Utah’s legislature is gambling that voters won’t punish them for disrespect. Photo: Rick Bowmer/AP/REX/Shutterstock

Utah’s Republican legislators and their governor have followed through on their threat, taking action to put aside a voter-approved ballot initiative to accept the Medicaid expansion offered in the Affordable Care Act. They seek instead to substitute a partial expansion linked to right-wing policy restrictions they hope the Trump administration will approve. As Vox explains, there’s a fiscal fig leaf for what they are trying to do:

Full Medicaid expansion was to be covered entirely by the sales tax increase that was already passed as part of the ballot referendum. That tax was pegged to an earlier estimate of the full expansion’s costs over the first two years, but the state government has since released a new projection that forecasts a $10.4 million shortfall in year three, which Republican leaders have then used to justify pursuing their partial expansion, saying it’s more fiscally responsible.

Trouble is, their own plan not only kills coverage for 60,000 Utahns that would be covered in a full expansion, but it also costs more. But Republicans hope they can get a waiver from the Trump administration that boosts the federal share of costs significantly in exchange for work requirements and a per-patient cap on costs:

The only way the Republican plan would save the state money is if they received federal approval to get a 90-10 match, something that hasn’t ever happened before, may not be legally permissible, and is the subject of fierce debate in the Trump administration.

As Politico notes, if the Trump administration doesn’t go along, Utah Republicans will at least partially back off their defiance of voters:

If the Trump administration refuses the state’s plan, the legislation includes a trigger automatically adopting the Obamacare expansion while adding requirements for some enrollees to work or remain on workplace health insurance coverage if available.

But Governor Gary Herbert is optimistic about Washington having his back in standing up to those fiscally irresponsible constituents of his:

Herbert and Republican lawmakers in Utah have insisted that the Trump administration will approve the enrollment limits and boosted federal funding the state is requesting through a waiver. Herbert said he has discussed the plan with Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, and other federal health officials.

But the enhanced match rate for proposing a partial expansion, even with the policy riders, could create an expensive incentive for Republican states that have rejected Medicaid expansion to rethink their position. And some states that have expanded Medicaid might prefer a partial expansion with a higher federal match. The administration may not be able to pick and choose states that do and don’t get waivers. So it’s a tricky situation. And for Utah Republicans, it’s especially tricky to disrespect voters who sent a pretty clear directive.