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Washington • Senators started returning to the Capitol on Monday with the Republican agenda in a state of flux after GOP leaders scrapped their plans to vote on a sweeping health care overhaul this week.
At the center of the uncertainty is Sen. John McCain, R-Ariz., who is recovering at home from surgery to remove a blood clot above his left eye that involved opening his skull.
Without McCain in the Senate, Majority Leader Mitch McConnell, R-Ky., lacks the votes he needs to proceed with a bill to revamp major parts of the Affordable Care Act. So he has put it off until after McCain returns.
But when that would happen was not clear Monday afternoon. McCain, 80, is awaiting the results of tissue pathology reports "pending within the next several days," the hospital treating him said in a statement over the weekend. A McCain spokeswoman had no further update on his condition Monday.
The most common causes of blood clots in the head, especially for older people, are falls, car crashes and other events that cause traumas, even minor ones, said Elliott Haut, a trauma surgeon at the Johns Hopkins University School of Medicine. By one estimate, 1.7 million people suffer traumatic head injuries each year, with motor vehicle accidents the leading cause and blood clots that affect the brain a common effect.
Traumas can cause blood to leak out of small vessels between the brain and a tough, fibrous layer known as the dura, causing "subdural hematomas" and others between the dura and the skull, known as "epidural hematomas."
"People die of these every day," Haut said in an interview, emphasizing that he could not speak about McCain's health because he had no details of the case. Blood clots as small as a half-centimeter are worrisome, he said. Epidural hematomas are less often fatal.
Another possibility is that the clot is related to McCain's history of melanoma, a dangerous form of skin cancer that can spread to other organs, including the brain, and form new tumors. Haut said that is much less likely but not impossible. Diagnosis of a clot requires a CT scan, which can follow symptoms such as blurred vision, headaches or a change in vision, he said.
Democrats are pressuring Republicans to use the delay in the Senate to hold public hearings on the controversial GOP health care bill. All 48 members of the Democratic caucus — along with two Republicans — oppose the legislation.
"This will allow members to hear unfiltered and unbiased analysis of how the bill will affect their states and the health and financial security of the constituents they represent, including the impact of Medicaid cuts to vulnerable populations like children, people with disabilities, and people with pre-existing conditions," wrote Senate Minority Leader Charles Schumer, D-N.Y., and two other leading Democratic senators in a letter to McConnell and a pair of GOP committee chairmen.
The letter also asks that GOP leaders not move ahead with the bill until the nonpartisan Congressional Budget Office releases a "complete score" on it. The CBO had been expected to release its findings as soon as Monday. But a GOP aide said that would not happen. The aide, granted anonymity to speak candidly, said a release later this week was possible but not certain.
The CBO has been projecting what the bill would do to insurance coverage levels, premium costs and the federal budget deficit. Having an unfavorable report in the public domain for an extended period of time with an uncertain date for a vote would fuel critics' argument against the bill, probably making it harder for McConnell to round up votes for it.
A CBO report on an earlier version of the legislation projected it would result in 22 million fewer Americans with insurance by 2026 compared with under current law. It predicted that measure would reduce the budget deficit by $321 billion over the same period. On average, premiums would first rise, then fall under the measure, the CBO projected.
Neither a McConnell spokesman nor the CBO immediately responded to requests for comment on when the report was expected and why it would not be released Monday.
White House officials have been seeking to cast doubt on the findings from the CBO and other independent analyses of the bill. But some key Republicans have responded to their pitch with skepticism.
Over the weekend, influential Republican governors said they were not sold, even after talking privately with the officials during the National Governors Association's summer meeting.
In an interview broadcast Sunday on NBC's "Meet The Press," Senate Majority Whip John Cornyn, R-Texas, said the Senate would vote on health care "as soon as we have a full contingent of senators."
But when that will happen depends on the severity of McCain's condition. Until that is known, Senate Republican leaders plan to focus on trying to confirm more Trump administration nominees and some less sweeping legislative goals.
"Following a routine annual physical," the Mayo Clinic Hospital in Phoenix said Saturday, McCain "underwent a procedure to remove a blood clot from above his left eye on Friday, July 14." The hospital added that "surgeons successfully removed the 5-cm blood clot during a minimally invasive craniotomy with an eyebrow incision. Tissue pathology reports are pending within the next several days."
Acute subdural hematomas can be fatal half the time and even more often in older people. They can also cause strokes. Unlike clots in the legs and lungs, they must be treated through surgery, rather than blood thinners, Haut said.
In 2009, actress Natasha Richardson died of the effects of an epidural hematoma after declining medical attention following a fall while skiing.
It is not known whether McCain takes blood thinners, but those can make it more likely that blood will escape from vessels after a trauma, Haut said.
Without McCain in the Senate, McConnell can count on at most 49 votes to move ahead on the health care bill. Along with all of the Democrats, Sens. Rand Paul, R-Ky., and Susan Collins, R-Maine, oppose it. Spokespeople for the two Republicans confirmed they still intend to vote against bringing the bill to the Senate floor.
If Republicans can round up 50 votes, Vice President Mike Pence can break a tie in their favor.
Beyond Collins and Paul, other Republican senators have expressed reservations about the bill — including McCain. It is far from clear that McConnell will be able to persuade enough Republicans to vote for it.
Several key GOP senators have voiced concerns about the measure's long-term federal spending cuts to Medicaid. Others have worried the bill does not go far enough in overhauling the ACA. The opposing pressures have left McConnell in a tough position in which he has struggled to find a solution.