Sandoval does right thing in expanding Medicaid

There came a moment at the end of Gov. Brian Sandoval’s meeting with the Review-Journal editorial board Wednesday when he said something very illuminating.

Asked about conservative criticism of his decision to expand the state’s Medicaid program, Sandoval highlighted the facts: 98,000 people would be joining the program regardless of whether it was expanded; expanding it would actually save the state $16 million by shifting some state-financed mental health patients to federal reimbursements; and the decision would have an important impact on 78,000 newly eligible people.

“As the chief executive of this state, I have to deal with the reality of that. I don’t get to sit in a cubbyhole,” Sandoval said. “I have to make decisions that affect real lives here and I have to go through a real budget.

“And, as I said, I couldn’t sit here and defend to any of you $16 million that just went away because of principle. I think, when you take the opportunity to look through all of this, at least the fiscal part of this, it makes perfect sense.

“I’m very concerned about [increasing borrowing to pay for the health care plan] on a national level, on a federal level, the direction this is taking us. But in terms of punishing the people of Nevada for that, I can’t do that,” the governor said.

Sandoval’s dismissal of “principle” will be an easy target for his conservative critics, whom he’s already infuriated by being willing to extend tax increases that were set to expire in 2011. They’ll say his compromise points up the problem with moderate Republicans, who govern no differently than Democrats.

And they’d be wrong.

Sandoval didn’t abandon his principles when he decided to expand Medicaid, he followed them. And while the governor remains staunchly opposed to the Patient Protection and Affordable Care Act, he also remains firmly rooted in the reality-based community that knows the law is here to stay. That’s why he established an insurance exchange long ago, and why the state is well on its way to being able to offer Nevadans a place to purchase health insurance when the law goes into effect.

When it came time to decide whether to expand Medicare, Sandoval carefully looked at the numbers. “This has been an evolving, deliberative process,” he said. “A lot of it had to really come down to, what would be the fiscal impacts?” And when the numbers became clear, Sandoval weighed one principle – his opposition to a sweeping federal health care law – with another, his duty as governor to promote the general welfare of the citizens of his state.

Yes, the decision will be politically popular. (Another initiative – to increase the exemption under the state’s payroll tax to help small business afford the levies they’ll pay under the Affordable Care Act – will earn him votes as well.) And while Sandoval says politics didn’t enter into his decision, it certainly represents good politics, robbing a potential Democratic opponent of a potent issue in 2014. (In fact, the question of what any future political foe will use to run against Sandoval remains wide open.)

But quite apart from politics, the decision to expand Medicaid was the right thing to do, even as questions remain.

Will there be enough doctors to serve more than 160,000 new patients? “Probably not,” Sandoval admits, which is why he’s asking for regulatory and licensing reform to quickly increase the number of doctors who can practice in the Silver State. Will doctors see these new patients? He’s working on extending a plan to keep reimbursements high for at least the next two years as an incentive.

Doing the right thing – and keeping in mind the reality that decisions aren’t just academic debates on white papers and websites – is sometimes lost in politics. But Sandoval kept that squarely in mind, and in the process, he upheld the only principle that really matters:

“I’m the governor of Nevada. I’m going to do what’s best for Nevada,” Sandoval said.

Amen to that.

Steve Sebelius is a Review-Journal political columnist and author of the blog SlashPolitics.com. Follow him on Twitter (@SteveSebelius) or reach him at (702) 387-5276 or ssebelius@reviewjournal.com.