Calling the governor's proposal unacceptable and politically dead at the Legislature, House Speaker Andy Tobin unveiled his own new plan Tuesday to expand Medicaid, one that would give Arizona voters the final say.
The measure would allow Arizona to add about 300,000 to the rolls of the Arizona Health Care Cost Containment System on top of the 1.3 million already enrolled. That is identical to what Gov. Jan Brewer wants to do.
But Tobin's plan puts far more strings on the tax on hospitals that would be needed to pay the state's share of the plan. That includes giving authority over the size of the levy to a legislative committee and not, as Brewer wants, her appointed head of the state's Medicaid program.
Tobin also includes provisions designed to cut health care costs and add money for graduate medical education, language he said is lacking in the plan unveiled by the governor in January. And there is funding for medical research for everything from heart disease to preventive care.
All that, he said, deals with the problems of high health care costs rather than the symptoms.
"What drives down the cost is better health care,'' he said.
More controversial is a separate measure designed to restrict, if not bar, any of the funds from going to organizations which also provide abortion "because we're a pro-life Legislature.''
The big change, though, is making the entire package subject to voter approval. The governor said Tuesday she does not like that.
"I believe we are all elected by the voters of Arizona to make these tough decisions,'' the governor said. And she contended that lawmakers should simply ratify what she has proposed.
There is precedent for what Tobin wants. When Brewer could not get lawmakers themselves to adopt a temporary one-cent tax hike in 2010 she did round up the votes to have the issue sent to the ballot.
Brewer said she believes the public supports her Medicaid plan as much as they did her sales tax hike. But the governor conceded she would rather not take it directly to voters.
"It's really complex,'' she said. "I think it's something that's really difficult to get out there to explain.''
And Brewer said she is not anxious to campaign in the middle of the summer, as the earliest this could get on the ballot would be August.
Tobin's move comes as Brewer is making another bid to pressure lawmakers themselves to adopt her plan. She is planning a rally on the Capitol lawn on Wednesday, her fourth since trotting out the plan in January.
Others have included hospitals, health care providers and patients. This new one features special interest groups like the Children's Action Alliance and the American Association of Retired Persons.
But Tobin said there just aren't the necessary votes, at least in the House, for what Brewer wants. And while some business groups are in support, the National Federation of Independent Business weighed in Tuesday against the plan.
Tobin said the governor should support any plan that gets the expansion she wants, even if it's not her way.
The fight surrounds the federal Affordable Care Act designed to provide free care for anyone up to an adjusted figure of 138 percent of the federal poverty level. AHCCCS already covers most families and some single adults up to 100 percent of the poverty level, about $19,530 a year for a family of three.
While the federal government will pick up most of the additional cost, expansion is not free.
Brewer proposes a $250 million levy on hospitals to cover the state's share. She said that will bring in about $1.6 billion in federal funds.
Most hospitals have signed on in support, figuring that the expanded eligibility will reduce the number of patients showing up without insurance and unable to pay their bills. And Brewer said her plan will bar hospitals from shifting the cost of the levy to others.
Tobin, however, said the plan is flawed. He wants to set up what would amount to an audit process, overseen in part by private insurance companies, to ensure that hospitals do not shift costs and that they use the extra federal funds they will get to reduce uncompensated care and not to bolster corporate profits.
While opposing a public vote, Brewer did say there's a "good chance'' she might adopt some of the details of what Tobin wants. That even includes his proposal to have the expansion dry up on Dec. 31, 2016, giving lawmakers a chance to decide at that time whether it makes financial sense or whether Arizona should opt out.
Brewer said, though, said she's not particularly interested in language in Tobin's plan aimed at Planned Parenthood.
That organization already gets Medicaid funds for family planning. And state and federal laws both bar public funds for elective abortions.
But proponents contend any cash that goes to Planned Parenthood effectively underwrites its fixed costs for other services, including abortion.
A prior attempt by lawmakers to bar Medicaid funding for Planned Parenthood was declared illegal by a federal judge. Tobin's plan would try some different language in hopes of getting it past the courts.
Brewer, however, said she does not want another court fight. And she called the proposal "unnecessary.''
Tobin needs to do more than sell his Medicaid expansion plan to lawmakers. Their action -- if he can round up the support -- would only forward the plan to the ballot.
He said, though, a public vote is necessary because of that hospital assessment.
The Arizona Constitution requires a two-thirds vote of both the House and Senate for any tax increase.
Brewer probably cannot get that. She contends, however, her plan simply gives the AHCCCS director authority to levy a fee, which is not subject to the two-thirds rule.
Tobin called her interpretation legally questionable.
Anyway, he said, his plan has the fee imposed by a legislative panel, not an agency chief, clearly making it a tax. And he pointed out that it takes only a simple majority of the Legislature to refer tax hike to voters -- and a simple majority of voters to approve the levy.
Beyond that, Tobin said this deserves public scrutiny.
"This is a huge issue,'' he said, calling it "potentially the largest expansion of any government department or program in decades, if not our history.''
Tobin also took a slap at Brewer for presenting her full-blown plan to lawmakers in January and then, in essence, asking them to simply ratify it.
"The bill that the governor's office produced didn't have any sunshine on it,'' he said.