Speaker takes on Medicaid standoff

House Speaker Andy Tobin has emerged as the key player in getting Gov. Jan Brewer's Medicaid expansion plan through the Legislature, and momentum may be shifting in the nearly dormant Capitol as he appears ready to negotiate.

Tobin, R-Paulden, who opposes the Brewer plan as drafted, said he is working on an alternative that could include putting a time limit on the broadened eligibility and the hospital tax that helps fund it, stronger legislative oversight of the state's Medicaid program and audits of hospital finances.

The speaker's comments came as Brewer hit the pause button on legislation, saying she won't sign any more bills until lawmakers get moving on a new budget and Medicaid expansion.

"The governor simply believes that it's time for the Legislature to really get down to brass tacks with the budget and Medicaid," Brewer spokesman Matthew Benson said Friday. "We are anxiously awaiting further details on Speaker Tobin's proposal."

Brewer has been prodding lawmakers to move on her expansion plan since she released draft language almost two months ago, and she has made clear that she won't sign a fiscal 2014 budget without it. But she has been battling members of her own Republican Party who say Medicaid expansion under the federal health-care overhaul is financially unsustainable and politically toxic.

The speaker's support is pivotal because it would bring along reluctant House Republicans to join Democrats and move a bill to the Senate, where a bipartisan majority favors expansion. Senate President Andy Biggs, R-Gilbert, has vowed to block an expansion bill from coming to the Senate floor, but a majority could force a vote if a bill arrives from the House.

Tobin wouldn't say when, or even if, a Medicaid bill would be ready. But he has become more engaged in talks with House members, pro-expansion lobbyists and the Governor's Office, and says he wants to find a way to protect taxpayers, relieve the uncompensated care burden on hospitals and keep people from losing health insurance.

"I want to make sure if I'm going down the road that I have a decent ball to move, or I won't have one," Tobin said. "I'm trying to be helpful."

The two sides also have reached a near-consensus on estimates of how much it would cost to insure poor Arizonans if they passed up Medicaid expansion and did without the billions of federal dollars that come with it.

Tobin and Biggs floated that plan to Brewer earlier in the session, with the state picking up the tab for thousands of childless adults, but she shot it down.

Rank-and-file lawmakers are becoming restless as work at the Legislature has slowed to a crawl and narrowed to three days a week. In coming days, their daily stipend will be cut in half. Rumors are flying around the Capitol that a Medicaid bill could be unveiled as early as next week.

Brewer, a longtime opponent of the rest of the federal Affordable Care Act, is one of eight Republican governors to support expanding the state-federal insurance program for the poor and disabled to 133 percent of the poverty level, or about $15,300 a year.

Florida Gov. Rick Scott was overrun last week by the GOP-led Legislature, and Ohio Gov. John Kasich remains locked in battle with his. So far, 20 states have agreed to expand Medicaid, 15 have said no and 15 are undecided.

In Arizona, Medicaid expansion would insure an estimated 350,000 people, prevent 60,000 from falling off the state's current insurance program for childless adults, and bring in roughly $1.6 billion in fiscal 2015, the first full year.

Under Brewer's plan, the state's additional expenses would be covered with a tax on hospitals, money the facilities would recoup by seeing more insured patients and spending less on uncompensated care.

A policy decision this massive should not be rushed, Tobin said. In an interview Thursday, he bristled at the notion that he has had months to work through the details and rewrite a bill.

"It's not that I haven't been working on it," Tobin said. "I think I've probably put a lot more time into it than the people who wrote the governor's plan."

Tobin said he spoke with Brewer on Tuesday and understands her desire to see action on the big issues of the session, but he can't move any faster than he is now.

"I'm spending all my waking hours trying to figure out a better way for Arizona," he said. "I can't speed that up (just) because she's not signing any more bills."

Tobin said the governor's draft bill was a "non-starter," as he has said since she unveiled it, but he provided a few more details about what should be included in a Medicaid bill for it to get an airing in the House, mostly posed as questions.

"Is the 'circuit breaker' a strong enough circuit breaker? And what do you do to make it stronger?"

Brewer's plan includes a so-called circuit breaker, a provision to roll back coverage for those between 100 percent and 133 percent of the poverty level if federal funding falls below 80percent of the expansion cost.

"Do you say this thing is all going away at a certain time? … Do you want something that goes on forever?"

That calls for a sunset review, which other lawmakers have suggested could come after three years, to reassess the program.

"How do we know that the hospitals won't continue to shift" costs for uncompensated care to privately insured patients?

Hospitals have seen their uncompensated care costs soar since Brewer and lawmakers capped the Arizona Health Care Cost Containment System's program for childless adults. More than 150,000 people have fallen off AHCCCS rolls since then, and an unknown number have been frozen out.

Brewer and expansion supporters, led by the health-care industry, the Arizona Chamber of Commerce and the AARP, say those with insurance are paying a "hidden health-care tax" because the costs of treating the uninsured are passed on to them in higher hospital rates and insurance premiums.

Tobin and other expansion skeptics want to make sure hospitals don't continue to pass along those costs to paying customers if more people become insured under Medicaid and hospitals' financial strain is eased.

That could mean a law that gives the Legislature a look into hospital finances.

They also want to curb AHCCCS authority to set the tax rate on hospitals to raise funds for expansion.

And although Biggs and Brewer have said they don't support sending the measure to the ballot for voters to decide, Tobin said he would not rule that out if negotiations failed.

"I don't take any options off the table on any of these big issues," he said. "I don't know why anyone else would. If the goal is, how do we get from Point A to Point B, then nothing should be off the table."

Republic reporter Mary Jo Pitzl contributed to this article.

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