Medicaid wounds are still raw in GOP

If the latest fracas between Gov. Jan Brewer and Republican Party operatives is any indication, it's going to be a long, ugly 13 months until the 2014 primary election.

Brewer recently reached out to the right wing of her party in hopes of healing wounds left by the bipartisan passage of Medicaid expansion, saying it's time to put differences aside and unite for the good of the party.

Conservative Republicans responded by sharpening their invective and moving forward with a series of "no confidence" votes against the governor and the 14 GOP lawmakers who backed the governor's expansion plan last month.

Supporters of the new law to broaden health-care coverage for the poor under the federal Affordable Care Act say the legislative precinct committee members represent a small fringe of the GOP and their symbolic votes don't matter.

But at the same time, they warn that, in some districts, working to knock off GOP moderates in the primary could give the seats to Democrats in the general election.

Brewer was concerned enough to send a letter Friday to thousands of precinct committee members across the state who make up the grass-roots political machinery of the GOP, making her case for Medicaid expansion and asking for their support.

"To continue efforts to potentially hurt and intimidate those who stood with me only puts Republicans' chances for electoral success next year back into harm's way," the governor wrote.

"We are allies. It is time to move on, work together for a united front in 2014 and focus on the key issues that face our state, including the economy, quality education and public safety."

Brewer sent a similar missive to GOP officials in March, when they were passing, during legislative-district meetings, harshly worded resolutions that opposed expansion and threatened the political careers of Republican lawmakers who supported it.

At that time, the governor argued that the GOP would be more at risk if it turned down the federal funds that will pay for most of the expansion and kicked their constituents off Medicaid.

But the conservative party loyalists say Brewer and the Republicans who teamed with Democrats to pass expansion have abandoned conservative GOP principles and made matters worse by pushing the bill through in a three-day special session that the governor called without consulting GOP leadership.

"They're elitists who think that what they've done can be forgiven. They're mistaken," Maricopa County GOP Chairman A.J. LaFaro said. "We are not going to be able to defeat all of them, but we will definitely defeat some of them. They are Arizona's 15 most wanted."

So far, GOP executive committees in five legislative districts have approved no-confidence resolutions or resolutions to censure the renegade Republicans and Brewer for supporting Medicaid expansion.

Most also include Rep. Michele Reagan, R-Scottsdale, who voted for expansion once but against it in the end. Another vote is scheduled in Mesa's Legislative District 16 on Thursday.

The votes have no legal impact, but GOP officials hope they will help turn voters against the incumbent lawmakers.

Rep. Heather Carter, R-Cave Creek, was out of town late last month when her Legislative District 15 GOP committee gave her a no-confidence vote.

Carter, who shepherded the expansion bill through the House, said she's proud of her vote but doesn't want to dwell on divisions within the party.

"I don't make decisions based on my political future," she said. "I make decisions based on what's best for my state. If you look back in history, when the Republican Party has done well, they have always provided a big tent."

Veteran Arizona pollster Bruce Merrill said the GOP split over Medicaid is another example of the conservative takeover of the state's GOP machinery.

"It just shows the extent to which the Republican Party is really fractured," said Merrill, a senior research fellow at Arizona State University's Morrison Institute for Public Policy. "The right wing has really taken over the party."

Merrill said the precinct committee members should not be underestimated in their ability to get conservative candidates elected in primaries, when most Arizona races are decided.

They may not represent mainstream Republicans, he said, but they know how to play politics.

"They're a smart, hardworking group of people who understand how the system works," Merrill said. "I reluctantly give them credit. … At the precinct level, they help you win."

Rep. Carl Seel, R-Phoenix, said he's not concerned about whether bouncing moderate Republicans could give Democrats the advantage in some districts.

As he sees it, the moderates, by voting with Democrats to pass Medicaid expansion, already have given Democrats control of the House, where the GOP holds a 34-26 advantage.

"One could make the argument that those nine turncoat Republicans in the state House are now Democrats," Seel said.

"It's not safe for any of them."

Copyright 2013 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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Pair in GOP committee won't attack on Medicaid

(PNI) Pushing back on Medicaid pushback …It's all the rage now for Republican precinct committeemen to vote to censure Gov. Jan Brewer and the 14 Republicans who voted in favor of Medicaid expansion.

When the issue came up at a District 26 meeting, district resident and gubernatorial candidate Hugh Hallman cast an unpopular "no" vote.

"In the interest of the Republican Party, I don't think it makes sense for Republicans to be attacking members of their own party," Hallman said.

Besides, censure is a legal concept and not within the purview of the committees, he said, showing his lawerly side.

Hallman called Medicaid expansion "a 'Sophie's Choice' of the worst magnitude," but said he comes down in reluctant favor of it because the piper must be paid and it's unfair to foist uncompensated emergency-room care onto hospitals and doctors.

Those costs will ultimately get passed on to the paying customers.

"It's not a Republican principle that we tax people who are paying the medical bills through insurance or private dollars to pay for those who aren't covered," Hallman said.

The other "no" vote at that meeting?

Former state Sen. Jerry Lewis, R-Mesa.

Signs around town… Dozens of campaign signs have sprung up on street corners in central Phoenix and Ahwatukee Foothills in the last week touting unusual messages: "Lobbyists Support Sal DiCiccio" and "Developers Support Sal DiCiccio."

As one might assume, the Phoenix City Council member isn't the one behind the signs.

An independent-expenditure group, Phoenix Truth and Safety, paid for the signs.

The group is funded by public-safety unions.

They hope to oust DiCiccio in the upcoming Aug.27 primary election.

It's the latest jab in a bitter feud between DiCiccio and the police and fire unions.

The two have been at war over DiCiccio's criticism of employee pensions and overall compensation.

"The signs are accurate," said David Leibowitz, a public-relations consultant working with the group. "Campaign-finance reports make that abundantly clear … and yet he holds himself as some paragon of virtue."

DiCiccio said that while he has accepted donations from lobbyists, businesses and developers, his opponent, Karlene Keogh Parks, is accepting contributions from unions.

He said the unions are trying to block his efforts to make reforms.

"I think people see through this," DiCiccio said. "It's all part of the union control of City Hall."

Your policy doesn't cover "Cat Scratch Fever" … Conservative rocker Ted Nugent will reportedly take up the anti-Medicaid-expansion banner at his concert scheduled for tonight at Celebrity Theater in Phoenix.

Frank Antenori, a former state senator from Tucson and an organizer of the petition drive to put the Medicaid-expansion law on the 2014 ballot, said he had dinner with the gun-loving, Obama-hating, 64-year-old "Motor City Madman" a couple of years ago and the two connected over their love of archery hunting.

When Antenori learned Nugent's tour was coming to Phoenix, he put in a call to see if the "tea party" darling would give an on-stage shout-out to the referendum effort and ask fans to sign petitions after the concert.

After last summer's U.S. Supreme Court decision upholding the federal health-care overhaul, Nugent called Chief Justice John Roberts a "traitor" and said he was "beginning to wonder if it would have been best had the South won the Civil War."

The United Republican Alliance of Principled Conservatives, which is leading the referendum drive, hopes to collect 120,000 signatures by the Sept.11 deadline.

Compiled by Republic reporters Mary Jo Pitzl, Dianna M. Náñez, Dustin Gardiner and Mary K. Reinhart. Get the latest at politics.azcentral.com.

Copyright 2013 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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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.

Copyright 2013 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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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.

Copyright 2013 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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Feds say no to funding a leaner Ariz. Medicaid

Federal health officials dealt a blow to opponents of Medicaid expansion Thursday, saying they're unlikely to fund a slimmed-down version of the state's indigent-health-care program as the political battle over the issue intensified.

Gov. Jan Brewer declared the federal announcement a game-changer in the debate, which is holding up a new state budget. She told GOP legislative leaders to stop delaying a vote on Medicaid expansion and move swiftly to present her expansion plan to lawmakers.

Senate President Andy Biggs rejected the governor's calls, and during a rally on the House lawn, expansion opponents played down the news from the federal Centers for Medicare and Medicaid Services.

Local Republican Party officials and "tea party" members cheered as GOP lawmakers pilloried Brewer's plan and said Arizona can do better on its own.

"We don't have to expand," said Biggs, R-Gilbert, who has vowed not to bring Brewer's proposal to the Senate floor for a vote. "We have an alternate plan, a plan that will not unfairly burden our children and grandchildren to pay for medical care today."

Thursday's developments, which included a significant increase in legislative cost estimates for rejecting expansion, served only to further entrench both sides, with rumors flying about everything from the potential collapse of budget negotiations to a Senate coup to bypass Biggs.

Brewer spokesman Matthew Benson said nothing will change the governor's mind on Medicaid expansion.

"She's committed to this proposal and is prepared to see it through, regardless of how hot it gets," Benson said. "This is life and death. … It's not some petty political problem."

In a memo released Thursday, Centers for Medicare and Medicaid Services officials indicated federal matching funds would not be available to continue Arizona's enrollment-capped Medicaid program for childless adults. The federal officials said, "We do not anticipate that we would authorize enrollment caps or similar policies" under the program, which would mean no federal funding.

Brewer and lawmakers froze the childless-adult program in 2011, and it will be eliminated entirely on Dec. 31 barring federal approval of a new application. That would end health coverage for an estimated 60,000 Arizonans.

Biggs wants to maintain the freeze and use state funds to cover those people, who include thousands with serious mental illnesses and other chronic diseases.

Under the GOP leadership's alternative, people above 100 percent of the poverty level could get subsidized health coverage through online insurance exchanges set up through the federal health law.

Under Medicaid expansion as part of the Affordable Care Act, the federal government would pay all the costs of insuring people between 100percent and 133 percent of the poverty level.

Brewer seized on the federal memo to renew her push for her top legislative priority, saying it eliminated the leading alternative to broadening Medicaid eligibility.

"Today's clear guidance from CMS makes it apparent that there is really only one viable option," the governor wrote to Biggs and House Speaker Andy Tobin, R-Paulden. "It is time for us to complete the people's work."

But Biggs, Tobin and other GOP Medicaid-expansion opponents viewed the federal guidance as a "maybe" and refused to be deterred by it.

"Whether the feds chip in or whether they don't chip in, this is the best option that we have," Biggs said of forgoing expansion, continuing the freeze and insuring the poorest Arizonans with state money. "At bare minimum, we have three years to watch 'Obamacare' implode around the nation while we don't have to suffer."

Biggs and Tobin, who have become the main roadblocks to Brewer's expansion plan, say their GOP members oppose broadening Medicaid eligibility as fiscally unsustainable and politically poisonous.

They don't trust the federal government to keep its promise of covering nearly all the expansion costs, and members fear voter backlash in the 2014 primary if they support it.

Brewer, a longtime opponent of the Obama administration's health-care overhaul, is among eight GOP governors to support expanding Medicaid, the state-federal program that covers more than 1.2 million poor and disabled Arizonans.

Her plan would add roughly 400,000 people to the Arizona Health Care Cost Containment System, the state's Medicaid program, with $1.6billion in federal funding by fiscal 2015 and a tax on hospitals to cover the state's additional share.

She is backed by business leaders, non-profit organizations and the health-care industry, including hospitals caring for a growing number of uninsured Arizonans. But she is facing stiff opposition from legislative leaders and grass-roots GOP loyalists.

While Tobin has not ruled out an eventual vote on Medicaid expansion, Biggs said he will not bring any legislation to the floor of the Senate if it includes the federally funded expansion.

In an interview with The Arizona Republic, Biggs said it's his responsibility as the Senate leader to stand firm against a policy that fellow Republicans oppose.

He said beyond his own objections to the federal health law, recent polls, constituent communications and conversations with lawmakers prove it is wrong for Arizona and for the GOP.

"I'm not going to put (Medicaid) expansion on the floor. The Republican Party in this state has said, 'Don't do this,'" he said. "Republicans hate this, and they're not going to vote for a Republican in a primary who's (supported) this."

Biggs said even GOP senators who support the expansion -- and there are at least three and perhaps as many as six or seven -- aren't eager to vote on it. But he conceded that there are other ways for a Medicaid bill to come to the floor, and he expects that it will.

"At this point at least, I'm not ready to give up," Biggs said. "At the bare minimum, we have an obligation to rationally discuss with the executive branch … (our) position and why."

Brewer's office, however, said Biggs' alternative is neither financially nor politically viable.

"He doesn't have the votes for that," Benson said. "There are enough votes in the Senate for the governor's plan. … But if legislators would prefer to do this later as opposed to sooner, that's their option."

Brewer met with 15 to 20 Republican House and Senate members last week. Many GOP lawmakers say they're undecided, but there appear to be just enough votes for a simple majority in the House, where Tobin said he isn't ready to advance Brewer's plan.

"I don't like her bill," he said this week.

Tobin said he is open to alternatives but conceded it would be difficult, if not impossible, to find a middle ground between the governor's proposal and the concerns raised by opponents.

"If there's a middle, it would be the first in the country," he said.

But Tobin said there must be changes to Brewer's plan, both to win GOP support and to ensure an expanded Medicaid program won't run out of control.

At the Capitol rally, physician and Sen. Kelli Ward, R-Lake Havasu City, said she supports good quality, accessible health care for as many people as possible, but she believes that Medicaid offers "substandard care" and that expanding it reduces the incentive for people to improve their circumstances and get off the public dole.

Ward said she doesn't know exactly what alternative Medicaid legislation would look like, but it would include funding to keep childless adults insured. Voters in 2000 expanded AHCCCS to cover everyone living below the poverty level, but more than 150,000 people have fallen off since the program was capped.

Also Thursday, legislative budget analysts significantly increased their estimates of the cost to insure poor, childless adults without using federal funding, surpassing Brewer's cost projections.

The Joint Legislative Budget Committee now estimates it would cost $266million to cover 55,800 people who would remain on the program Dec. 31, compared with the governor's estimates of $200million and 60,225 people for fiscal 2014.

Lawmakers had been working with much smaller numbers, projecting coverage for just 35,000 people at a cost of $83million in fiscal 2014.

Under the new JLBC estimates, keeping the freeze on the childless-adult program would cost $880million through fiscal 2016. Brewer's budget office puts that number at $863million.

The cost of expansion has been a sticking point, with opponents maintaining the state can afford to reject federal funding and supporters saying infusion of billions of federal dollars would be a boon to the economy.

While Biggs and Tobin have the authority to decide what bills are voted on, there are ways around them.

Brewer's proposal isn't officially a bill yet, but several parliamentary strategies are being discussed behind the scenes to turn Medicaid expansion into formal legislation, including adding it to an unrelated health-care measure as an amendment during floor debate or combining it with bills in a conference committee.

Biggs could not prevent those moves, but he likely would refuse to schedule the amended bill for a formal vote of the full Senate. That's when a majority of senators could vote to suspend the rules, insist that the bill be brought forward for a vote or even replace the president.

A majority vote in the House also is required to force a vote on a bill that hasn't been scheduled by the speaker.

Barry Aarons, a longtime lobbyist who doesn't have a client on either side of the debate, said there are "so many moving pieces," including Medicaid's connection to the budget, that the endgame is difficult to predict. "This is not a policy issue anymore. This is a mechanical issue," he said. "This is not a monolithic up-or-down vote on Medicaid expansion."

Republic reporter Mary Jo Pitzl contributed to this article.

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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.

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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.

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Medicaid growth would aid vets

Though they have served their country and are eligible for health benefits through the Department of Veterans Affairs, a new study shows that 1.3million U.S. veterans, including 11,000 in Arizona, are uninsured and an estimated 40percent of them are poor enough to qualify for Medicaid.

Another 2,000 Arizona veterans would be eligible for the state-federal health-insurance program if the state agrees to Medicaid expansion under the federal health overhaul, according to the study released this week by the Urban Institute and the Robert Wood Johnson Foundation.

The analysis also shows Medicaid expansion would extend health coverage to an additional 61,000 veterans' spouses who are uninsured, including 1,300 in Arizona whose incomes put them between 100percent and 133percent of the federal poverty level.

Ten percent of uninsured veterans would qualify for Medicaid without expansion, according to the study, compared with an estimated 40percent if states broaden eligibility. In states that forgo expansion, a so-called doughnut hole in the Affordable Care Act would leave childless adults below the poverty line without access to Medicaid or subsidized coverage in the online insurance exchanges.

"As with the general population, uninsurance among veterans and their family members is related to greater problems accessing care," the study said.

Gov. Jan Brewer cited the report Tuesday as another reason for state lawmakers to approve Medicaid expansion. The issue has caused a Republican Party split in states across the country and Brewer is struggling to cobble together enough GOP votes to get her proposal through the Legislature.

"It is unacceptable to me that so many of our veterans who honorably served this nation would be without access to basic health care," Brewer said in a statement. "With my (Medicaid) plan, we have an opportunity to provide basic, cost-effective care to the men and women who have sacrificed for this nation. This is our chance to throw them a lifeline."

Veterans are eligible for health care through the Department of Veterans Affairs, but according to the analysis, many are uninsured because they don't have access to facilities in their area or are unaware that they qualify for health coverage.

Some also miss out because the VA gives care first to higher-priority veterans, including military retirees and those with service-related medical conditions.

Most of those eligible under Medicaid expansion would remain uninsured in states that fail to broaden eligibility.

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Brewer faces political struggle to expand Medicaid

(PNI) From the political notebook:

A lot of attention has been paid to the substance of Gov. Jan Brewer's Medicaid-expansion proposal. Less attention has been paid to a political and legal question that may be more important in determining its fate: How many Republican votes does it need in the Legislature to be enacted?

The assumption is that all the Democrats in the Legislature will vote for it. They may be tempted to attempt to bargain for something else in exchange for their support. If they are serious about the priority they claim to put on the expansion, they will forgo that temptation.

Republican votes for expansion will be tricky to come by. If Brewer has to sell not only the expansion but what Democrats want in exchange for their votes in favor, it might become a bridge too far.

So, assume Democrats play it straight and Brewer can pocket their votes. If the expansion only needs a simple majority to be enacted, that would require just three Republican votes in the Senate and seven in the House. Not much of a hill.

But Brewer's Medicaid-expansion proposal arguably needs more than a simple majority. Brewer is asking the Legislature to give the state agency that administers Medicaid authority to levy a provider assessment to pay the state's cost of providing Medicaid coverage for childless adults.

In 1992, voters approved an initiative that requires a two-thirds approval from both houses of the Legislature for any "net increase in state revenues." It explicitly includes "the imposition of any new state fee or assessment or the authorization of any new administratively set fee."

That would certainly seem to cover what the governor is proposing. The Governor's Office, however, is arguing that the assessment falls within an exception to the rule for "fees and assessments that are authorized by statute but are not prescribed by formula, amount or limit, and are set by a state officer or agency."

That's a stretch. While there might not be an amount set in the authorization to the penny, there's a clear understanding about its size. The number is in the governor's budget and proposal. Claiming that exception would be a dubious wink and a nod at a voter-approved constitutional requirement.

If the two-thirds approval applies, that raises the number of Republican votes Brewer needs to seven in the Senate and 16 in the House. The hill just became steeper.

There is an informal rule in both the Senate and the House that leadership will not bring any bill to the floor that doesn't have the support of a majority of the majority. That would require nine Republican votes in favor in the Senate and 18 in the House. Even steeper.

Put another way, if "the majority of the majority" requirement prevails, just nine of 30 senators or 19 of 60 House members could block the expansion.

The governor might be able to bargain for an agreement from leadership to bring Medicaid expansion to a vote without "the majority of the majority" requirement as part of a broader deal. But it would require pretty bruising negotiations. Permitting a vote on a Medicaid expansion opposed by a majority of his caucus would be particularly difficult for Senate President Andy Biggs.

My bet is that sequestration at the federal level occurs. Those are the budget cuts Congress adopted on a standby basis if the so-called supercommittee didn't come up with an alternative way to cut the deficit. They were designed to be so unpalatable that the supercommittee couldn't fail. It did anyway, and Congress and President Barack Obama are no closer today than then to agreeing on an alternative.

Republicans don't like the sequestration cuts because they fall disproportionately on defense. The House has passed an alternative that puts more of the burden on domestic spending.

Democrats aren't willing to come up with alternative cuts. They insist on more revenue and fewer cuts overall. It's becoming increasingly obvious to Republicans that the choice isn't between sequestration cuts and some alternative set of spending reductions. The real choice is between sequestration cuts and no cuts.

Despite deep misgivings about the effect on defense, I think Republicans will opt for the sequestration cuts rather than no cuts. At this point, deficit hawks in the Republican Party are stronger than the defense hawks.

Reach Robb at robert.robb @arizonarepublic.com.

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Medicaid After the Supreme Court Decision

Last week there were two disturbing reports about Medicaid, a program of health insurance for the poor that is mostly managed by the states and jointly paid for by the federal and state governments. The Congressional Budget Office predicted that states with a large number of poor people would not expand their Medicaid programs as required by the health care reform law now that the Supreme Court had made expansion optional. And a Harvard study unrelated to the court decision made it clear that a failure to expand Medicaid would likely doom thousands of low-income people to death or poor health.

Revising earlier estimates to take account of the decision, the budget office said that making expanded assistance optional could leave three million more people uninsured in 2022, saving the federal government $84 billion through 2022 because it would not have to subsidize their coverage.

The analysts made no effort to predict which states would or would not expand Medicaid. Instead, they looked at various factors that might influence the states’ decisions and predicted that some would not respond to even the extremely generous matching money that the reform law provided.

They forecast that some states that already had trouble paying for their existing Medicaid programs would put off expanding Medicaid until their economies improved, or would expand the program partially, not to the extent originally required. Other states may shun the program entirely, as some Republican governors have vowed to do. By 2022, the budget office projects, only two-thirds of those who would become newly eligible for Medicaid if all states expanded to the levels sought by the reform law will actually gain eligibility. One-third will not, either because their states refuse to expand Medicaid at all or expand it only partially.

Leaving low-income people uninsured will almost certainly damage their health. A study by three researchers affiliated with the Harvard School of Public Health, published by The New England Journal of Medicine, compared three states (New York, Arizona and Maine) that had already expanded coverage of childless or disabled adults with four neighboring states (Pennsylvania, New Mexico, Nevada and New Hampshire) that had not. Deaths among people ages 20 to 64 dropped in the three expansion states by about 1,500 a year, adjusted for population growth, whereas death rates in the comparison states went up. Expansion also brought a 21 percent reduction in cost-related delays in getting care.

Some critics, mostly conservative Republicans, contend that Medicaid does not improve the health of beneficiaries and may even harm them. The new study should lay that canard to rest. State officials who want to save money by not expanding Medicaid will be harming their most vulnerable residents, and will most likely shift the cost of any emergency care they need to safety net institutions, taxpayers and charities.

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