Confusion pervaded the national capitol Wednesday as President Donald Trump once again switched directions on health care, scolding Republican senators at a White House lunch to stay in town until they “repeal and replace” the Affordable Care Act or Obamacare as he calls it.

Kentucky’s senior senator, Majority Leader Mitch McConnell, announced Monday Republicans lacked the 50 votes required to pass replacement legislation he originally wanted to vote on last week. His announcement came after four of the 52 Senate Republicans announced they would not support the bill.

Trump, who campaigned on promises to replace the “disaster” he claims the ACA represents with a better bill which would increase coverage and lower premiums, then suggested the Senate should simply repeal the ACA.

The next day, he said Republicans should just let the law collapse and blame Democrats.

Outright repeal, according to estimates by the Urban Institute, a Washington, D.C.-based policy group, would increase the number of uninsured Kentucky residents from 244,000 to 730,000. Along the way, more than 550,000 Kentuckians would lose coverage they gained under the ACA. 

But when Republican senators joined Trump for lunch at the White House Wednesday, the president switched directions once again.

“We can repeal but we also should replace,” Trump said before scolding Republican lawmakers who had delayed their scheduled August recess in order to vote on McConnell’s Better Care Reconciliation Act.

“Frankly, I don’t think we should leave town unless we have a health insurance plan,” Trump said. Then he leaned on them.

“For seven years, you promised the American people you would repeal Obamacare,” Trump admonished. He said he’s waiting, “pen in hand,” to sign repeal legislation.

Seated next to Nevada Sen. Dean Heller, who is considered the most vulnerable Republican senator in 2018 and who said he couldn’t vote for the BCRA, Trump said he assumes Heller “wants to remain a senator.”

Outside groups which support Trump aired television ads critical of Heller, angering McConnell who reportedly called White House Chief of Staff Reince Priebus, telling him to stop the ads.

All Senate Democrats oppose repeal and, with only 52 senators, Republicans can’t break a Democratic filibuster. So they’re relying on a procedure called “reconciliation” which allows them to pass legislation with only 51 votes so long as it impacts the budget.

McConnell hoped to pass the bill through that process, because even if he lost the support of two Republicans Vice President Mike Pence could cast the tie-breaking 51st vote.

Kentucky’s other Republican senator, Rand Paul, and Maine’s Susan Collins were already on record as opposing the bill. Then Monday, Mike Lee, R-Utah, and Jerry Moran, R-Kansas, announced they, too, would vote against proceeding with the bill.

Despite Trump’s admonishment, McConnell said the Senate will vote on a repeal only bill next week.

It’s the same measure all Republicans voted for in 2015. It was a safe vote then — they knew Democratic President Barack Obama would veto any attempt to repeal his signature legislative achievement.

After the White House lunch, McConnell said the Senate will first vote on a motion to proceed to debate on the repeal legislation. That also requires 51 votes and puts pressure on Republicans like Collins who voted for repeal in 2015 but now opposes to cutbacks in the ACA’s expanded Medicaid provisions.

“It’s better to vote to repeal and replace,” McConnell said. “But we can have a vote on either.”

He emphasized the repeal legislation is “fully amendable” and, if it passes without amendment, it includes a two-year delay before implementation.

That’s supposed to allow states and insurance markets to prepare, but it also conveniently gets Republicans past the 2018 congressional elections and the pain some voters might begin to feel following repeal of legislation which extended coverage to more than 20 million.

According to Dustin Pugel, a research policy associate for the Kentucky Center of Economic Policy, a lot of Kentuckians would feel pain.

Repeal would mean 475,000 Kentuckians insured through Medicaid expansion would lose coverage. Another 81,115 would lose coverage purchased through individual plans on health exchanges, Pugel said.

He said the non-partisan Congressional Budget Office estimates insurance premiums would rise 25 percent in the first year and double over 10 years. And without the ACA’s subsidies, insurance companies might decide not to offer individual plans, Pugel said.

Ronnie Ellis writes for CNHI News Service and is based in Frankfort. Reach him at rellis@cnhi.com. Follow him on Twitter @cnhifrankfort.