Originally Published: May 14, 2013 9:55 p.m.
PHOENIX - Gov. Jan Brewer's proposal to expand the state's Medicaid program to 300,000 more poor Arizonans may pass or fail based on just one person in the Legislature: Republican House Speaker Andy Tobin.
The trick for Brewer is figuring out just what Tobin wants in exchange for his support. And he's not making it easy.
Tobin, R-Paulden, has talked repeatedly about making sure hospitals don't pass on to insurers a new tax that will pay for the state's share of expansion. He worries about the state Medicaid director having unchecked power to raise the tax. And he's spoken about lawsuit reform.
But so far he hasn't said exactly what he wants in a potential deal, according to governor's spokesman Matthew Benson.
Tobin also has several other items on his wish list, including a big tax cut for insurance companies and two smaller insurer tax credits.
The governor must work through Tobin. As speaker he controls which bills make it to a vote, and he has vowed to block the Medicaid legislation unless his concerns are addressed. With Tobin's support will come enough fellow Republicans to get it out of the House.
Senate President Andy Biggs has said repeatedly that he opposes the expansion and will do everything he can to block it. However, it's clear there are enough Republican votes in the Senate for it to pass.
Democrats are unified in support, but the Legislature's Republican majority is split on the proposal. Moderate Republicans who support the expansion agree with Brewer that it will come at no cost to taxpayers, bail out hospitals that have seen uncompensated care skyrocket and bring billions in new federal dollars into the state.
Conservatives argue that states should reject Medicaid expansion that is a signature part of President Barack Obama's health care overhaul because it eventually will consume a huge chunk of the federal budget. They're floating alternatives, all of which have been rejected by Brewer.
Biggs and Tobin have been meeting with Brewer each week to try to hammer out a deal on the budget and the Medicaid expansion, but last week's meeting was canceled for unknown reasons. Brewer then turned up the heat by telling the two leaders not to send her additional bills to sign until they act on the state budget and her Medicaid proposal. She says she won't sign a budget if it doesn't include Medicaid.
Biggs said last week that he still opposes Medicaid, but negotiations are ongoing and he's hopeful a budget deal is close.
"Here's the way it is. We have one of the biggest issues - if not the biggest issue - in a generation that is overshadowing everything else we do. If any of us say, 'Oh, we're going to do X, Y, Z,' in public, one side or the other then positions to defeat what they think they're going to do," Biggs said. "What I'm comfortable saying is that I'm really hopeful that we can get a budget out of here that is a really solid budget. And I'm hoping we get that out sooner rather than later."
So the focus returns to Tobin.
In an hour-long interview with two reporters late last week, he ticked off a variety of concerns, many of which he has brought up before. He scoffed at pressure to say what he needs to support the expansion.
"This is something that wasn't on the radar screen until four months ago. It's the largest increase in government I think possibly in Arizona history," Tobin said. "And it's being run through very quickly in my view, without really an awfully lot of conversation about the language.
"Just because it's not soup yet doesn't mean it's not in process," he added. "We're trying to find options to the governor's plan that are better."
The governor's plan calls for an assessment on hospitals to bring in about $250 million a year to pay for the state's share of an expanded Medicaid program. The state can expect $1.6 billion a year in new federal funding, freeing health care providers of hundreds of millions of dollars in uncompensated care. The expansion would add at least 300,000 poor Arizonans earning up to 138 percent of the federal poverty level to the nearly 1.3 million already on the plan, called the Arizona Health Care Cost Containment System.
The government will pay 100 percent of most costs for three years and 90 percent thereafter, a much more generous share than with the rest of the Medicaid population. The governor's proposal included a "circuit breaker" that would cut the new insurance if federal funding drops below 80 percent.
Tobin said the circuit breaker proposal isn't strong enough, and he suggested an expiration date for the coverage.
"Do you want something that goes on forever, or is this the ultimate pilot program for Arizona's hospital system?" he asked.
Whatever Tobin agrees to, he made it clear it will include some things Democrats likely will find hard to stomach.
"I know that the majority is the Republicans, those are the ones who are in the majority and elected me. I'm a Republican," Tobin said. "So the goal is always for me that we lead with the Republican agenda."