By assuming that conservatives and moderates would come together to repeal the Affordable Care Act, Senator Mitch McConnell seems to have miscalculated.
WASHINGTON — Senator Mitch McConnell of Kentucky, the majority leader, has long enjoyed a reputation as a master tactician. But when it comes to repealing the health care law, he seems to have miscalculated in the first round of play.
He assumed that his conservative and moderate colleagues would come together to make good on their seven-year promise to repeal the Affordable Care Act, and quickly.
But when he put together a group of senators to cobble together a health care bill last month, he seemed to go out of his way to exclude some of the most knowledgeable members and moderate voices on health care, like Senators Bill Cassidy of Louisiana, a doctor, and Susan Collins of Maine, an insurance expert and one of the few women in the Senate Republican conference. Views outside Mr. McConnell’s ideas on health care did not enjoy extensive consideration.
When Republicans from states that expanded their Medicaid programs quickly found themselves at odds with more conservative members who wanted a large rollback of Medicaid, Mr. McConnell did little to allay those worries. Conservatives generally wanted to rein in costs while moderate members wanted to increase spending, particularly in states with high health care costs and where opioid addiction is escalating.
On those key issues, Mr. McConnell put his legislative thumb on the scale in favor of conservatives, quickly alienating many from states that expanded Medicaid, such as Senator Lisa Murkowski of Alaska and Ms. Collins, who became an early and vocal opponent of the bill.
Ms. Murkowski raised concerns on several levels. She expressed worries about soaring health care costs in rural areas, about women’s access to health care if Planned Parenthood was defunded, and how the most vulnerable citizens, such as Alaska Natives, would get health care. Those concerns were largely unanswered.
“I certainly wasn’ t ready, ” Ms. Murkowski said of voting on the bill after Mr. McConnell announced on Tuesday that it would be put off until after the Fourth of July recess.
Conservatives point out that, compared with the House bill, the Senate bill delayed the phaseout of the expansion of Medicaid as detailed in the Affordable Care Act, and that preserving protections for patients with pre-existing conditions was something that moderates wanted. But over all, the bill was similar to the House version in broad strokes that moderates disliked, and conservatives won out on the key issue of reining in the growth of Medicaid in the long term.
Mr. McConnell may have been betting that pressure from a majority of Republicans — who have been promising for the better part of a decade to unravel President Barack Obama’s signature domestic policy achievement — would get senators from Medicaid expansion states on board to do just that.
But the forces arrayed against Mr. McConnell were many, including doctors and hospitals, patient advocacy groups and, perhaps more than anyone else, governors — many of them Republicans — from states where tens of thousands of residents have found themselves newly insured under the health care law and are not eager to see that evaporate.
“There may be some philosophical, you know, kind of textbook disagreement, ” Gov. John Kasich, Republican of Ohio, said at a news conference in Washington on Tuesday. “But when you sit in a room and you say to people, ‘Should we strip coverage from somebody who’s mentally ill?’ I’ ve never heard anybody say yes.”
Last week, Senator Dean Heller, Republican of Nevada, stood at a news conference with Brian Sandoval, the state’s extremely popular Republican governor, and said that the “bill that’s currently in front of the United States Senate is not the answer — it’s simply not the answer.”
Mr. Heller added, “It’s going to be very difficult to get me to a yes.”
Mr. Heller gave voice — an early and deeply unappreciated one, it seems, from Mr. McConnell’s perspective — to a number of senators from across the spectrum who were feeling pressure from their governors, and in some cases state insurance officials, to resist any bill that was going to raise premiums, increase the number of uninsured and anything else that officials there disliked.
Then there is the not-so-small matter of President Trump, who in any other universe would be the greatest asset Mr. McConnell could have, but has turned out to be quite the opposite. Republican senators all watched carefully as Mr. Trump at times berated, cajoled and mildly wooed House Republicans, who had their own divisions, to get to yes on their version of a health care bill.
After celebrating in the Rose Garden with Speaker Paul D. Ryan and a bevy of other Republicans, Mr. Trump then turned around and told senators that the House bill was “mean.”
This allowed Republican senators to understand that, as in most areas, Mr. Trump is a mercurial force at best on health care policy. What is more, even though a group that supports him came out with a vicious ad attacking Mr. Heller — and hinted that it would spread to other senators who opposed the health care law — senators are also keenly aware that Mr. Trump did not win the White House by promising to take away voters’ Medicaid.
Then there was the fundamental math problem. Moderate senators simply want more money for the bill. Conservatives like Mike Lee, Republican of Utah, want policy changes that would not only alienate more moderates in the Senate, but also would probably be impossible under the strict rules imposed by the process that Mr. McConnell is using to try to repeal the law. Mr. McConnell chose that path because he needs a mere 51 votes — including one cast by Vice President Mike Pence — to get it done. Senator Rand Paul, Republican of Kentucky, insisted that the bill could not even fairly be called a repeal, so Mr. McConnell started his counting one vote down.
But Mr. McConnell cannot be counted out. Like House leaders, he may be able to push recalcitrant senators his way, but the issues, like fried fish, are not inclined to improve over time.
