• Restore cuts to Arizona’s Medicaid program made in 2010 as an austerity measure – at no expense to the state!
• Infuse $1.6 billion of federal funding to Arizona to restore these cutbacks to our program – again at no cost to the state,
• Enable an estimated 300,000 additional low-income Arizonans (many of whom are members of the working poor) to access quality health care, dramatically increase their quality of life and save thousands of lives in the process,
• Provide a substantial boost to our state’s economy by creating 21,000 jobs, many of which will be high paying jobs in the health care sector, and
• Protect both rural and urban safety net hospitals (including several Tucson hospitals) from being pushed to the brink of bankruptcy by growing costs of uncompensated care following the 2010 Medicaid cutbacks.

This is precisely the proposal that Governor Brewer introduced in her January 14 State of the State address, and more recently rolled out as a legislative proposal at a press conference on March 12.

To anyone looking at the situation rationally, the Governor’s proposal to take advantage of funding available under the Affordable Care Act to restore the cuts to our Medicaid program would appear to be a no-brainer!

While Gov. Brewer was staunchly opposed to passage of the Affordable Care Act, commonly known as Obamacare, she is a pragmatist and a shrewd fiscal manager who simply wants to do the best thing for the people of Arizona.  On January 14 she acknowledged that the Affordable Care Act is clearly the law of the land, together with the fact that on two separate occasions our citizens have voted to expand our Medicaid program to cover several hundred thousand medically indigent Arizonans.  Given these realities, she contends that it would be fool-hardy for our state to walk away from the opportunity to recoup a sizable portion of our federal tax dollars to restore  our Medicaid program to the level that existed before the 2010 cut-backs.

Furthermore, the Governor’s plan will raise the $220 million needed to access the federal funding of $1.6 billion through imposing an assessment on hospitals, which they will readily recoup from the infusion of federal funds.  And finally, her proposed legislation contains a “circuit breaker” clause to ensure that if at some point in the future the federal government reneges on its promise to cover 80 percent of the costs, our state will automatically opt out of the expansion.

So, what’s not to like?

Governor’s proposal faces formidable opposition

Earlier this week I learned from a colleague with the Grand Canyon Institute that the bill is being introduced into the House by Heather Carter (R-District 7), Vice Chair of the House Health and Human Services Committee.  Most likely the first step will be forwarding the bill to the House Appropriations Committee for vetting.

While Democrats are largely supportive of the bill, they hold only 24 of the 60 House seats and 13 of the 30 Senate seats.  To date Brewer has been  unable to persuade a majority of legislators from her own party to support the bill.  She is pulling out all stops in attempting to turn votes her way, one by one, through personal persuasion and building support among constituents of recalcitrant lawmakers.  Fortunately for those of us who support this common sense measure, our Governor has a reputations of not taking “NO” for an answer!

Despite the Governor’s status as a  strong statewide Republican leader and the fact that the bill enjoys widespread support from the hospital/health care community, chambers of commerce, informed voters and the Arizona Medical Association, proponents of this landmark legislation face heavy opposition in our struggle to successfully gain approval by both houses.

Unbelievably, Speaker of the House Andy Tobin has pronounced the draft bill “dead on arrival”, stating that he is unlikely to allow the measure to be brought to the floor of the House without the blessings of the majority of the GOP caucus.  Likewise, both Tobin and Senate President Andy Biggs are trying to ensure the measure’s defeat by playing the “Prop 108 card” (more on this later). Exasperated by Speaker’s Tobin’s negative stance Gov. Brewer asked “What does Speaker Tobin want?”

What does Tobin want?

Tobin has candidly stated that he wants assurances that hospital bills will stop going up if the Medicaid cut-backs are eliminated.  Quoting from a front page article in Wednesday’s Daily Star (March 13), Tobin wants the legislation to contain assurances that if the hospitals have less uncompensated care they will agree to stop cost-shifting to the private sector.  Cost-shifting, whereby privately insured and self-pay patients are presented with inflated charges in order to cover losses from uncompensated care, is a common practice in the hospital industry.

Having worked in the hospital/health care field for over 40 years in a variety of administrative capacities, I believe that Tobin’s position here constitutes a reasonable point for negotiation.   In regard to fiscal management, the hospital industry presents a rather schizoid posture in regard to billing and collections practices.

While many non-profit hospitals, such as St. Mary’s, St. Joseph’s and Tucson Medical Center are hemorhaging  from an excessive burden of uncompensated care following the 2010 Medicaid cut-backs, excessive profiteering is also rampant among many members of the hospital community, including both for-profit hospitals and many so-called “non-profit” institutions.  (For a detailed discussion of this frightening phenomenon, see the 40-page lead article featured in the March 4 issue of Time Magazine titled “Bitter Pill”.)

This being the case, I believe that Tobin is completely justified in wanting to build into the Medicaid Restoration bill reasonable assurances from the hospital community that they will substantially reduce cost-shifting if the bill is passed.  I urge that the Arizona Association of Hospitals and Health Care Providers assume a leadership role in working with our legislature in negotiating a resolution of this vital point.

Playing the Proposition 108 card

Proposition 108 is a voter-generated issue that passed overwhelmingly in the 1992 statewide general election.  This proposition added a provision to the Arizona Constitution that requires a 2/3 vote of each House to enact a bill that will provide for a net increase in state revenues IF the increase falls within one of seven enumerated categories.  The items that attract the most attention are the imposition of new taxes or increases in already existing taxes or the elimination of a tax credit or deduction.

Both Tobin and Biggs are attempting to block passage of the bill by treating the proposed hospital assessment as a tax increase, and arguing that a 2/3 super-majority in both houses is thereby required under terms of  Prop 108.  Governor Brewer’s office contends that a super-majority requirement does not apply, as the proposed $220 million dollar contribution from the hospitals represents an assessment.  Furthermore, the hospitals will easily recoup these funds via reductions in uncompensated care if the bill passes.

Does Tobin’s and Biggs’ contention that Prop 108 requires a super-majority for passage hold water?  To respond to this question we need to examine the proposition’s intention.

Clearly, the intent of this constitutional amendment is to safeguard the people of Arizona by  preventing the legislature from pushing through any unsound tax increases.  I strongly contend, however, that the intended purpose of Prop 108 does not apply to the Medicaid Restoration Bill, as the additional assessment on hospitals will not represent an increase to be borne by taxpayers.  Clearly, the intent of the Medicaid Restoration Bill is to serve the best interests of the people of Arizona.  As stated earlier, passage will be a boon to the state’s economy – creating an additional 21,000 jobs – in addition to restoring Medicaid coverage to an estimated 300,000 Arizonans.

Steps we can take to ensure passage

While the Medicaid Restoration bill’s passage will be an uphill battle, there are many steps you and I can take to ensure the measure’s passage.

1. Contact your three state legislators, urging their support of this measure that will serve the best interests of the people, in addition to giving our economy a much-needed boost.
2. Contact Speaker of the House Andy Tobin (atobin@azleg.gov) and Senate President Andy Biggs (abiggs@azlez.gov), urging them to respond to the will of the people by supporting passage of the Medicaid Restoration bill.
3. Contact Gov. Jan Brewer (azgovernor.gov/contact.asp) and Rep. Heather Carter (hcarter@azleg.gov), the bill’s sponsor, congratulating them for supporting this vitally needed measure and offering to help in any way you can.
4. Spread the word to your friends and community via group emails, facebook, letters to the editor, etc.  Follow the publisher’s guidelines, focus on one or two key points and bring them across succinctly and emphatically.

As the saying goes, “United we stand!”  Let’s all band together to ensure enactment of this vitally important measure for the people of Arizona.

Recommended Reading and Viewing:

1. “Will AZ legislature support Medicaid expansion proposal?” www.tucsoncitizen.com/healing-tucson (January 23, 2013).
2. “Brewer’s Medicaid details are revealed”, Arizona Daily Star, March 13, 2013.
3. “Bitter Pill”, Time Magazine, March 4, 2012.
4. Arizona Public Media Television (PBS, Channel 6), Arizona Week, March 15, 2013, 8:30 pm.  Special broadcast featuring a panel on Medicaid Expansion including Gov. Jan Brewer, Rep. Heather Carter, Senate President Andy Biggs, Rep. Victoria Steele and others.  Visit the Arizona Public Media website (www.tv.azpm.org) for other scheduled times, or view this presentation anytime by accessing “Play PBS” – Arizona Week via the AZPM website.

Last Monday at her State of the State address, Gov Brewer presented a practical proposal for expanding Arizona’s Medicaid program to take advantage of funding available under the Affordable Care Act, popularly known as Obamacare.  Her proposal was greeted by stunned looks from many members of her own party.

Brewer recounted her strong opposition to the President’s health care plan, which led her last year to join a coalition of states that sought to block the program in court.  She candidly acknowledged, however, that the law was upheld by the U.S. Supreme Court, Obama was re-elected and his party now controls the U.S. Senate.  These realities have prompted her to acknowledge that “the Affordable Care Act isn’t going anywhere – at least not for the time being.”

She also acknowledged that residents of Arizona have voted on two separate occasions to expand our Medicaid program to cover several hundred thousand medically indigent Arizonans.

Under the Affordable Care Act, the federal government will provide generous financial assistance to states that opt to expand Medicaid eligibility to families and individuals with incomes at or below 133 percent of the current federal poverty level.  The governor’s plan will impose a tax on hospitals to raise $220 million a year, which she claims will cover the state’s share of costs of expanding Medicaid eligibility under the Arizona Health Care Cost Containment System (AHCCCS).  The federal share will amount to $1.6 billion a year, enabling our state to provide Medicaid coverage to about 240,000 additional  residents.  Other key features of the governor’s plan include:

• It will protect both rural hospitals and urban safety net hospitals from being pushed to the  brink of bankruptcy by their growing costs of caring for the uninsured.
• By taking advantage of the infusion of federal funds, it will inject close to 2 billion dollars into the state’s economy, saving and creating thousands of jobs.  According to analyses conducted by the Grand Canyon Institute, a bi-partisan think tank, the proposed Medicaid expansion would create some 21,000 jobs and increase Arizona’s growth by nearly 1 percentage point!
• And most importantly from a human perspective the expansion will avail hundreds of thousands of low-income Arizonans to quality health care, dramatically increasing their quality of life and saving thousands of lives in the process.

Viewing the governor’s proposal strictly from a business perspective, the resultant 1:7 cost/return ratio represents a phenomenal return on the proposed up-front investment, to be covered by a tax levied on hospitals rather than through dipping into the state’s coffers.

To anyone looking at the situation rationally, the Governor’s proposal to take advantage of funding available under the Affordable Care Act to expand our Medicaid program would appear to be a no-brainer.  Under the current system, Arizona has a disproportionately large number of uninsured residents who already present themselves at doctors’ offices and hospital emergency rooms – an extremely expensive source of care.  Hospitals throughout the state, which have been providing an unsustainable amount of uncompensated care, have been hemorrhaging financially to the point where some facilities are considering closure.  Here in Tucson the Carondelet Health System, which operates St. Mary’s and St. Joseph’s Hospitals, has been hit particularly hard and Tucson Medical Center reports that its burden of uncompensated care has close to tripled over the past 18 months.

In unveiling her proposal, Brewer correctly pointed out that the uncompensated care burden that hospitals and other providers are forced to bear results in major cost-shifting as insurance premiums rise to cover the difference.  Dramatizing her point, Brewer stated that these premium increases amount to a hidden tax estimated at nearly two thousand dollars per family per year!

Prospects for passage

The Medicaid expansion proposal is receiving strong support from the healthcare community and the Arizona Hospital and Healthcare Association.  Chambers of commerce throughout the state can also be counted on to be overwhelmingly in favor of the Medicaid expansion due to the boost that passage would provide to communities throughout the state.  Democrats overwhelmingly support the proposal and centrist/moderate legislators should be supportive of passage – one does not need to be a rocket scientist to do the math!

As readers are well aware, however, both houses of our state legislature have sizable contingencies of conservative members, a number of whom are prone to oppose Medicaid expansion on ideological grounds.

The current State Senate President, Andy Biggs, has told the press that he opposes the expansion, while the Tucson Weekly reports that in 2011 he actually sponsored legislation to eliminate Arizona’s Medicaid program.  When recently interviewed Senator Al Melvin (R-District 11, Oro Valley) stated “Frankly I hate to see it…I wish she would stand shoulder to shoulder with her fellow Republican governors and resist this as much as we can.”

Thus, despite the many merits of the Governor’s proposal for Medicaid expansion, its passage is by no means a slam-dunk.  There are, however, a number of hopeful signs, including:

• Governor Brewer is well liked among Republicans, and I believe she can be counted upon to wield considerable clout in persuading her colleagues in both the  house and senate to see the light.
• When viewed solely from a common sense perspective, the Medicaid expansion makes overwhelming sense in both economic and humanitarian terms.
• For obvious reasons, passage enjoys strong support from both the hospital/health care community and chambers of commerce throughout the state.
• I believe there is a growing contingency of bright legislators in both parties who are primarily concerned with providing what is best for the people of Arizona.  As such, I hope and pray that they will focus their wholehearted efforts on convincing their colleagues to do the right thing.
• I also believe that the greater majority of Arizona voters will strongly support Medicaid expansion, provided that they are made fully aware as to what is at stake!

Be a part of the solution

As concerned citizens we must band together to ensure that expansion of our state’s Medicaid program passes both houses.  Presented below are some suggestions on how to become proactively involved in furthering this cause:

• Contact Gov Brewer’s office and congratulate her on bringing this important issue to the front burner, while urging her to do whatever it takes to get her colleagues in the legislature to stand fully behind her.  The address for the Governor’s website is www.azgovernor.com and the phone number is 602-542-4331.
• Contact the two representatives and senator from your own district, expressing your strong support of the Medicaid expansion proposal.  Especially be sure to contact Republican legislators who may be either opposed to the proposal or sitting on the fence.  Be courteous – highlight your selling points: be sure to emphasize the tremendous boost that passage will bring to our state’s economy, together with the humanitarian aspects.  Appeal to their better nature and tell them that you hope they will support this measure and work with their colleagues to garner their full support.
• The House Health Committee and the Senate Health and Human Services will each play a vital role in determining the fate of the Medicaid expansion proposal.  I urge you to send an email to members of each of these committees, expressing your strong support of this proposal.  Members of each committee and their email addresses are listed below:

House Health Committee:

Chair: Heather Carter (R-28) hcarter@azleg.gov

Vice Chair: Paul Boyer (R-20) pboyer@azleg.gov

Kate Brophy McGee ((R-28) kbrophymcgee@azleg.gov

Sally Ann Gonzales (D-3) sgonzales@azleg.gov

Phil Lovas (R-22) plovas@azleg.gov

Eric Meyer ((D-28) emeyer@azleg.gov

Victoria Steele (D-9) vsteele@azleg.gov

Kelley Townsend (R-16) ktownsend@azleg.gov

Senate Health and Human Services Committee:

Chair: Nancy Barto (R-15) nbarto@azleg.gov

Vice Chair: Kelli Ward (R-5) kward@azleg.gov

David Bradley (D-10) dbradley@azleg.gov

Judy Burgess (R-22) jburgess@azleg.gov

Katie Hobbs (D-24) khobbs@azleg.gov

Linda Lopez (D-2) llopez@azleg.gov

Kimberly Yee (R-20) kyee@azleg.gov

• If possible, arrange a small group meeting with a targeted legislator who has either stated that he or she is opposed to the expansion proposal, or is sitting on the fence.   All legislators want to be perceived as being attuned to the needs of their constituents, and you can count on having their undivided attention!  Again, be polite, present your selling points – especially those that will appeal to their constituency – and appeal to their better nature.
• And last but by no means least – do whatever you can to educate your friends, neighbors and other members of your community concerning the importance of this issue!  Talk with your minister, priest or rabbi and ask to make an announcement on this topic at your church, synagog, mosque or other religious institution.  Many if not most religious leaders will embrace the humanitarian appeal of educating their congregation on this vital issue.  Letters to the editors of the Daily Star, Arizona Republic and other papers are critically important as they provide an excellent vehicle to make sure that your points are noted by thousands of concerned citizens!

In summary, Gov Brewer’s proposal to expand our state’s Medicaid program is a classic example of a win-win proposition.  Let’s all join together to ensure passage of this vitally important measure!!