Kasich’s temper has made it harder to endear himself to the GOP’s wealthy benefactors. Last year, he traveled to Southern California to appear on a panel at a conference sponsored by the Republican mega-donors Charles and David Koch. At one point, according to accounts provided by two sources present, Randy Kendrick, a major contributor and the wife of Ken Kendrick, the owner of the Arizona Diamondbacks, rose to say she disagreed with Kasich’s decision to expand Medicaid coverage, and questioned why he’d expressed the view it was what God wanted.

The governor’s response was fiery. “I don’t know about you, lady,” he said as he pointed at Kendrick, his voice rising. “But when I get to the pearly gates, I’m going to have an answer for what I’ve done for the poor.”

The exchange left many stunned. About 20 audience members walked out of the room, and two governors also on the panel, Nikki Haley of South Carolina and Bobby Jindal of Louisiana, told Kasich they disagreed with him. The Ohio governor has not been invited back to a Koch seminar — opportunities for presidential aspirants to mingle with the party’s rich and powerful — in the months since.

It’s worth contemplating just how deeply Kasich’s heresy runs. Conservatives disagree about the optimal health-care policy they would implement in a world without political constraints. The closest a Republican can come to insisting upon the need to provide some alternative to Obamacare is to insist that repealing the law is not enough, that the party must put in place an alternative plan as well. A Republican can argue that their alternative plan is better than Obamacare, and that their alternative plan is better than the pre-Obamacare status quo. The thing you cannot say, and remain a Republican in good standing, is that Obamacare is better than the pre-Obamacare status quo.

But that is the fissure Kasich exposed. As a governor, the choice he faced was not the hypothetical one that Republicans prefer, between Obamacare and an imagined Republican plan that doesn’t impose costs on anybody. His choice was whether to accept the Medicaid expansion or let poor Ohioans suffer. He chose the former. And he defended his choice by stating that the alternative is cruel and barbaric.