G.O.P. in Arizona Is Pushed to Expand Medicaid

PHOENIX — In the battle to get the Medicaid expansion being championed by Gov. Jan Brewer approved by the state’s legislators, her closest advisers are hanging their hopes on the number eight. That is how many of the 17 Republicans in the State Senate they believe they can get on their side.

They were working on an equally modest tally in the State House of Representatives, an unusual state of affairs for a staunchly conservative governor: her most reliable supporters on this issue are on the other side of the aisle, in the Legislature’s usually powerless Democratic minority.

“It is not often we agree with her,” said Representative Bruce Wheeler, the minority whip, “but we certainly do on this issue.”

Indeed, the governor has won respect in conservative circles for her outspoken criticism of President Obama and for her support of Arizona’s strict immigration legislation.

Last week, Ms. Brewer took her fight from conference rooms and the halls of the Senate and House to the steps of the State Capitol, surrounding herself with health care professionals in a public show of force before the Legislature, where the Medicaid bill she endorses will be unveiled on Tuesday.

In the meantime, a coalition of business leaders began running television advertisements promoting Ms. Brewer’s plan as a lifeline to hospitals, particularly in rural areas, where the number of Medicaid recipients is large, as is the number of uninsured seeking care in emergency rooms.

But in their push to win over Republicans, the governor’s advisers have found that they have no single persuasive argument, and at times, no chance at all for persuasion.

To make their case, they are pressing the idea that expanding Medicaid, the federal and state program that provides health care to poor and disabled people, is the best way to stabilize the state’s health care system, already buckling under the weight of caring for uninsured patients. They invoke the burden borne by the insured, whose high premiums cover, in part, the cost of treatment that goes unpaid. They remind legislators that to back the plan is to honor the choice of voters, who overwhelmingly passed ballot measures, in 1996 and 2000, expanding coverage for childless adults with incomes up to 100 percent of the federal poverty level.

For good measure, they warn of the perils of bad press just as the 2014 campaign season is getting started. If the state got hammered in 2010 for cutting Medicaid coverage for certain organ transplants, affecting 94 patients, the thinking goes, imagine the reaction if the expansion does not go through and thousands of childless adults are dropped from the rolls just days after Christmas. (The waiver that has allowed for their coverage expires on Jan. 1.)

“The legislative dance is just getting started,” said Chuck Coughlin, the governor’s former campaign manager and one of the lobbyists leading the effort.

It is a choreography that has fostered unlikely alliances and uncertain behind-closed-doors deals, in Arizona and in other states where Republican governors’ embrace of Medicaid expansion set off a backlash from Republican legislative majorities.

Committees are exploring other options in Florida, where Gov. Rick Scott faces increasing uncertainty over whether the expansion there will pass. In Ohio, Gov. John R. Kasich invoked dollars and God during his State of the State address, telling conservative legislators that the vulnerable should not be left behind.

For Ms. Brewer, getting the expansion approved has become a matter of personal pride, even if it has gone against her strong opposition to the Obama administration’s health care overhaul. She has thrown all of her political capital behind the effort, traveling across the state to sell her message and encouraging a Republican lawmaker, State Representative Heather Carter, who has generally been in line with the governor’s health policies, to nudge her colleagues in the Legislature.

“One of the things she has demonstrated is that she generally gets what she wants,” said her spokesman, Matthew Benson.

The battle has sometimes boiled down to semantics. For example, the state’s Medicaid director, Thomas Betlach, refuses to use the word expansion. “Restoration,” he said assertively during an interview, referring to the fact that the under the governor’s plan, the program would again apply to people who lost coverage when the recession hit and the state froze enrollment. (The expansion would stretch the coverage beyond the state’s income threshold to 133 percent of the poverty level, or $30,675 for a family of four.)

Ms. Brewer and her supporters call a fee that would be levied against hospitals to help offset the state’s share of the costs a “hospital assessment.” Opponents call it a “bed tax.”

Recently, 40 lobbyists, representing at least 110 groups pushing for the expansion, among them hospitals, health care associations and business organizations, huddled in the executive wing of the State Capitol to update the governor’s advisers on their progress and hone strategies. One of them reminded colleagues not to encourage enthusiastic Democrats to interfere; later, he said that in Arizona, using Democrats to win over Republicans can be disastrous.

The lobbyists have trained their focus on the Senate, whose president, Andy Biggs, a conservative Republican from a conservative district southeast of Phoenix, they hope to sway.

If enough Senate Republicans get behind the expansion, their thinking goes, House Republicans will follow. The House speaker, Andy Tobin, a Republican, has been carrying on his own offensive, meeting with freshman Democrats to try to dissuade them from voting for the expansion. And in an interview, State Representative John Kavanagh, chairman of the Appropriations Committee and a vociferous opponent of the governor’s plan, said that if the measure were to get a vote in the coming days, “it wouldn’t pass.”

“As more facts are revealed about the way it’s being funded, the bed tax and all,” he added, “more members of our caucus fall off.”

The Medicaid expansion is, by all accounts, the most contentious element of Ms. Brewer’s proposed budget, and the proposed hospital fee its sharpest thorn. In private, conservative groups like the Phoenix-based Goldwater Institute have been weighing whether to sue the state, arguing that the assessment is a tax, which would require approval by a two-thirds vote in the Legislature, as prescribed in a ballot measure passed in 1992.

“They’ll never get two-thirds out of this chamber,” Mr. Kavanagh said.

The governor’s advisers seemed certain that the vote would not be necessary.

John Arnold, the state’s budget director, said the fee would be equal to the difference between what Arizona gets each year from the 1998 settlement with tobacco companies, which was struck as a means for most states to recover health care costs linked to tobacco use, and the state’s share of the Medicaid program. The amount is not fixed, he added, as settlement payments, federal contribution to the program and enrollment fluctuate.

Ms. Brewer has argued that expanding Medicaid would provide the state about $1.7 billion in federal financing, and that the state would be able to stop offering benefits to childless adults if federal reimbursement dropped below 80 percent.

In an interview, Darcy A. Olsen, the Goldwater Institute’s president, said: “This money doesn’t come free from Washington. Arizona taxpayers pay federal taxes, too.”

The governor has also emphasized Medicaid’s current cost (its cost per participant is $680 lower than the national average, according to an analysis by the Kaiser Family Foundation) and managed-care system (it functions like an H.M.O.), which has helped reduce the number of emergency room visits and the length of hospital stays among participants. And Ms. Brewer has showed no signs of backing off.

“The governor is committed,” Mr. Benson, her spokesman, said. “People who follow politics in this state know that when she makes a decision, she digs in her heels.”