âIt could not be more different from the difficulty of raising the debt limit because it is policy that affects millions of Americans and health care is so personal,â said Senator Susan Collins, Republican of Maine, who is among those who have balked at her partyâs plan.
Mr. McConnell knew his best chance to pass the bill was a quick strike before the Fourth of July recess, and he was right. As expected, the weeklong break has only complicated his already difficult task. Even usually certain Republican votes such as Senators Jerry Moran of Kansas and John Hoeven of North Dakota have joined the cadre of Republicans expressing resistance to the health care proposal, creating more distance between Mr. McConnell and the magic number of 50 votes needed to pass the bill.
At the same time, conservative advocacy groups have intensified their demand that Republicans follow through on their repeated promises to repeal former President Barack Obamaâs health care bill or incur their wrath. They have also gotten behind a proposal by two Republican senators, Ted Cruz of Texas and Mike Lee of Utah, that would move the health care proposal to the right and potentially drive off more support than it gathers.
âRepealing Obamacare was the central and most explicit promise of G.O.P. Senate candidates for eight years,â Ralph Reed, head of the Faith and Freedom Coalition, wrote on Facebook this week. âThe Senate must act now to repeal Obamacare to keep trust with the American people. To fail to do so will have far-reaching consequences for our health care system, our economy, and at the ballot box in 2018.â
Mr. McConnell has expressed mounting frustration at the inability of the unified Republican government to make progress on health care and other issues.
âThe American people said, âWe elected a Republican president, a Republican House and a Republican Senate and we want to see some results,â â he told an audience in Kentucky over the recess. âAnd I canât say anything other than I agree with you. But it is not easy, and we are going to continue to wrestle with this and try to get it done.â
âNo action is not an option,â he emphasized. That remark seemed aimed at quelling calls to simply repeal the law, an alternative that faces steep procedural obstacles because it would require Democratic votes and Democrats will not provide them.
On Thursday, Mr. McConnell again suggested that Republicans might find themselves in negotiations with Democrats on a modest plan to shore up the existing health insurance exchanges if they cannot advance their own legislation. His comment both laid the groundwork for a defeat while trying to provide an incentive for Republicans to get behind the leadership plan.
The health care fight does not play to Mr. McConnellâs typical strengths. It is an extremely complex policy matter, and Mr. McConnell has often reveled more in tactics and procedure than the arcana of community rating and adverse selection.
Even some fellow Republicans acknowledge that Mr. McConnellâs refusal to allow hearings on the health care proposal has backfired, denying Republican lawmakers the opportunity to hear from experts, gauge the strengths and weaknesses of the legislation, and discern potential lines of attack as well as the support for any changes.
Republicans are finding how constituents respond when Congress tries to take a benefit away. The closest comparison might be the decision in 1989 to repeal a new Medicare catastrophic coverage law.
But it was overturned in only about a year with the enthusiastic approval of the people who were supposed to benefit from it. The Affordable Care Act has had much more time to become enmeshed in the health care system, with millions of people relying on it â especially those receiving guaranteed coverage for pre-existing conditions. The beneficiaries of the law are now making their sentiments clearly known.
âI think it is so difficult for Mitch to thread the needle on this given the narrow majority in the Senate,â Ms. Collins said. âI just donât see how he does it. But I donât ever underestimate his abilities.â
Mr. McConnell has had failures in the past, like his inability to prevent the 2013 government shutdown. But he has more often fashioned a way out that few others saw, whether it was cutting a deal on student loans and transportation spending or keeping the Congress and the country from plunging over a fiscal cliff.
He has compared the current situation to a Rubikâs cube, where he is busily twisting and turning until he finally lines up the elusive 50 votes. But in this case, he is discovering that there is no solution within easy reach.