as happened when pandemic-era coverage provisions were rolled back.

Plus: The bill constrains states' abilities to fund their share of Medicaid costs. And it repeals some Biden-era rules that made it easier for older Americans to enroll in the program.

It would take time for states to implement such major changes, says Jennifer Wagner, director of Medicaid eligibility at the Center for Budget and Policy Priorities.

• Doing it on a rushed timeline means it's less likely that states can test to see if their new systems work. That could lead to more people falling through the cracks, adds Wagner, who previously worked on health policy in Illinois.

Follow the money: Any cuts to Medicaid wind up affecting everyone who gets health insurance under the program, state treasurers said on a call with reporters last week.

• Fewer people getting insurance through Medicaid strains the overall health system — since the uninsured tend to avoid getting care until problems worsen and grow more costly.
• "The long-term health care impacts for them individually means that they are going to cost more in the long-run," said Deb Goldberg, the state treasurer of Massachusetts.

What they're saying: "This is just another attack on the Affordable Care Act," says Alker.

• "Here we are again, back in this kind of philosophical debate whether we believe all Americans should have access to high-quality, affordable health care," Rep. Kathy Castor (D-Fla.) told reporters Monday afternoon.