Conceding he lacks the votes, House Speaker Andy Tobin gave up Tuesday in his bid to block the Medicaid expansion plan by Gov. Jan Brewer with his own alternative.
Tobin said he's not against adding 300,000 to the rolls of the Arizona Health Care Cost Containment System. He said, though, the proposal by the governor -- and already approved by the Senate -- lacks sufficient checks and balances to ensure that the state isn't just throwing money away and that it actually reduces the number of uninsured who show up at hospitals.
But Tobin's bid in the last two weeks to negotiate with Brewer proved fruitless. He said she was unwilling to even consider what he considered moderate compromises.
"The counteroffers that we heard from her staff were so far away from where I was at,'' he said. At the same time, supporters of Brewer's Medicaid expansion lined up enough Republican votes in the House to provide a majority, without him, if all 24 Democrats agree to go along.
"It wasn't looking like the plan I was offering for Medicaid was getting a lot of support,'' he said.
The final blow, Tobin said, was the realization that the new fiscal year begins in less than four weeks and the Legislature has yet to adopt a proposed $8.8 billion spending plan. And the governor's Medicaid expansion is interwoven with the budget.
"Clearly, I think everyone's felt we've had to start getting a budget moving,'' he said. "I didn't know what else I was left to do.''
Out of bargaining chips and running out of time, Tobin agreed to have the House Appropriations Committee consider entire budget, including Medicaid expansion, on Thursday. And that, he said, could mean final House approval likely next week -- including the distinct possibility of the Medicaid provision being adopted over his objections.
That leaves it up to others to take the lead in a final effort to sideline Brewer's plan.
"I guess we'll have to kill it in the Appropriations Committee,'' said Rep. Carl Seel, R-Phoenix.
That move, however, could be irrelevant. Rep. Heather Carter, R-Cave Creek, who is carrying the plan on Brewer's behalf in the House, said she has at least the seven Republicans it would take to ensure that Medicaid expansion is part of the budget when it gets to the full House.
But Rep. Adam Kwasman, R-Oro Valley, said he thinks some of the Republicans that Carter is counting on can be politically spooked into supporting one key amendment. And if that is added to the bill, it would require 40 House votes for final approval of Brewer's plan, and not a simple majority of 31.
"I find that political survival here usually trumps almost all principle,'' said Rep. John Allen, R-Scottsdale. He said there are enough GOP lawmakers who, while they personally support Medicaid expansion, will have to go on record in favor of that supermajority requirement. And there aren't 40 votes for the plan.
A key provision of the Affordable Care Act has the federal government pay the cost of expanding health care to everyone below an adjusted figure of 138 percent of the federal poverty level. Arizona now covers only those up to the poverty level, about $19,530 a year for a family of three, with Washington paying about two-thirds of the cost.
While that's the carrot, there's also a stick: Unless Arizona signs up for Medicaid expansion, the federal government will stop paying its share of care for single adults.
Arizona's $240 million cost, to be generated by what Brewer calls an "assessment'' on hospitals, would generate about $1.6 billion a year in federal aid.
It is that assessment that Kwasman believes gives foes of her plan the best chance to kill it outright.
He contends that the levy is actually a tax. And the Arizona Constitution requires a two-thirds vote for any tax hike.
So Kwasman said he will push for an amendment to make the entire plan contingent on a two-thirds vote of the House. That amendment is a poison pill: There are not the necessary 16 House Republicans to provide that 40-vote margin needed for final approval
Allen said he believes that several of the GOP votes Carter is counting on to reach 31 -- the simple majority to approve Medicaid expansion -- will be forced politically support an amendment, backed by a majority of the GOP caucus, declaring the assessment to be a tax.
"It will cost some of them their seats to vote for something without the majority of their own caucus,'' he said.
Even if Brewer's plan is approved, two former state senators said they will try to gather then 86,405 valid signatures needed within 90 days of the end of the legislative session to delay enactment until there can be a public vote. Gubernatorial press aide Matthew Benson said, though, his boss believes the expansion plan is not subject to referendum because it is part of the budget.