Homeless in Arizona

Of course I wouldn't vote for her either way. I have hated Jan Brewer since she was a member of the Maricopa County Board of Supervisors and voted to steal $1 billion from the taxpayers and give it to Jerry Colangelo to build his Bank One Ballpark.

Source

Governor Brewer works to sell GOP on Medicaid

By Mary K. Reinhart The Republic | azcentral.com Wed Mar 6, 2013 10:30 PM

Gov. Jan Brewer says Medicaid expansion makes sense once people “do the math.” But she may not be including the political calculus.

For some Republican lawmakers, the cost of supporting their governor’s top legislative priority this year may be too great. Local GOP officials have ramped up the pressure, passing resolutions that excoriate federal health-care reform and the expansion of “socialized medicine” and threatening the political careers of those who support it.

These same legislators have become prime targets for a well-heeled, tightly organized pro-expansion campaign led by the health-care industry and Arizona business leaders, in cooperation with the governor’s office and some of the state’s top lobbyists and political strategists.

The campaign, which now has its own lobbyist, is buying TV ads, writing newspaper columns and encouraging uninsured patients to tell their stories in hopes of convincing recalcitrant Republican legislators and their constituents to support Brewer’s plan to extend Medicaid coverage to thousands of low-income Arizonans under the federal health-care overhaul she had strongly opposed.

Brewer needs the GOP-controlled Legislature’s approval, and with Democrats already on board and a dozen or more Republicans firmly opposed, the focus is turning toward GOP members, some of them House freshmen, who remain on the fence in the biggest battle of the 2013 session.

Opponents are urging legislators to insist that a two-thirds majority of the Legislature be required to approve the plan under the terms of a voter-approved constitutional amendment aimed at restricting tax and fee hikes. House Speaker Andy Tobin, R-Paulden, and Senate President Andy Biggs, R-Gilbert, appear to agree that a supermajority is required, making it a much tougher proposition for pro-expansion forces.

At stake are billions of dollars and health insurance for thousands. Expanding the state federal health-insurance program for the poor is the largest public-policy decision states will make this year. For Brewer, it has become a legacy agenda item, and insiders say she will not allow the Legislature to adjourn without its passage.

“We’ve got a lot of educating to do,” the governor told reporters following a Capitol rally with doctors Tuesday. “I’m hopeful that they will listen to their constituents and that they will do the math. Because it’s the right thing to do.”

But Brewer’s own party faithful are fighting her and accusing her — and anyone who supports expansion — of abandoning GOP principles of limited government and fiscal constraint. They say Medicaid expansion is a trap for states, enticed with federal subsidies that won’t last. The hospital tax, they say, is a “scam” to grab more federal money.

“All of us at the grass-roots level are rising up,” said A.J. Lafaro, chairman of the Maricopa County GOP, which is scheduled to vote on an anti-expansion resolution today. “We’re not doing this as an exercise in futility.”

Arizona expansion supporters hope to win legislators’ votes by going straight to their bedrock GOP constituents with a media campaign that frames Brewer’s proposal as “fiscally conservative” and “protecting taxpayers.”

“Arizonans who don’t know about this issue are going to hear about it,” said Jaime Molera, a lobbyist and former state school superintendent recently hired to coordinate the campaign for the Arizona Chamber of Commerce-led coalition. “The pain of voting no is going to be greater than the pain of voting yes.”

The proposal, the arguments

Brewer stunned local and national observers in January with her full-throated support of Medicaid expansion. An early and frequent critic of the Obama administration and the president’s health-care plan, she joined 25 other states to try to repeal it and now is among eight GOP governors to back the proposal. So far, 24 governors have indicated they’ll accept federal money for expansion but still need legislative approval.

Federal law boosts funding for states that increase Medicaid eligibility to anyone earning up to 133 percent of the federal poverty level, or just under $15,000 a year, paying nearly all the costs of expansion in the first few years. The plan would add up to 17million people to the Medicaid rolls. The Arizona Health Care Cost Containment System, the state’s Medicaid program, estimates that more than 400,000 more Arizonans would gain health insurance in the first two years, including about 140,000 adults and children who are eligible but not enrolled.

Expanding the state-federal program, which insures 1.2million low-income or disabled Arizonans, would bring in about $1.6 billion in new federal funding in fiscal 2015, the first full year. Brewer is proposing that the additional state matching funds, $154million in fiscal 2015, be raised through a tax on hospitals that treat Medicaid patients. The so-called provider assessment would trigger more federal funding, allowing hospitals to recoup their share and netting about $100million for the state general fund.

Brewer also is proposing a built-in trigger, or “circuit breaker,” that would roll back coverage if federal funding falls short of its commitment. Federal funding covers all of the costs of expanding Medicaid through 2020 and up to 90percent for restoring coverage to childless adults earning below the poverty line, whose coverage has been frozen since 2011.

The provider assessment is the trickiest part of the proposal, both politically and policy-wise. Under the plan, AHCCCS would levy a tax of up to 6 percent on most Arizona hospitals that would raise at least $256million in the first full year of expansion.

Brewer and Medicaid expansion supporters say Arizona can’t afford not to broaden AHCCCS eligibility and extend health coverage to hundreds of thousands. The health-care system is an important economic driver, and hospitals have lost millions of dollars caring for the uninsured since the AHCCCS freeze took hold.

Turning away billions in federal dollars will increase human suffering and further cripple hospitals and other health-care providers, but it won’t help reduce the federal deficit, they say.

“The longer these patients wait to be treated, the more complex and expensive their treatment is,” said Dr. Randy Oppenheimer, a Phoenix surgeon. “If they have insurance and can be treated early, it saves everybody money.”

But opponents, including conservative groups and GOP officials, argue that the federal government can’t afford “Obamacare” and the huge cash infusion to states under expansion. They accuse federal officials of bribing states to grow their Medicaid rolls now, only to renege on the deal when the money runs out, forcing states to either starve education, transportation and other programs to pay for health care or kick thousands off AHCCCS.

“Trying to argue against the helicopter drop of money on the state is very difficult from a short-term perspective,” said Byron Schlomach, an economist with the Goldwater Institute. “But the federal government is as good as bankrupt. Nothing that they say financially is believable.”

The circuit breaker and provider tax, aimed at luring Republican votes, don’t appear to have helped much. Key lawmakers alternately dismiss them as a “gimmick” and “a scam.”

Freshman Sen. Kelli Ward, R-Lake Havasu City, a family physician married to an emergency-room doctor, opposes expansion.

“It’s more of a gimmick than something we will ever pull,” Ward said of the circuit breaker. “I think that the federal government will probably run out of funding and decrease the amount they give us, and it will fall on Arizona to serve that population.”

Tobin said his members have similar concerns and believe political pressure would prevent them from cutting people from AHCCCS. Tobin said lawmakers were pilloried when they froze the childless-adult program in 2011.

“I don’t want to put my members through what I had to go through,” Tobin said. “Nobody here believes that there are not going to be cuts coming to the program. There is little or no trust with the system.”

But national health-care experts say there’s no historical evidence to support those fears. Federal matching rates have gone up, as they did temporarily during the last recession, but have never been reduced in Medicaid’s 57-year history. Cutting the more generous expansion rates would require congressional approval.

Charles Brecher, a professor of public health administration at New York University who studied Arizona’s late and reluctant entry into Medicaid in 1982, says the political battle over expansion has states sounding similar themes.

“It’s become a conservative Republican issue to say we don’t want to go along with this,” Brecher said. “Ultimately, the fiscal pressure wins out. In the U.S., and even in Arizona, we don’t let people die in the streets. We pick up some of their health-care bills.”

The Proposition 108 question

Further complicating matters for Brewer is whether a simple majority or a supermajority of two-thirds of the Legislature will be required to approve giving AHCCCS the authority to levy the hospital tax.

Legislative leaders in both chambers say the provider tax should be subject to the constitutional amendment, known as Proposition 108, requiring a two-thirds majority. The 1992 ballot measure allows the Legislature to authorize agency directors to raise fees, as long as the amount is not defined in law.

“I should at least plan on that,” said Tobin, adding that he doesn’t believe there are 40 votes in the 60-member House for expansion.

Brewer’s office disagrees. The Medicaid legislation — which is still being drafted — gives AHCCCS permission to assess the hospital fees, not unlike the authority Tobin and lawmakers have given to other agencies, most recently the state Department of Health Services, which hiked child-care licensing fees dramatically in 2009 to help balance its budget.

But Tobin, Biggs and other GOP lawmakers argue that earlier fee increases were minor compared with the proposed hospital tax.

Schlomach said the Goldwater Institute hasn’t ruled out a lawsuit if legislators OK the plan with less than a supermajority.

What’s at stake

More than 150,000 Arizonans have lost health coverage over the past two years because of budget cuts.

Medicaid expansion would continue coverage for an estimated 50,000 childless adults who would otherwise lose AHCCCS coverage on Jan. 1, when the program expires; restore health insurance to an estimated 200,000 more childless adults who earn less than the poverty level; and broaden eligibility to cover about 57,000 people between 100 percent and 133 percent of the poverty level.

As the Medicaid-expansion debate heats up and legislators wait for Brewer’s office to draft a bill, those on the fence are coming up with ways to make the proposal more palatable, or at least give them cover so they can tell voters back home they gave it their best shot.

“My argument is, if we can put a (circuit breaker) in it, we can put other things in it,” Tobin said. “Maybe there’s an audit. Maybe there’s House-Senate oversight. Maybe there’s financial disclosure (for hospitals). Maybe we have tort reform in there. Maybe there’s a premium, even though it was just thrown out in court.”

The issue is ripe for legislative haggling, with lawmakers likely to suggest other items, or insist on passage of unrelated legislation, in exchange for their support of expansion.

The Medicaid plan is expected to become part of the overall state budget debate. But a key question is whether it will be a separate bill — as Democrats, Brewer and other supporters would prefer — or included in budget-related legislation. Amending the Medicaid bill to gain support from one quarter could lose support from another.

What’s not likely to happen, Biggs said, is “punting” the issue to the ballot for voters to decide. This campaign has many similarities to the successful 2010 effort for a temporary state sales-tax hike, but Biggs said this effort won’t make it to the ballot.

“We are obligated as a Legislature to make those tough decisions,” said Biggs, who voted against referring the sales-tax increase to the ballot. “If you don’t have the wherewithal to either stand up for or against something, you probably shouldn’t be here.”

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