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Senate Majority Leader Mitch McConnell's decision to pull the plug on an expected health care vote this week was somehow both inevitable and shocking. Conservatives and moderates had been fleeing from the bill, sure, but McConnell is revered in Washington as a master tactician. He also had $200 billion to spare to win over skeptical senators while still meeting the saving targets he must under the Senate rules.

I heard more than once this week from Republican aides and lobbyists: "Don't bet against Mitch McConnell."

So there is something strange about this setback. Several key swing votes have said in recent days that they haven't heard at all from the leader's office.

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Where was the dealmaker everybody expected? McConnell was seen giving tours at the Capitol on Tuesday, but apparently not calling Sens. Rand Paul and Susan Collins, two critical defectors.

"So far, I've had not one call from Senate leadership," Paul told reporters Monday. "I've gotten a call from the White House, but nobody from Senate Republican leadership is interested at this time in our vote."

On the other end of the ideological spectrum, Collins — who announced Monday night that she would oppose the procedural vote to start debate on the bill — told reporters Tuesday she had received "no outreach" from McConnell.

Republican leaders can lose those two votes, but no others, and Sen. Dean Heller (R-NV) also sounds like a firm "no" on anything resembling the current Senate bill. It won't be easy to find a plan that satisfies both conservative Mike Lee and moderate Lisa Murkowski. But some bridge between the center and the right is the only way this bill can pass.

Which makes the reports from Republican senators on what they've heard — or haven't heard — from McConnell all the more puzzling.

Medicaid cuts and opioids funding are two contentious issues that have helped derail the bill for now. Yet when I asked Sen. Shelley Moore Capito (R-WV), who is focused on those issues, what changes she would like to see, she also suggested there had been little flexibility from the GOP leadership thus far.

With the $200 billion McConnell has to play with, boosting funding for the opioid crisis or softening the Medicaid cuts seemed like obvious moves to make. But so far, nothing.

"There are several things that we've put on the table," Capito said. "At this point, not much give."

Defector of the day: Senate leadership

Each day leading up to the Senate vote, we'll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they're likely to play in the debate.

We may have to retire this feature for the time being, but I thought it was worth noting how abruptly things changed in the Senate on Tuesday.

On Monday, Senate Majority Whip John Cornyn (R-TX) tweeted that he was "closing the door" on the possibility that this week's vote could end up being delayed.

Twenty-four hours later, as he walked through the Capitol basement, Cornyn told reporters: "We're not gonna vote this week, so we have more time to work on it until we get it done."

Senate leaders could still recover. People in Washington tell you not to bet against McConnell for a reason. He still has that $200 billion to woo wavering senators. The partisan motivations for Republicans to say they have repealed Obamacare should not be underestimated. We saw this same show in the House.

But today's setback is a stark reminder of how steep the climb will be.

Chart of the Day

The future arc of the opioid crisis. Opioid overdoses are already killing more than 30,000 Americans annually, and the problem could still get worse. Stat asked public health experts to forecast what would happen over the next 10 years. The high end was 94,000 overdose deaths in 2027. The low end was 21,000. Read more from Stat.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

"Six-Figure Ad Buy Targets 5 GOP Senators to Oppose ACA Repeal" : “Consumers Union, the political arm of product ratings organization Consumer Reports, announced Monday that it’s expanding a six-figure radio ad campaign against Senate Republicans’ health care bill to a total of five states. The $100,000 ad buy targets vulnerable and centrist Republicans who are seen as most likely to buck their party and oppose the bill, which Senate GOP leaders aim to pass this week.” —Jon Reid, Morning Consult

“Consumers Union, the political arm of product ratings organization Consumer Reports, announced Monday that it’s expanding a six-figure radio ad campaign against Senate Republicans’ health care bill to a total of five states. The $100,000 ad buy targets vulnerable and centrist Republicans who are seen as most likely to buck their party and oppose the bill, which Senate GOP leaders aim to pass this week.” —Jon Reid, Morning Consult "From Birth to Death, Medicaid Affects the Lives Of Millions" : “The report issued by the Congressional Budget Office on Monday estimates that 15 million people would lose coverage through Medicaid by 2026 under the proposed Senate bill.

“The report issued by the Congressional Budget Office on Monday estimates that 15 million people would lose coverage through Medicaid by 2026 under the proposed Senate bill. Here are five key things to know about Medicaid as the debate moves forward.” —Alison Kodjak, NPR

"The Trump-McConnell bond is being tested. So is the GOP agenda." : “That fragile peace between a taciturn insider and a brash newcomer has helped both men pursue Republican priorities, but it faces an uncertain future this week as a major rewrite of the nation’s health-care laws falters in the Senate. McConnell and Trump are both hungry for a win. Their understanding, built to score legislative victories, does neither of them any good if victories remain out of reach.” —Robert Costa and Sean Sullivan, Washington Post

“That fragile peace between a taciturn insider and a brash newcomer has helped both men pursue Republican priorities, but it faces an uncertain future this week as a major rewrite of the nation’s health-care laws falters in the Senate. McConnell and Trump are both hungry for a win. Their understanding, built to score legislative victories, does neither of them any good if victories remain out of reach.” —Robert Costa and Sean Sullivan, Washington Post "The hard-to-answer question at the core of the health-care fight: How many more people might die?": “It’s certainly the case that a hard number on the tally of deaths from loss of insurance is tough (and perhaps not even possible) to determine. In broad strokes, [Sen. Bernie] Sanders’s assessment that thousands more would die annually appears to be supported by the data: If some 800,000 people lack insurance in a given year, about 1,000 would be expected to die. Under the Senate bill, 15 million more people would be uninsured next year alone, according to the CBO.” —Phillip Bump, Washington Post

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