If you want to understand the health care bill that’s faltering in the Senate, consider John Kasich, the governor of Ohio. These days, he’s seen as the quintessential moderate Republican. Even though he opposed Obamacare, he was among a handful of Republican governors who accepted its Medicaid monies when others turned it down. And now Kasich is opposing the House and Senate health care bills because they would cut too much from Medicaid.

“They think that’s great? That’s good public policy?” Kasich said in Washington on Tuesday. “What, are you kidding me?”

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The slashing of Medicaid rolls would have a devastating impact in Ohio on everyone from senior citizens in nursing homes—nationwide, 64 percent of seniors in nursing homes are on Medicaid—to people in drug treatment programs, a huge issue in Kasich’s opioid-plagued state.

But when Kasich, now 64, came to Congress in 1983, he wasn’t unlike House Speaker Paul Ryan: a bit of a conservative insurgent. He quickly became head of the House Budget Committee, where, like Ryan, he was seen as a bit of a nerd, someone with good ties to the most hardcore conservatives and the House leadership. In the 1990s, Kasich was a Newt Gingrich ally and a Bill Clinton nemesis. When he left Capitol Hill, his conservative bona fides were so good he filled in on Fox News for Bill O’Reilly when “Papa Bear” was off.

Now, the party has shifted so much that Kasich finds himself at once an apostate, opposing the No. 1 legislative priority of the Republican president and the Republican House speaker and the Republican Senate majority leader. But now, he’s not alone.

On Tuesday, in a huge embarrassment for the White House, Senate Majority Leader Mitch McConnell delayed a scheduled vote on the bill to repeal and replace Obamacare until after the July 4 recess. A vote had been scheduled for as early as Wednesday.

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But a pincer revolt of conservatives like Senator Rand Paul of Kentucky and more moderate members like Senator Dean Heller of Nevada scuttled chances of the bill’s passage this week. Even Senator Jerry Moran, a mainstream Republican who is a former chairman of the Republican Senatorial Campaign Committee—which is in charge of increasing GOP ranks in the chamber—joined in, tweeting on Tuesday afternoon: “The Senate healthcare bill missed the mark for Kansans and therefore did not have my support.”

That doesn’t mean the bill is dead. In fact, the American Health Care Act was scheduled for a vote that had to be delayed before it ultimately passed the House this spring. The same may yet happen to the Senate’s attempt at rewriting a law that governs one-sixth of the American economy.

But the opposition to the bill is striking and revealing. Conservatives hate that it enshrines many of the regulations and expenses that are in Obamacare, such as requiring insurance companies to adhere to pricing guidelines and handing out large subsidies for those same companies. Moderates such as Heller and Kasich have fought the slashing of Medicaid under the GOP bill and rules that allow insurance companies to raise premiums and deductibles dramatically for older Americans.

On Monday, the Congressional Budget Office found that 22 million fewer Americans would have health insurance come 2026 than if the nation stuck with the Affordable Care Act, the law known informally as Obamacare.

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Even if McConnell and President Trump can somehow resurrect the bill in July, there’s still the problem of getting the more conservative House to agree to a version of the repeal.

At its heart, health care reform is always a series of unfortunate tradeoffs. It was that way for Hillary Clinton in 1994, when her signature health care plan went down in defeat, and it was the same when President Obama struggled to pass Obamacare in 2010 despite huge Democratic majorities in both houses. The GOP bill that passed the House and the one being considered by the Senate suffer from the same endemic malady, but more so.

By cutting taxes so dramatically for the wealthy, the bill would force cuts that make even conservative Republicans such as Rob Portman of Ohio, George W. Bush’s director of the Office of Management and Budget, blanch. By keeping elements of Obamacare, conservatives are denied the free-market health care reform of their dreams, which is why senators Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah are joining Rand Paul in opposition to the bill.

To make matters worse, the secretive process for writing the bill—it didn’t go through the usual committees, and there were no hearings—hasn’t allowed either side to really make its case. Obamacare took more than a year to pass. Even with the delay until after the recess, the Senate health care reform is on track for a vote with lightning, and some say alarming, speed.

Before the delay was announced, President Trump invited all Republican senators to the White House as part of a dramatic effort to save the bill. But with a low approval rating himself, often in the 30s, he may not have the clout to cajole and persuade members to pass a bill that has even lower support. By the close of business on Tuesday, nine Republican senators announced they opposed the bill.

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