How Arizona's governor made Medicaid expansion happen

State Senate voted 18-11 to approve expansion

Republican Gov. Jan Brewer scored a major policy victory on Thursday when Arizona's conservative legislature approved Medicaid expansion after a lengthy fight that divided the state's GOP leaders.

The win may bring hope to other GOP governors who have supported the Affordable Care Act (ACA) expansion but encountered stiff resistance from their Republican legislatures, including Florida's Rick Scott.

How Brewer brought the legislature to her side

An early critic of the ACA, Brewer surprised many when she announced her support for Medicaid expansion in January. She said that rejecting the expansion would force Arizona taxpayers to subsidize care in other states without receiving any benefits.

She also argued that expanding Medicaid would protect hospitals from rising costs for uncompensated care, add $2 billion to the state economy, and create thousands of jobs. Brewer noted that her expansion plan will include a "circuit breaker" to halt enrollment if federal funding declines.

Since January, Brewer has rallied lawmakers and voters to support the Medicaid expansion, and she refused to sign any other legislation until the Legislature advanced a budget measure with an expansion plan.

In May, she rejected five bills approved by the Legislature in an effort to push lawmakers on a deal for Medicaid expansion. "I warned that I would not sign additional measures into law until we see resolution of the two most pressing issues facing us: adoption of a fiscal 2014 state budget and plan for Medicaid," Brewer wrote in a letter explaining her vetoes, adding, "It is disappointing I must demonstrate the moratorium was not an idle threat."

On Thursday, the Arizona Senate voted 18-11 to approve the $8.8 billion bipartisan budget plan just hours after the measure cleared the state House on a 33-27 vote.

Following Thursday's votes, Brewer in a statement said, "By joining me in extending health coverage to hundreds of thousands of Arizonans, legislators of my own party have come under sharp criticism in some quarters ... [b]ut I also know this in my heart: The great majority of Arizonans stand with us." The expansion "will extend cost-effective care to Arizona's working poor using the very tax dollars our citizens already pay to the federal government," she added.

In remarks to the media after the votes, Brewer said it is "win, win, win all the way around." She added that "Medicaid was here long before Obama health care. I have never liked Obama health care," noting that her support for the expansion "has nothing to do with Obama health care."

Expansion remains a contentious issue in Arizona

While Brewer celebrated "a huge political victory," many members of her party reiterated their opposition to the measure, the Associated Press reports. 

State House Speaker Andy Tobin (R)—who voted against the expansion and had attempted to work with Brewer on an alternative—said opponents might challenge the measure in court or introduce a ballot initiative next year to revoke the expansion. Tobin noted the issue was "very contentious" among state Republicans, adding, "The party is really split on this issue" (Viebeck, "Healthwatch," The Hill, 6/13; Adams, CQ HealthBeat, 6/13 [subscription required]; Crawford, Bloomberg Businessweek, 6/13; Christe/Silva, AP/Modern Healthcare, 6/13 [subscription required]; Jo Pitzl, The Arizona Republic, 5/24).

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