Entrepreneur and civic leader Algenon Cash is the host of “Locked In,” a program on Greensboro radio station WTOB. I appeared on a recent episode along with former Gov. Pat McCrory, who’d just lost the Republican primary for U.S. Senate.

McCrory had much to say about that race, as you might expect. But what I found particularly striking were his reflections about the political label RINO.

Reportedly coined in 1992 by a writer for the New Hampshire Union Leader, it’s an acronym for Republican In Name Only.  During McCrory’s primary contest with U.S. Rep. Ted Budd, former U.S. Rep. Mark Walker, and several others, the former governor got called a RINO numerous times — and not just by supporters of the eventual winner, Budd.

It was hardly the first time McCrory had drawn criticism from fellow Republicans for positions he’d taken. During his lengthy tenure as mayor of Charlotte, he supported a sales-tax increase to fund the construction of a light-rail system. That wasn’t popular with local Republican activists and conservative writers, including yours truly.

McCrory got his tax hike, and the transit project, and believes to this day it was a good policy. He’s well-aware of that fact that other conservatives disagree. Moreover, when he was governor, McCrory occasionally took other positions with which prominent members of his party differed. Again, he’s been in politics a long time. He’s never struck me as surprised at having to defend his views. Indeed, he appears to relish it.

What has left McCrory frustrated about the 2022 campaign, however, is that there was so little discussion of serious issues, including any substantive case made against his authenticity as a Republican. Asked whether he’d support Budd in the fall campaign, McCrory replied that he was no longer sure of the “definition of conservatism in North Carolina, because it may have changed and I need to get clarification of that.”

For example, he noted that Senate leader Phil Berger and many of his colleagues endorsed Budd as the conservative choice in the GOP primary — and then voted overwhelmingly to expand Medicaid, which McCrory called “the most damn liberal thing I’ve seen.”

The former governor has a point here. For more than a decade, Republican leaders and conservative activists have expressed stalwart opposition to Medicaid expansion. They argued it would make more North Carolinians into welfare recipients. They also argued it was fiscally irresponsible. I made those arguments many times myself.

I’m still against Medicaid expansion, as is McCrory. But state senators, including Berger, now favor it. Does that make them RINOs?

No. It only means they’ve changed their minds. When Phil Berger became Senate leader, the state’s Medicaid program was poorly administered and often ran deficits. “Fortunately, over the past decade, Republican leadership in the General Assembly has turned Medicaid around in North Carolina,” he told reporters.

Berger also observed, correctly, that “the Affordable Care Act is not going to go away.” Republicans held the White House and Congress in 2017 and 2018. That was the time to rewrite at least the ACA’s Medicaid component (which was its most significant and expensive). Republicans did nothing. Berger argues their inaction left holdout states such as North Carolina with no practical alternative but to strike the best expansion deal possible. He thinks this is the year to do it.

Many conservatives, including members of the North Carolina House, remain unpersuaded. They point out another practical reality: Medicare and Medicaid are fiscally unsustainable in their current form. They consume nearly 30% of all federal revenues, a share that is rapidly growing (and will grow even faster if North Carolina and other holdouts expand Medicaid). From 1967 to 2020, the two programs cost a combined $17.8 trillion. During the same period, federal deficits totaled $17.9 trillion. You do the math.

Can Republicans disagree about this pivotal issue without resorting to political excommunication? I think the answer is yes. But I can understand why McCrory finds that answer unsatisfying.

John Hood is a John Locke Foundation board member. His latest books, Mountain Folk and Forest Folk, combine epic fantasy with early American history.