The crowning achievement of Mitch McConnell's notorious career in politics came on Tuesday, when the Senate majority leader got 49 of his Republican colleagues to vote to begin formally debating how many more Americans should lack health insurance.

Moderate Republicans concerned about their constituents may have been allayed by the possibility that Medicaid cuts will be partially offset by new funds intended to help people left uninsured by the bill. Kentucky's Rand Paul, who wanted to vote on a full repeal of the ACA, was told he'd get that chance. Arizona's John McCain, recently diagnosed with brain cancer and fresh from surgery to remove a blood clot from his head, traveled across the country to excoriate his colleagues for the way this process has played out—and voted for the motion to proceed anyway. Conservatives with doubts evidently didn't want to be the vote that torpedoed the long-promised repeal of Obamacare. So the quest for repeal is slouching forward.

In other words, McConnell is winning—as usual.

Except for Barack Obama and Donald Trump, no American politician has been as powerful or as influential as Mitch McConnell over the past decade. As an opposition leader, he stonewalled Obama's agenda as much as possible and created conditions that helped Republicans win majorities in both houses of Congress. Now, thanks to Trump, McConnell has the ability to actually wield power, to enact policy—and like the Republican Party he leads, he has very few ideas about how to do that. He's bent the Senate to his will but has no idea what to do with it, other than to break it completely. He's conquered American politics but doesn't seem to know why.

Watch: Start a new life free of liberals with "Conservative Move"

There are no shortage of ideologues in the GOP, but McConnell is not one of them, which is maybe why he's been so successful for so long. Elected from Kentucky in 1984, he started his career as a moderate, an internationalist who opposed South African apartheid and backed foreign aid. In 1990, he sponsored a healthcare bill that would have, among other things, given tax credits to people to help them buy insurance—a signature component of Obamacare. That year, he campaigned on his efforts to "make sure healthcare is available to all Kentucky families, hold down skyrocketing costs, and provide long-term care."

But the man's views have "shifted," to use a euphemism—by 2014, McConnell was comfortable withholding support for economic assistance to Ukraine in an attempt to extract concessions from Obama and the Democrats. After Trump's election, he insisted that the GOP agenda "is exactly the same as the Trump agenda" despite obvious and fundamental divides on issues like infrastructure. Just about the only thing he's remained consistent on during his time in elected office is his steadfast opposition to campaign finance reform.

There is very little evidence that McConnell cares about policy one way or another. He rose to prominence as minority leader because he unified fellow Senate Republicans in blocking anything Obama tried to do. Destroying what little bipartisanship remained in Congress was McConnell's goal in those years—instead of working with the Democrats on the Affordable Care Act, his Republicans did everything they could to stop it from becoming law, then tried to kill its effectiveness. In one especially nakedly political play early in the Obama years, he supported a bipartisan debt commission until the president agreed—at which point McConnell switched views.

In 2010, he famously said that "the single most important thing we want to achieve is for President Obama to be a one-term president." Beyond that, he told Republicans after the party won major victories in midterms that fall, he wanted to "repeal and replace the health spending bill, to end the bailouts, cut spending, and shrink the size and scope of government."

All of his goals were negatives: repeal, end, cut. What the ACA should be replaced with was not clear then and isn't clear now, even on the eve of its potential repeal. But McConnell was very good at gumming up the works. After Republicans won control of the Senate in 2014, he became majority leader and blocked Obama's judicial appointments aggressively. Most chillingly, he prevented the appointment of Merrick Garland to the Supreme Court last year, even though Obama's nomination of the jurist, a widely praised moderate, could be seen as a concession to Republicans, many of whom had lauded him in the past.

There was no precedent for denying Garland a hearing, but McConnell blows past precedents and norms almost as easily as Trump does; he's just less bellicose about it. He is not solely responsible for the Senate's descent into partisanship and gridlock—that is a larger American story of polarization—but he has done as much as anyone to paralyze the institution he's been a part of for over three decades. Processes that used to be routine business are now battlegrounds. Nominees are blocked by the opposition party as a matter of course. Major bipartisan legislation is a fantasy.

But all of McConnell's previous efforts were in the service of stopping the Democrats from getting things done. Passing legislation is much, much harder than blocking it. Needing to follow through on promises to repeal the Affordable Care Act, McConnell convened a small group of Republicans earlier this summer to write a bill outside the normal committee system, an apparent effort to avoid public debate and scrutiny.

Throughout weeks of intra-GOP discord, McConnell didn't seem wedded to any particular aspect of the bill—he was just trying to get to 50 votes. When that didn't work, when too many senators came out against each of the ideas proposed, he forced his followers to walk the plank: Either they vote to move forward without even knowing what the final bill might be, or be blamed for not living up to their campaign promises. As usual, Senate Republicans folded to McConnell's will.

Now they have to vote on a bill, a piece of legislation that will be McConnell's most lasting tangible legacy, whatever it turns out to be. The first option—the product of the majority leader's prolonged negotiations with himself and his colleagues—was voted down resoundingly Tuesday night. But there will be more votes, more amendments. McConnell will likely work until he reaches a compromise that is just acceptable enough to just enough Republicans—not cruel enough that all moderates reject it out of hand but enough of a tax and spending cut that conservatives can't say no, either. If such a compromise exists, McConnell will find it.

That compromise will likely leave millions more people uninsured and stick millions of others with catastrophic medical costs. I doubt McConnell cares too much about that. He's been very, very successful in controlling the country's most dysfunctional institution and thwarting his enemies. But what happens out here in America as a result of his maneuvers is our problem, not his.