In an historic move, a group of Republican senators united with Democrats Thursday to approve the plan by Gov. Jan Brewer to sharply expand the state's Medicaid program.
The 19-11 vote came after supporters beat back more than a dozen amendments by foes, each of which sought to weaken or totally undermine the proposal. That pretty much keeps the plan close to what Brewer proposed in January.
But not exactly.
One key change would have the plan self-destruct at the end of 2016, three years after implementation. Even Senate Majority Leader John McComish, who spearheaded the push, conceded it is a good idea because it will force future lawmakers to revisit the whole issue. And gubernatorial press aide Matthew Benson said his boss is "open to a potential sunset date.''
Even with that, though, Thursday's Senate vote does not mean Medicaid expansion is a sure thing.
First, the measure still needs House approval. And while House Speaker Andy Tobin said he's willing to expand Medicaid, he wants charges, some technical and some to add what he said are cost-containment provisions.
But the key difference is that Tobin wants to make the plan subject to voter approval. And at least part of the reason for that goes to another hurdle that awaits the plan.
Arizona provides care for most individuals who fall below the federal poverty level, about $19,530 a year for a family of three.
This proposal taps a provision in the federal Affordable Care Act to provide care for those up to what equals 138 percent of the federal poverty level. The federal government would fund most of the expansion which will add 300,000 or more to the 1.3 million already on rolls of the Arizona Health Care Cost Containment System, the state's Medicaid program
But there is a cost to the state. So Brewer's plan -- and the Senate measure -- proposes what the governor calls an "assessment'' on hospitals to raise $240 million a year.
Senate President Andy Biggs, a key foe of Medicaid expansion, said this is really a tax. And the Arizona Constitution requires a two-thirds vote of both the House and Senate, a margin of support the measure does not have.
Tobin's plan to send the measure to the ballot would eliminate the need for that super majority.
The Senate proposal includes no voter ratification. And it passed by only a simple majority.
That, Biggs told colleagues, all but guarantees a lawsuit that could wipe out the entire Medicaid expansion plan.
Sen. Steve Farley, D-Tucson, said the requirement for a two-thirds vote does not apply to fees levied by the director of a state agency. And this measure would let AHCCCS Director Tom Betlach determine the amount sought from each hospital.
But Sen. Steve Yarbrough, R-Chandler, said this is no more a fee than if the state were to authorize the director of the Department of Revenue to set income tax rates for Arizona residents. He warned colleagues they will regret this decision.
"It is a stunning example of our ceding legislative power to the executive branch that will serve as a terrible precedent and will haunt the balance of power, the constitutional checks and balances, perhaps forever,'' he said.
Thursday's vote came after a contentious Republican caucus where foes of expansion actually outnumber supporters. Sen. Rick Murphy, R-Glendale, was particularly miffed at McComish for working with Democrats to line up the votes, saying he betrayed his party.
"I didn't think it was appropriate for the majority leader of the caucus to be participate in -- and particularly to lead -- a rolling of his own caucus when the vast majority of his caucus doesn't want to do what he wants to do,'' he said.
McComish rejected claims by some colleagues that he is, in effect, a traitor to the Republican cause.
"I'm no more a traitor than those who are opposing our Republican governor,'' he said.
McComish also said his election last fall by Republicans as their leader does not require him to always advance what the majority of them want. He said even party leaders are allowed to go their own way on "issues of conscience.''
Murphy said this is different.
"This is too big of an issue and too big of a policy shift to be something that the majority leader goes against his caucus on and, particularly, leads the opposition,'' he said. "If they didn't want to be in majority leadership then they shouldn't have run for the position.''
Much of the GOP opposition was focused not on expanding the health care program itself but how it came about.
"This monstrosity of a bill, Obamacare, passed in Washington in the dead of night without one single Republican vote,'' said Sen. Al Melvin, R-Tucson. And he took a slap at the five Republicans who united with the 13 Democrats to provide the margin of support, saying they are "perpetuating this sorry situation.''
He also argued that the amount of federal spending that will be required is unsustainable.
"Fifty cents on the federal dollar is borrowed from the Chinese or generational theft,'' he said. "We have to stop it and we have to stop it now.''
Even if the plan gets final approval, and even if it survives a lawsuit, the measure still has what amounts to an escape clause. It says the law is automatically repealed if federal reimbursement for the expansion falls below 80 percent of the cost.