Since the implementation of the Affordable Care Act’s Medicaid expansion in 2014, 23 states have refused the federal money to offer health insurance to their low-income residents, depriving almost 4 million people of coverage. Slowly, some of the holdout red states are finding a way to say yes, but only if they can claim a conservative twist on expanding coverage. Tennessee last week became the latest state to release details on a proposal for its own unique version of Medicaid expansion via a waiver of Medicaid rules (known as an 1115 waiver). "We made the decision in Tennessee nearly two years ago not to expand traditional Medicaid," Gov. Bill Haslam, a Republican, has said. "This is an alternative approach that forges a different path and is a unique Tennessee solution.”

Versions of Haslam’s statement are common among Republican lawmakers who have negotiated with the Obama administration to pursue this path: They’re willing to accept Obamacare money so long as they can plausibly sell it as not Obamacare, and they want to use their leverage to attach conservative reform ideas to Medicaid. At the Washington Post, Sarah Kliff has called these measures “making Medicaid more Republican.” Arkansas, Iowa, Michigan and Pennsylvania have already advanced unique versions of Medicaid expansion thanks to waivers that feature GOP-backed wrinkles to the program; Indiana has submitted a waiver pending approval from the federal Department of Health and Human Services, while Tennessee, Wyoming and Utah have developed proposals after active negotiations with the feds; and lots of other states are taking a look, including North Carolina, Georgia, and even Texas.

That’s good news for those states' poorer residents, who have been left to fend for themselves while state legislatures offer massive resistance to Obamacare. In practice, however, crafting plans that are ostensibly more conservative has tended to add layers of bureaucracy and administrative complexity. The Republicanized versions of Medicaid thus far have ended up more complicated, confusing, and possibly costlier than the program Republicans refused to expand in the first place.

Take, for example, Arkansas—the state that got the ball rolling for red states seeking GOP twists on Medicaid expansion with its privatized version known as the “private option.” Last month the state got approval for a byzantine new program, called Health Independence Accounts, that imposes co-pays on some beneficiaries unless they pay a small monthly fee. Those who have paid their fees are eligible, under certain conditions, for up to $200 to pay for the costs of private health insurance if their income goes up and they transition off of Medicaid. To run the program, the state will pay a third-party administrator about $15 million annually (covered by the feds as part of the cost of expansion).

Meanwhile, Iowa is now imposing low premiums, tied to a wellness program, on some beneficiaries. “The administrative complexity of the system the state is contemplating is somewhat mind-boggling,” Joan Alker of the Georgetown University Health Policy Institute commented when Iowa’s waiver was approved, adding that “[t]he wellness program is of questionable policy value.” Indiana’s proposal includes small premiums and savings accounts tied to different benefits packages, leaving advocates for beneficiaries worried that low-income adults "face categorization into a bewildering array of benefit plans and options.”