Mitch McConnell had some time to try to rework his health care bill and a version of his revisions has leaked out. It looks like he made the calculation that he needed to keep the Medicaid cuts to hold conservatives in line. Despite some tweaks in the new draft, that’s the bottom line, and it means that more moderate members are simply not on board.

There are several other complicating factors for McConnell, but the Medicaid issue is the most confounding because he can’t find a way to turn the dial in either direction without causing a loss of support. His attempted solution seems to be that he will cave to conservative demands and then try to convince the moderates that the Medicaid cuts will be so unpopular that they will never go into effect. In other words, much like the Doc-Fix, future congresses will perpetually write patches to prevent the law from going into effect.

McConnell could be correct about that, but it’s not something his conservative members want to hear. A similar argument was used by the House leadership to convince moderate members to support their version of Obamacare repeal. Essentially, they said that whatever the problems might be with the bill, the Senate would fix them. Better to just pass something and send it to the Senate and let Obamacare repeal be their problem for a while.

The reason this is different is that the Republicans are reaching the point where they actually need to pass something. They can’t play ping-pong, sending unacceptable versions of the bill back and forth between the House and Senate. McConnell can’t argue that the House will fix the Medicaid problem, so he insists that future congresses will do so.

It hasn’t convinced the doubters in McConnell’s caucus. As of right now, it doesn’t look like McConnell can even win on a procedural motion to proceed to consideration of his bill, which in this case would only require fifty votes.

It’s a predictable failure, and one I have been predicting all along.

Unless he can get past this impasse, nothing else in the bill matters.

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