Andy Tobin

Ross Franklin/AP File photo

PHOENIX - House Speaker Andy Tobin gave up his bid to block the Medicaid expansion plan by Gov. Jan Brewer, conceding he lacks the votes.

Tobin said he's not against adding 300,000 people to the Arizona Health Care Cost Containment System.

But he was pushing his own alternative, saying the plan proposed by the governor and approved by the Senate lacks sufficient checks and balances to ensure the state is not wasting money, and that it actually reduces the number of uninsured who show up at hospitals.

Tobin said efforts to negotiate changes with Brewer were fruitless. Meanwhile, supporters of Brewer's Medicaid expansion lined up enough Republican votes in the House to provide a majority, if all 24 Democratsgo 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 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 state's 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 the entire budget, including Medicaid expansion, on Thursday. If the committee signs off, a final House approval would likely come next week.

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 Republican votes it would take to ensure 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 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 Medicaid plan.

A key provision of the Affordable Care Act has the federal government paying most of 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 bring in about $1.6 billion a year in federal aid.

It is that assessment Kwasman believes gives foes of her plan the best chance to kill it outright.

He contends 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 the 40-vote margin needed for final approval.

Allen said he believes several of the GOP votes Carter is counting on to reach 31 - the simple majority to approve Medicaid expansion - will be forced politically to 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 the 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, that his boss believes the expansion plan is not subject to referendum because it is part of the budget.