The effect of the “Repeal Now; Replace Later” is to force a choice upon senators: either cast a vote truly dangerous to their careers—or admit that they have been playing politics all along. Again, why? Sam Baker at Axios quoted the pungent comment of a Senate aide: "Repeal and 2015 are pathologically stupid and it's criminal for Trump and conservatives to put us in that position.”

McConnell is not doing what is best for his party—in fact, he is pushing it further along the path most likely to cost Republicans one or both houses of Congress. He is not doing what is best for President Trump, who would be better served in his present legal jeopardy by trying to pass laws that Americans would like: a tax cut or an infrastructure bill. He is certainly not serving the cause of conservative healthcare reform by choosing as his probably final effort a vote that cannot pass and that would plunge health markets into chaos if it somehow did.

But what he is doing is reasserting his own personal leadership, punishing and rewarding senators all at once—in ways that diminish everybody in his caucus other than himself.

The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith. It punishes the cautious senators who recoiled from huge Medicaid cuts by thrusting upon them a clear alternate they would prefer to evade. It intensifies mutual suspicion and ill-feeling inside a caucus where two senators—Nevada’s Dean Heller and Arizona’s Jeff Flake—have been explicitly threatened by the president and head of party.

As Republican poll numbers sink, as the Russia scandal putrefies, as enraged donors complain they have received nothing for their contributions, as the caucus snarls and snaps in frustration, as defeat looms, a terrible paradox is revealed. Dissension and disunion guarantee an even worse outcome in November 2018. The only thin and fading hope for safety is to cling ever tighter to the leadership that has led Republicans to the edge of disaster … and that now demands they jump over the ledge and into the abyss.