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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Poll says half favor Medicaid expansion

As both sides of the political debate dig in for weeks, or perhaps months, of tough negotiations over Gov. Jan Brewer's proposal to expand Medicaid in Arizona, a statewide poll indicates that nearly half of likely voters support the plan but that more than a third have never heard of it.

The poll, paid for by pro- expansion forces, also said that almost half of Republicans surveyed back the idea of broadening health-care coverage to low-income and disabled Arizonans under federal health reform.

Those who identified themselves as "tea party" members, however, oppose the move by a 2-1 ratio, 45percent to 22percent.

The survey of 500 voters was conducted March19-21 by the national polling firm Public Opinion Strategies. The poll had a margin of error of plus or minus 4.4percentage points.

The results were shown to The Arizona Republic this week as House GOP leaders finished a series of small meetings with the rank and file, showcasing a preliminary state budget plan that doesn't include Brewer's Medicaid proposal. The governor also has been meeting privately with GOP members who support her plan.

She wants to expand the state-federal program, which insures about 1.2million Arizonans, to provide health insurance to an additional 400,000 and bring in about $1.6billion in federal funding in fiscal 2015, the first full year of expansion. The state's additional matching funds would be raised through a tax on hospitals that treat Medicaid patients.

The Arizona Business Coalition, led by the Arizona Chamber of Commerce and the health-care industry, commissioned the poll and released portions of the survey, which lobbyist Jaime Molera said also included questions about Brewer's popularity.

Molera said results showed that the more voters know about the governor's Medicaid plan, the better they like it. He said the poll did not include "push" questions designed to lead respondents.

"It tells me exactly where we're at and what we need to do. … It tells me we're going in the right direction," he said.

Brewer's proposal has sharply divided her own Republican Party, and while most observers believe there are enough votes in the Legislature to win a simple majority, the politics are dicey enough that GOP backers want cover from more members before they vote for it.

Republican opponents, including the House and Senate leaders, are concerned that cost estimates of expansion are way off and that the federal government can't afford it and will eventually renege, leaving Arizona to pay or toss people off the rolls.

"My proposal is, you don't expand Medicaid," said Senate President Andy Biggs, R-Gilbert. "There are a million and one reasons I think this is a bad idea."

Among those surveyed, 47percent said they supported Brewer's expansion plan, 17percent opposed it, and 36percent had not heard of it.

The poll also indicated that support for expansion grows among people who say they've heard a lot about the plan.

Nearly three-fourths of those who say they're somewhat familiar with Brewer's plan are supportive.

And it also hinted at strong support for Brewer and her conservative credentials, which supporters say should comfort GOP lawmakers whom local party officials are threatening to unseat in the next election.

"Republicans are getting threatened that they're going to lose their seats," Molera said. "If Governor Brewer is behind something, and certainly behind them … having her behind you is going to be tremendously powerful."

In a separate question, survey respondents were given three choices: Restoring the voter-approved childless-adult program at a cost to the state of $450million; expanding Medicaid to cover more people at a state cost of $150million; and doing nothing to restore or expand the program. Fifty-two percent chose expansion, 21percent wanted to restore coverage for childless adults and 21percent wanted to do nothing.

Sen. Nancy Barto, R-Phoenix, said she remains concerned about the costs of expanding Medicaid and the accuracy of the state's estimates of how many people will qualify. And she questions why states or the federal government would want to expand Medicaid to people earning 133percent of the federal poverty level, or about $15,000 a year, instead of providing subsidies to help people find their own insurance on newly created online health exchanges.

"I still have some huge reservations because of the cost going forward," Barto said. "I just think we're not doing people any favors by pushing them onto a Medicaid system."

Rep. Heather Carter, R-Cave Creek, who is leading efforts to get expansion through the House, said she believes that the more lawmakers and their constituents learn about Medicaid expansion, the more supportive they will become.

Copyright 2012 The Arizona Republic|azcentral.com. All rights reserved.For more information about reprints & permissions, visit our FAQ's. To report corrections and clarifications, contact Standards Editor Brent Jones. For publication consideration in the newspaper, send comments to letters@usatoday.com. Include name, phone number, city and state for verification. To view our corrections, go to corrections.usatoday.com.

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Medicaid expansion debated in House

The first public airing of Gov. Jan Brewer's proposal to expand Medicaid was a four-hour, wide-ranging, sometimes- vitriolic debate Wednesday that offered a preview into how nasty this year's biggest legislative battle could become.

The informational hearing before the House Appropriations Committee didn't yield new information or formal action, but dozens of people testified about the perceived benefits and evils of expanding the Arizona Health Care Cost Containment System, the state's Medicaid program, under the federal health-care overhaul.

An overflow crowd jammed the hearing room and another room down the hall, lawmakers talked over each other and exchanged snide remarks, and a Republican Party official likened the governor to Judas.

Patients, health-care professionals, business owners and people who work with the poor and the mentally ill said broadening eligibility for Medicaid and uncapping a program that insures childless adults would be a lifeline to hundreds of thousands of Arizonans, a huge relief to hospitals across the state treating a growing number of uninsured and ultimately bring savings for taxpayers.

But opponents of expansion, including committee Chairman John Kavanagh, R-Fountain Hills, and GOP officials, said adding 400,000 people to the state-federal program for the poor and disabled, taxing hospitals to help pay for it and accepting billions in new federal funding would only add to the country's dangerously high debt without solving the problem of skyrocketing health-care costs.

The debate among committee members frequently devolved into partisan bickering, but people who waited hours to testify were testament to the issue's significance.

"AHCCCS has been my lifeline, and it is the reason I can see all of you right now," said Chantal Duquette, 25, an Arizona State University senior who has an autoimmune disorder that could blind her without proper treatment. "By supporting AHCCCS, we are contributing to the future of Arizona."

Duquette's health coverage will end Dec. 31, along with an estimated 50,000 other Arizonans insured under a voter-approved program for childless adults that legislators capped to help balance the budget in 2011 and which is due to expire. Under Medicaid expansion, those earning up to 133 percent of the federal poverty level, or just under $15,000 a year, would be eligible for AHCCCS.

The governor's plan is backed by a coalition led by the Arizona Chamber of Commerce and the health-care industry, but her harshest critics are conservative Republicans, particularly precinct committeemen.

GOP groups in three counties and numerous legislative districts have passed resolutions calling for lawmakers to reject expansion, and testimony from Maricopa County GOP Chairman A.J. LaFaro showed how ugly the issue has become.

"Jesus had Judas. Republicans have Governor Brewer," LaFaro said before walking away from the podium.

Though there were some groans in the audience, committee members did not rebuke him. Brewer chief of staff Scott Smith, however, had words with LaFaro outside the House, and House Speaker Andy Tobin, R-Paulden, sent a tweet calling for LaFaro to apologize and resign.

"Obviously, his statement was irrational and unhinged," Brewer spokesman Matthew Benson said. "But if that's who opponents of the governor's plan want to have as their spokesperson, I say, 'Fantastic.'"

Brewer's proposal would bring in nearly $1.6 billion in additional federal funding in 2015, the first full year of expansion, and pay for the state's share with an assessment on hospitals. The so-called bed tax is expected to raise $256 million in 2015 by pulling in additional federal matching funds.

In addition to objections over federal debt and government-run health care, many Republican lawmakers believe the hospital tax should be subject to a two-thirds majority under a 1992 ballot measure, Proposition 108, designed to make it more difficult for the Legislature to raise taxes and fees. The GOP governor has enough votes to get a simple majority in the Senate, and likely in the House, but a supermajority would be far more difficult to muster.

"I think we need to take Prop. 108 very seriously," said Rep. Justin Olson, R-Mesa, and be prepared for the state to be sued if the measure passes without a two-thirds majority.

Legislators also argued over whether there was another option available: asking federal health officials to continue the childless-adult program and the 66 percent funding match that comes with it. If Arizona agreed to expand Medicaid, federal funds would pay for 85 percent to 100 percent of the cost.

Kavanagh said growing the program is not the way to get hold of health-care costs.

"When people have insurance, they use it," Kavanagh said. "There is going to be a tsunami of new people seeking medical treatment."

Dozens testified that insuring more Arizonans would save the state money by preventing unnecessary hospitalizations and emergency-room visits.

Yavapai County Attorney Sheila Polk said she has seen more people with mental illness wind up in jail as Arizona has reduced funding for AHCCCS and mental-health treatment.

"Incarceration is an expensive way to provide mental-health care," Polk said. "And, of course, it's not the appropriate or humane way to treat those with mental illness."

Copyright 2012 The Arizona Republic|azcentral.com. All rights reserved.For more information about reprints & permissions, visit our FAQ's. To report corrections and clarifications, contact Standards Editor Brent Jones. For publication consideration in the newspaper, send comments to letters@usatoday.com. Include name, phone number, city and state for verification. To view our corrections, go to corrections.usatoday.com.

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GOP split on Medicaid expansion

The next few weeks could prove critical in determining the direction of Arizona's debate over Medicaid expansion, setting the stage for months of interparty rancor or a relatively smooth transition into a critical phase of federal health-care reform.

State lawmakers have the framework of Gov. Jan Brewer's proposal to expand eligibility for the state-federal health-insurance program for low-income and disabled people, but Republican leaders still must decide how -- or whether -- to amend the legislation to get the governor's top legislative priority through the House and Senate and to her desk.

Brewer signaled this week that she wants legislators to slow their work on routine bills and shift their attention to the session's thorniest issues, including the fiscal 2014 budget, Medicaid expansion and simplifying the state sales-tax code.

With regular daily committee hearings at the Legislature winding down, attention invariably turns to the budget, and those negotiations are expected to ramp up in the coming weeks. The Medicaid debate is intertwined with budget talks because the governor's expansion plan would add money to the general fund, and failing to do so could be a net loss.

The discussions between legislative leaders, the Governor's Office and staff also will include the usual haggling over amendments and horse-trading over other unrelated bills that lawmakers want passed, or at least considered, in exchange for their votes.

While those talks will be behind closed doors, there may be opportunities for additional public testimony on the issue.

House Appropriations Committee Chairman John Kavanagh, R-Fountain Hills, said he tentatively plans to schedule a hearing next week with presentations from state Medicaid officials, the Goldwater Institute and hospital administrators.

Kavanagh, a firm opponent of expansion, presided over the first public hearing on Medicaid last week, a sometimes-bitter debate that included testimony from dozens of patients, business leaders and health-care officials in favor of Brewer's plan and Republican Party loyalists who oppose it.

House Health Committee Chair Heather Carter, R-Cave Creek, said she wants to talk with House Speaker Andy Tobin this week about scheduling an informational hearing in her committee. Brewer's office wanted Carter to host the first hearing, but Tobin decided to put the matter before the Appropriations Committee.

At this point in the session, additional committee meetings, with the exception of appropriations committees, must get approval from Tobin, R-Paulden, or Senate President Andy Biggs, R-Gilbert.

"I'd like to dive into the health policy about why this makes sense for Arizona," Carter said. "We've talked about the economics in Appropriations. Maybe the next step is to look at the health policy in Health."

After headlining two Capitol rallies earlier this month, the governor is expected to spend the coming weeks in budget negotiations with legislators and traveling across the state selling her Medicaid plan, which provides health coverage to an additional 400,000 people by 2015 with an infusion of $1.6billion in federal funds.

Supporters include the state's heaviest hitters, from the health-care industry to top business leaders, as well as more than 100 other organizations. They've been raising money to run a pro-expansion campaign that includes radio and TV spots, and to support GOP legislators in the next election.

Opponents are led by conservative Republicans, particularly people within the GOP apparatus, who are sending e-mail blasts and passing resolutions likening expansion to socialism and, at the Appropriations hearing last week, comparing Brewer to Judas for betraying the party over federal health-care reform.

The GOP split is putting increasing pressure on more than a dozen Republican lawmakers who remain undecided and who are being heavily lobbied by their local hospitals, precinct committee members and fellow legislators on both sides of the issue.

The Republican loyalists have threatened recalcitrant legislators with their jobs, saying they will face GOP primary opposition in the next election if they support expansion.

But the coalition backing Brewer's plan has been assuring these same legislators that they'll provide the campaign funding to beat back any primary challenge.

Another player that could turn critical votes toward the plan is the AARP, which is looking to Arizona as a bellwether for other states where Republican governors have backed the plan but face opposition from their GOP-led legislatures. Lawmakers representing districts with large retiree populations, including constituents on fixed incomes but not yet old enough to qualify for Medicare, are hearing from local AARP members encouraging their support for Medicaid expansion.

Two other factors that could work in Brewer's favor are her veto pen and time. By all accounts, the governor is willing to wait as long as she has to -- long after lawmakers' daily allowances get cut in half next month -- to get Medicaid expansion through the Legislature.

"We'll just continue to beat the drum," said Jaime Molera, a lobbyist for the pro-expansion forces. "I believe that when they start seeing the ramifications of (not expanding Medicaid) … it becomes harder and harder to say with a straight face that nothing important is going to happen."

Reach the reporter at maryk .reinhart@arizonarepublic.com.

Copyright 2012 The Arizona Republic|azcentral.com. All rights reserved.For more information about reprints & permissions, visit our FAQ's. To report corrections and clarifications, contact Standards Editor Brent Jones. For publication consideration in the newspaper, send comments to letters@usatoday.com. Include name, phone number, city and state for verification. To view our corrections, go to corrections.usatoday.com.

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