Senate backs Medicaid expansion

The Arizona Senate on Thursday approved expanding the state's Medicaid program, capping a rancorous debate that had split the Republican Party and had been building since January, when Gov. Jan Brewer issued a surprise call to increase Arizona's health-care program for the poor.

How they voted on Medicaid expansion

YES

Sen. Ed Ableser, D-Tempe

Sen. David Bradley, D-Tucson

Sen. Olivia Cajero-Bedford, D-Tucson

Sen. Rich Crandall, R-Mesa

Sen. Adam Driggs, R-Phoenix

Sen. Steve Farley, D-Tucson

Sen. Steve Gallardo, D-Phoenix

Sen. Katie Hobbs, D-Phoenix

Sen. Jack Jackson Jr., D-Window Rock

Sen. Leah Landrum Taylor, D-Phoenix

Sen. Linda Lopez, D-Tucson

Sen. John McComish, R-Phoenix

Sen. Barbara Maguire, D-Kearny

Sen. Robert Meza, D-Phoenix

Sen. Lynne Pancrazi, D-Yuma

Sen. Steve Pierce, R-Prescott

Sen. Michele Reagan, R-Scottsdale

Sen. Anna Tovar, D-Tolleson

Sen. Bob Worsley, R-Mesa

NO

Sen. Nancy Barto, R-Phoenix

Sen. Andy Biggs, R-Gilbert

Sen. Judy Burges, R-Sun City West

Sen. Chester Crandell, R-Heber

Sen. Gail Griffin, R-Hereford

Sen. Al Melvin, R-Tucson

Sen. Rick Murphy, R-Peoria

Sen. Don Shooter, R-Yuma

Sen. Kelli Ward, R-Lake Havasu City

Sen. Steve Yarbrough, R-Chandler

Sen. Kimberly Yee, R-Phoenix

A handful of Senate Republicans teamed with Democrats to approve the fiscal 2014 budget plan and overcome a flood of amendments intended to scuttle Medicaid expansion, pushing through the governor's top legislative priority on a 19-11 vote after three hours of debate.

Although the legislation faces an uncertain future in the House, its passage late Thursday was a key victory in the governor's effort to bring health care to an additional 350,000 Arizonans.

Brewer and her supporters -- including some who, like her, oppose the federal health-care overhaul that makes expansion possible -- said Arizona could not afford to reject the billions of federal dollars that come with it.

But opponents of expanding the state-federal health-care program for the poor and disabled, including Republican legislative leaders, said it goes too far, beefing up an already unaffordable, unsustainable government entitlement program that goes against GOP principles and discourages people from taking responsibility for their own health care.

A standoff set in for weeks, with Senate President Andy Biggs, who was an early and ardent expansion opponent, saying he would not bring a Medicaid expansion bill to the floor and House Speaker Andy Tobin saying he didn't like Brewer's plan and was working on alternatives.

On Tuesday, Biggs cranked the legislative machinery into gear and started moving toward a vote on the fiscal 2014 budget without Medicaid. By bringing it to the floor, it allowed proponents of Medicaid expansion the opening they needed, setting up what Biggs called "the most consequential decision of a generation."

Weighing down the bill

The maneuvering began the evening before the vote, and it could be heard as the copy shop in the state Senate buzzed with activity.

As soon as the Senate Appropriations Committee finished its work Wednesday afternoon, setting up Thursday's vote, lawmakers started flooding staffers with budget amendments for the floor session.

By 6 p.m. Wednesday, Sen. Kelli Ward, R-Lake Havasu City, had filed seven amendments designed to weigh down the expansion proposal. Ward, a physician and freshman lawmaker, is one of the Senate's most outspoken Medicaid- expansion opponents.

Biggs came in with 13 anti-expansion amendments.

Majority Leader John McComish, R-Phoenix, filed two amendments, which contained the heart of the fight.

Though he had not publicly expressed support for the plan, he was thought to be on board and, in the end, became the spear carrier for Medicaid expansion.

In all, there were 24 Medicaid-related amendments, and 34 were related to other parts of the budget.

Decision day

Thursday opened with a tense Republican caucus meeting. GOP senators aired their differences on the the expansion proposal as a crowd of lobbyists, reporters and Capitol regulars listened in.

Sen. Rick Murphy, R-Peoria, called McComish's sponsorship of the Medicaid-expansion amendment a "betrayal" because most of his GOP colleagues were opposed to it.

And, he predicted, the move would be an incentive for more Arizonans to take a cut in pay so they would qualify for state-sponsored health coverage.

Sen. Al Melvin, R-Tucson, urged his colleagues to reject the lure of the federal money that would pay for most of the expansion.

"To me, it's immoral and unethical to accept this money," he said.

The meeting lasted an hour and a half. McComish held his comments to the end.

"People of good faith and good conscience differ," he said. He wanted a civil debate.

With that, the meeting ended, and members filtered out of the room and up to the Senate floor, where proceedings opened with debate and voice votes on all the budget bills except the Kryptonite that is Medicaid expansion.

Other proposals pass

Proposals to increase spending on K-12, child welfare and universities passed with support from a changing array of three to six Republicans, who were joined by all 13 Democrats. Their amendments added about $34 million to the $8.8 billion budget, frustrating conservatives in what just two years ago was called the "tea party Senate."

Conservatives attempted to pressure their colleagues by forcing formal votes on motions to cut some of the spending.

They failed.

Ward, who is among the chamber's conservatives, tweeted: "The rolling of the conservative majority has begun."

Medicaid debate

Biggs had saved Medicaid for last and was ready with his amendments intended to kill, or at least weaken, the bill.

But again and again, McComish and four other GOP senators -- Majority Whip Adam Driggs and Sens. Rich Crandall, Steve Pierce and Bob Worsley -- stood with the chamber's 13 Democrats to defeat most of Biggs' amendments. And they teamed with Democrats to approve the Medicaid amendment on an 18-12 vote.

Democrats remained mostly silent, letting McComish do most of the work defending the governor's plan.

"We're faced with two unpleasant choices," he said. "If we don't do Medicaid expansion, our rainy-day fund will be totally wiped out."

Biggs chided his colleagues for not taking more time to consider such an enormous public-policy issue and warned that they would regret their decision for generations to come.

There had been no hearings, not even a proper bill, he said, just an amendment tacked on during floor debate -- hardly befitting a decision of this magnitude.

"This is the most important policy decision that we've encountered in a generation," Biggs said during a rambling floor speech that included lessons about why the federal government -- "a dubious partner" -- should not be trusted.

Unfair 'burden'

"This is not about expanding health care because it's some kind of altruistic program. It's about expanding health care to get federal money," Biggs said. "The money will unfairly burden our children and our grandchildren."

Sen. Steve Yarbrough, R-Chandler, made an impassioned plea for an amendment to require a two-thirds majority vote in keeping with a 1998 voter-approved law intended to curb tax and fee hikes.

The assessment on hospitals, although it would be implemented by the state's Medicaid program, is clearly a tax, he said, adding that failing to require a supermajority approval is unconstitutional and sets a dangerous precedent.

Two of Biggs' amendments were successful, including one requiring a three-year "sunset" review by the Legislature of the expanded health-care program. That provision also is contained in a package of bills unveiled this week by House Speaker Andy Tobin, R-Paulden.

The second amendment requires the Arizona Health Care Cost Containment System, the state's Medicaid program, to report each year how much uncompensated care hospitals are claiming and the amount each hospital pays in provider taxes.

The debate went on for three hours, then ended abruptly after the underlying budget bill, with the Medicaid-expansion amendment, won approval on a voice vote.

In a statement, Brewer thanked the Senate "for acting in a bipartisan, courageous and collegial fashion …. to approve the single most critical policy issue that has faced our state in years."

Next steps

House Speaker Andy Tobin, R-Paulden, said he has not studied what he calls the Senate budget and can't yet say what he'll do with it. But, he said, he won't move a budget along unless he has Brewer's support. And he won't take up Medicaid expansion unless he has the support of at least half of his 36-member Republican caucus.

If he sends the Senate budget to the House Appropriations Committee, it appears a hostile welcome awaits it.

Chairman John Kavanagh, R-Fountain Hills, called the Senate legislation so loaded with personal vendettas that have resulted from a rift in the GOP caucus in the Senate that he may just toss the whole proposal and start over.

"This is not policy, this is politics," he said.

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