Sen. Bernie Sanders (I-Vt.) told reporters at the Capitol on March 13 that the GOP plan to replace the Affordable Care Act “is disgusting.” (Justin Sullivan/Getty Images)

Monday night, after the Congressional Budget Office’s score of the American Health Care Act was released, senators walked on and off the floor for their only votes of the day — confirming Seema Verma as the Medicare and Medicaid chief. Sen. Bernie Sanders (I-Vt.) walked into a throng of reporters to condemn the AHCA.

“I think that legislation is disgusting,” he said. “It is immoral. And it should not see the light of day. Let’s be clear — and I have no hesitation in saying this — if this legislation is passed, millions of people are thrown off of health insurance, not able to get to a doctor when they must. Thousands of Americans will die. That’s what this legislation is about.”

A few minutes later, Sen. Joe Manchin III (D-W.Va.) — another member of the Senate Democratic leadership, representing the right as Sanders represents the left — ambled into the same group of reporters.

“I got an older population, I got a poorer population, and I got an opiate issue we need to clean up,” Manchin said. “And now, talk about insult to injury. You’ve got to have a moral compass inside of you. You can’t do that. Look at the elderly, look at the poor, look at the sick. How can you look at yourself and say, ‘Okay, I’ll help the person who needs help the least, the wealthiest people, with more tax cuts, because I’m going to be taking away from the elderly population?’”

Not 10 days after progressive activists demanded that Manchin be expelled from Senate leadership, the AHCA has brought him back in line with Democrats, fully opposed to Republican repeal efforts. It brought into relief a problem with the Republicans’ three-phase repeal strategy — the third phase, of getting eight Democrats on board with bills to pass the Senate through normal rules, counts on support that does not exist.

Sen. Joe Manchin III (D-W.Va.), seen in February, said on Monday night of the American Health Care Act, “talk about insult to injury.” (Alex Brandon/AP)

Manchin’s position isn’t new. Elected in 2010, after the ACA was law, he has been open to small tweaks but voted against full repeal. During the brief 2013 period when Republicans shut down the federal government over ACA funding and tried to pass piecemeal reforms to break the impasse, Manchin voted with every Democrat against the GOP.

For the moment, that means he’s in league with Sanders, who (to Manchin’s quiet consternation) has tried to build relationships inside West Virginia. Sanders won that state’s 2016 Democratic primary in a rout, carrying every county. His critics noted that, in the exit poll, almost half of the Democrats who’d backed Sanders intended to vote for Donald Trump — as they went on to do, giving the New Yorker the biggest Republican victory in the history of the state.

But Sanders became compelled by West Virginia, a state where the New Deal and the labor movement had built a mighty Democratic Party, and where the backlash of the Obama years wiped the party out. On Sunday, the night before the score was released, Sanders held an MSNBC-hosted town hall meeting in McDowell County, the state’s poorest, where Trump had won a 51-point landslide. (As recently as 2008, McDowell was voting Democratic for president.) The result was a parade of locals sharing Sanders’s view of health care.

“I happen to believe that health care is a right, and we should move to Medicare for all,” Sanders said at one point, stopping for applause. “If Obamacare is repealed, we are looking at hundreds of thousands of people who got Medicaid losing that. How many of those folks will die? How many will lose the opioid treatment they’ve now got?”

West Virginia, controlled by Democrats until 2014, expanded Medicaid and saw 164,400 people jump on the rolls. When Republicans took control of the state legislature, they pushed through long-held goals like a right-to-work bill — but they did not roll back Medicaid or scrap the ACA exchange. At the town hall, Sanders heard Trump voters explain that Trump finally won them over with promises not to touch their health care.

“I voted for him, only, solely because he said he was going to help us,” one voter said. “He was going to put the coal miners to work; we’d have health care. Some people are elderly, they can’t work.”

Manchin, who won easy reelection in 2012 as Barack Obama was losing West Virginia, would need tens of thousands of Trump voters to make the same calculation. As of Monday night, he was urging them along.