Ms. Murkowski raised concerns on several levels. She expressed worries about soaring health care costs in rural areas, about womenâs access to health care if Planned Parenthood were defunded, and about how the most vulnerable citizens, such as Alaska Natives, would get health care. Those concerns were largely unanswered.
âI certainly wasnât ready,â 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 â who have been promising for the better part of a decade to unravel President Barack Obamaâs signature domestic policy achievement â 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 â many of them Republicans â 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.
âThere may be some philosophical, you know, kind of textbook disagreement,â Gov. John R. Kasich, Republican of Ohio, said at a news conference in Washington on Tuesday. âBut when you sit in a room and you say to people, âShould we strip coverage from somebody whoâs mentally ill?â Iâve never heard anybody say yes.â
Last week, Senator Dean Heller, Republican of Nevada, stood at a news conference with Brian Sandoval, the stateâs extremely popular Republican governor, and said that the âbill thatâs currently in front of the United States Senate is not the answer â itâs simply not the answer.â
Mr. Heller added, âItâs going to be very difficult to get me to a yes.â
Mr. Heller gave voice â an early and deeply unappreciated one, it seems, from Mr. McConnellâs perspective â 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 or 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 turned around and told senators that the House bill was âmean.â
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 â and hinted that it would spread to other senators who opposed the health care law â senators are also keenly aware that Mr. Trump did not win the White House by promising to take away votersâ 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 probably be impossible under the strict rules imposed by the process Mr. McConnell is using to try to repeal the law. Mr. McConnell chose that path because he needs a mere 51 votes â including one cast by Vice President Mike Pence â 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.
âIt appears that we do not have the votes at the moment,â said Senator Patrick J. Toomey, Republican of Pennsylvania, who stood firmly in the conservative camp as a member of Mr. McConnellâs working group. Mr. Toomey said he thought there was some way that the Senate would eventually vote on a health care repeal bill, but conceded, âI canât be certain of that.â