So states that expanded Medicaid likely will face a dilemma: Pay more to keep insuring people who gained coverage via Obamacare. Or change the rules — possibly reverting to pre-Obamacare days? — so that thousands are no longer eligible. That sounds harsh, but there's another way to think about this: Medicaid was designed to help the neediest Americans, not able-bodied adults capable of holding jobs. Many states are reshaping their Medicaid programs to preserve the safety net for the neediest, while providing a more temporary safety net for others who can be job-trained or encouraged to find work so they can buy their own coverage.