Take Action & Make A Difference

Arizona Gov. Jan Brewer staking legacy on Medicaid

May 19, 2013
The Republic | azcentral.com
Yvonne Wingett Sanchez

Inside a Sun City West clubhouse one recent afternoon, Republican Gov. Jan Brewer stood before fellow Republicans, many of whom she once represented as a state lawmaker or county supervisor. She was there to explain why she had bucked many conservatives in her party to embrace Medicaid expansion, a signature piece of Democratic President Barack Obama’s health-care overhaul.

It was a tough sell for some in this crowd — just as it has been with many GOP state legislators, who are divided on whether to accept billions in federal funds under the Affordable Care Act to provide health coverage to tens of thousands of uninsured Arizonans.

Brewer, one of the state’s conservative firebrands who has attracted a national following with her messages of states’ rights and border security, is walking a political tightrope as she pushes to reshape how the state provides health care to the poor.

If she succeeds, it would be an important piece of her legacy, improving her image with moderates and Democrats who have criticized her for being too extreme on illegal immigration. It could also hurt her standing with some Republicans, who have lauded her fiscal conservatism as she shepherded the state through the economic downturn.

Despite the division within the GOP, the Arizona Senate late Thursday approved the governor’s proposal. A bloc of six Senate Republicans teamed with Democrats to approve a fiscal 2014 budget plan and Medicaid expansion, overcoming efforts by conservative Republicans to kill it.

The Medicaid expansion plan faces an uncertain future in the House of Representatives. Speaker Andy Tobin, R-Paulden, has said he won’t consider it unless it has the support of at least half of his 36-member Republican caucus. Brewer told The Republic on Friday she will work throughout the weekend to get her proposal quickly moved through the House.

She’ll likely work House members as she did the crowd of Republicans in Sun City West. Flanked on that afternoon by U.S. and Arizona flags, Brewer fielded pointed questions about Medicaid expansion.

“Being governor is tough — you have to make tough decisions and you have to look at the whole state, you have to do what’s right,” Brewer told the crowd. Without expansion, “we would’ve had to go in and get people off of Medicaid, they would still be in our hospitals, you would still be paying for them.”

Many in the crowd nodded as she spoke, and some who were initially skeptical said later that her arguments about the economic advantages of insuring more low-income Arizonans by expanding Medicaid had changed their minds. Others applauded but did not join in a standing ovation, saying later that the governor had not persuaded them.

“I am just not supportive of her proposal,” said Anna Morrison, who added she usually agrees with the governor’s policies. “It’s not that I don’t want to help people, but at some point we have to draw a line in the sand and say we can only do so much — there is no money at the federal level.”

It’s the same argument Brewer has heard from grass-roots party leaders who oppose expansion: Current federal spending on health care is unsustainable.

In talking to Republican clubs, precinct committee members and elected officials, Brewer has found herself in the unusual position of explaining why she is signing on to signature legislation from Obama, a political adversary in whose face she once wagged her finger.

She brandishes her conservative credentials to those who accuse her of abandoning her party’s principles. She also reminds them, as she did the Sun City West crowd, that Republicans trusted her in 2010, when she promoted a temporary sales-tax increase to help fund education, health care and public safety. They should trust her now, she says.

Her broader message about expansion has been consistent: Turning away billions in federal Medicaid dollars would increase human suffering and further cripple hospitals and other health-care providers that care for the uninsured. Arizonans have shown they want more people covered by the program, she notes, twice approving ballot measures to restore coverage to childless adults who live below the poverty line.

Under her expansion proposal, Arizona would provide health coverage to 350,000 more people by fiscal 2015; without expansion, Brewer says, about 60,000 residents will be dropped from the program when a federal waiver expires Dec. 31. Federal funds would pay to cover most of those extra people, and a proposed tax on hospitals would raise additional federal funding and cover the state’s increased share, leaving an estimated $55 million for the general fund in 2014.

Since unveiling her plan in her January State of the State address, Brewer has garnered support from 400 community groups, ranging from health-care workers to teachers and faith-based organizations. She is promoting her plan in TV commercials, with robocalls, on social media and with a series of rallies in an effort to sway Republican legislators — and their constituents — who oppose her plan.

But many Republicans remain unconvinced. Some of them — who said they tend to side with Brewer on most other issues — booed her at last week’s pro-expansion rally outside the Capitol, held signs deriding her plan and yelled “traitor” as she finished her remarks. At one point during the four-month debate, one GOP official compared Brewer with Judas.

Marcus Huey, a conservative with “tea party” leanings, said she has “sold out” to the health-care lobby and big government.

“We’ve been betrayed,” said Huey, of Phoenix. “And it will have very dire consequences down the road. She had the chance to do the right thing, and she didn’t.”

If Brewer wins this battle, Arizona will become the second state with a GOP governor and a Republican-led legislature to approve Medicaid expansion. Such a victory almost certainly would define her legacy as Arizona’s 22nd governor, observers say, which is largely marked by Senate Bill 1070, the tough immigration bill that she signed into law.

“This is something I had great difficulty with — I was such an opponent of ‘Obamacare,’ ” said Brewer, sipping an Arnold Palmer (half ice tea, half lemonade) in her ninth-floor office at the state Capitol. “But this is truly life and death.”

If she wins, Brewer said, “I would like to believe that they (historians) would say I made a tough decision under very difficult circumstances and that it was the right thing for Arizona — and I do believe that,” she said. “I wouldn’t do it if I didn’t believe it.”

Making a decision

Brewer’s decision to expand Medicaid was a gradual one, reached in January as she prepared to unveil her proposed budget and legislative priorities. Even her closest aides believed at the time there was “no way” an expansion of Medicaid would be seriously considered because of GOP disdain for federal health-care reform.

John Arnold, the governor’s budget director, recalled the weeks leading up to Brewer’s announcement. “I don’t think there was an ‘aha’ moment,” Arnold said. “It was more of a process, and I think it started with staff.”

In early December, Brewer learned that a partial expansion of Medicaid would bring no additional federal benefit beyond the traditional share already paid to states. Days later, a budget analyst who was poring over the numbers told Arnold expansion should be seriously considered. Arnold took the idea to Brewer’s chief of staff, Scott Smith, who showed it to Brewer.

Under Medicaid expansion, the federal government would cover 90 percent of the costs of insuring the poor and disabled who are added to the rolls. Currently, Arizona receives two federal dollars for every state dollar spent.

Throughout December and early January, the governor met often with advisers and administrators to study every aspect of expansion and the arguments for and against.

As an early and frequent critic of Obama’s administration and the president’s health-care plan, Brewer had joined 25 other states to try to repeal the Affordable Care Act. But Arnold said Brewer remained open-minded: “She was very thoughtful,” he recalled. “There was never a ‘No, no, no.’ It was always, ‘Let’s go through this.’ ”


The governor had Arnold prepare two budgets: one with Medicaid expansion in it, one without it.

During the weekend before her Monday, Jan. 14, State of the State address, she practiced two versions of her speech. In one, she would announce Medicaid expansion. In the other, that passage had been deleted.

While budgets are typically printed a week before the address, Arnold did not send a budget to print until the day of the State of the State.

He did not know which speech she would give until Sunday night. In the moments before Brewer announced and before most other states said they, too, would move forward, Arnold said that “it was a little scary,” because of the potential political fallout.

“She held it very close to the vest,” he recalled.

Brewer has told skeptics about wrestling with the decision, and praying about it. She told The Republic she made up her mind alone, “very, very late Sunday night,” in her Glendale home.

“I knew it was going to be very difficult. I knew it was going to be a huge challenge and I had to decide in my own mind to get right with it,” she recalled.

“I knew mathematically it was the right thing to do. But I had to get it from the heart that it was the right thing,” she said, thumping her chest.

“If you’re going to engage in a campaign like this, knowing the firestorm that it might elicit, then you have to have the fire in the belly,” she said. “Once I came to that conclusion, I never looked back. That’s sort of the way I’ve always been my whole life. Once I make up my mind, I’m all the way in.”


Brewer’s conviction hasn’t stopped the backlash.

Opponents, led by conservative Republicans, have threatened wavering lawmakers’ jobs, saying they will face GOP primary opposition in the next election if they support Brewer’s expansion.

With a little more than a year left in her second term, Brewer is not expected to seek re-election and so her decision would not haunt her in a campaign. A win would give her momentum for her final legislative session next year, observers said, while a loss could weaken her ability to achieve her other legislative priorities.

More than anything, observers said, the decision will affect her legacy.

Bruce Merrill, a veteran Arizona political scientist, said Brewer’s decision underscores how unpredictable she can sometimes be.

“She does very, very conservative things, and now she’s come out for (Medicaid expansion), which she is personally opposed to,” he said. “It just simply adds to the … enigma of Jan Brewer.”

Rep. John Kavanagh, R-Fountain Hills, predicted Brewer’s stance will taint how some Republicans remember her. Until now, he said, her legacy in the GOP was SB 1070 and “budget-cutting conservatism.”

“Her Medicaid position, of course, for at least Republicans, makes the legacy somewhat mixed,” Kavanagh said. “Republicans have spent the last five years bashing Obamacare, and this is an extension of Obamacare — you can’t escape that. On multiple levels, the plan is adopting principles that Republicans have been criticizing. It’s a 180, and that’s tough to do politically.”

Susan Gerard, a Republican and chair of the Maricopa Integrated Health System’s governing board, said the GOP can’t retaliate in a meaningful way.

“How can they hurt her? Not let her speak at the state convention?” asked Gerard, a former lawmaker. “As you get older, you think about what you’re leaving behind, and is it better than when you came in, and this is what legacies are made of.”

<- Go Back