Republican Gov. Brian Sandoval said his decision Tuesday to extend Medicaid benefits to another 78,000 Nevadans didn't involve political calculation.
But because the decision was a direct result of the controversial Affordable Care Act, there is no doubt it will have political ramifications.
The important political question for Sandoval, who is expected to seek a second term in 2014, is whether the decision burnishes his credentials as a pragmatist who can put politics aside for the good of the state or undermines his ability to hang onto conservative voters he will need to win re-election.
On Tuesday, Sandoval became the first Republican governor in the country to agree to expand state Medicaid coverage through the Affordable Care Act, a signature first-term achievement of President Barack Obama that Republicans nationally fought tooth-and-nail.
In Las Vegas on Wednesday, Sandoval said that while he opposed the legislation, and Obama's re-election last month, Obamacare is now the law of the land, and expanding Medicaid with substantial federal subsidies is the smart move for the state.
"I am the governor of Nevada. I am going to do what is best for Nevada," Sandoval said during a Review-Journal editorial board meeting. "Any political consequences never entered into the calculation."
The decision won quick praise from Republicans and Democrats alike.
U.S. Senate Majority Leader Harry Reid, D-Nev., said he agreed with Sandoval's analysis. He called it "wonderful for the people of Nevada."
State Senate Minority Leader Michael Roberson, R-Las Vegas, also lauded the move.
"Ensuring that poor Nevadans have access to primary health care through Medicaid is very simply the right thing to do," Roberson said. "It will reduce our rate of uninsured and provide individuals with greater economic security."
Supporters of Sandoval's decision said the bipartisan praise shows the governor chose correctly on a tricky issue.
"Any reasonable person looking at the math would come to the same conclusion as the governor," said Republican lobbyist and political consultant Pete Ernaut, a friend of Sandoval. "It really only leaves people who are extreme partisan as opposition."
Assembly Speaker-elect Marilyn Kirkpatrick, D-North Las Vegas, gave qualified support for Medicaid expansion, noting legislators still must review details.
"We are very pleased with the governor's decision, as we have long advocated that we need to be doing everything we can to provide coverage for more uninsured Nevadans. This is an important step forward not only for those currently without health care coverage, but for all Nevadans whose health care costs are affected by the high costs of treating the uninsured in emergency rooms."
The view that Medicaid expansion would provide an economic stimulus and create new jobs for Nevada has been emphasized by Jon Sasser, a legislative lobbyist for legal aid societies in Washoe and Clark counties.
"We have been hearing about how much it would cost us, but not how much money will come into Nevada. Every dollar is gong to be spent in the state and create jobs. I am glad the governor recognized that."
Assembly Minority Leader Pat Hickey, R-Reno, said he supports the Medicaid expansion but reserves the right to alter that view after he learns more about potential future costs and the effects of the federal "fiscal cliff."
"This is the baby elephant syndrome," Hickey said. "The governor agrees to pay for hay while the elephant is young, but later the elephant grows up and has a bigger appetite."
Hickey intends to introduce a bill to require Medicaid recipients to pay a small and yet undetermined fee each time they visit a doctor. He said recipients might be more cautious about using medical services if they have a stake in the costs.
Nevada funds Medicaid at 87 percent of the federal poverty rate. For a family of three, that amounts to an annual income of $16,608.
Expansion under the federal law would raise that threshold to $31,890 and extend coverage to single, childless adults - a population not previously covered in Nevada - with incomes as high as $15,415.
The federal government will cover 100 percent of the medical costs for the first three years, though states are supposed to share administrative expenses. Sandoval said he is discussing those shared costs with federal officials.
Critics of the decision, including conservative political consultant Chuck Muth, said Sandoval runs the risk of alienating conservatives, which could hurt him in 2014.
While Sandoval isn't expected to draw a serious challenge from the right, Muth said disenfranchised conservatives might defect to minor-party candidates and boost the chances of a strong Democrat.
"I think he is making a huge mistake spitting in the eyes of conservatives," Muth said.
The Nevada Policy Research Institute, a conservative think tank, called Sandoval's decision shortsighted and said it could backfire on the poor by exacerbating a shortage of doctors.
"If approved, such a shortsighted decision to expand Medicaid will have grave consequences for taxpayers - crowding out spending on other governmental services and harming current Medicaid beneficiaries," the institute's Geoffrey Lawrence wrote. "When the full weight of Governor Sandoval's unfortunate decision falls upon Nevadans, he may well have moved on from his current office. The consequences experienced by the state's citizens, however, will be no less real."
Sandoval has taken pains to paint the decision as one of pragmatism, not politics.
He said expanding the system actually saves Nevada millions of dollars largely by shifting costs for mental illness care for some patients from the state general fund to the federal government.
And he said the state can back out of the arrangement later if the costs become too great and federal support wanes.
When asked about being the first Republican governor to come out in favor of a Medicaid expansion, Sandoval compared it with his earlier decision to implement state-run insurance exchanges as part of the health care law even as other Republican governors resisted.
"Am I going to be an outlier with the other Republican governors? Maybe yes, maybe no," Sandoval said.
"As a governor you have to respect the law of the land, which is every state will have a health care exchange. It is either going to be run by your state or run by the federal government. My choice was to have a state-based exchange."