The Kentucky lawmaker, who has tangled with Democratic presidents and liberal members of Congress for decades, survived polio as a toddler with a paralyzed left leg to eventually claw his way to the top of Capitol Hill's heap and become the Senate's longest-serving party leader.
Confidants and allies are keeping a brave face, saying that McConnell remains sharp and looks forward to steering the Republican caucus back to a majority in 2024.
But lately, his aides increasingly have had to try to tamp down speculation on how much longer the GOP leader can or should hold onto power. He faces mounting questions, from Washington, D.C. to Kentucky, about his health after he suddenly stopped speaking for the second time in as many months during an event Wednesday in the Bluegrass State.
"There's something that's not right somewhere. I'm afraid that the next time it happens you may see him fall over and go into cardiac arrest or even die God forbid," Chris Dickerson, chair of the Elliott County Republican Party in Kentucky, told USA TODAY.
"I mean I just think there's something seriously wrong with his health."
One longtime Republican, who is a close friend of McConnell and spoke to the senator recently, said the GOP leader is a workhouse who can still do the job effectively.
"Obviously, from a health standpoint, if I were advising him I would advise him to take it a little bit easier, but he's got to set that tone," the McConnell friend, who asked for anonymity in order to speak freely, told USA TODAY.
"That's something he's been doing all of his life, think how many years he's done this in the Senate?"
But the physician's note didn't inspire any confidence for Dickerson, who said McConnell should pass the torch to another leader. He said he was on the fence about whether the longtime senator, first elected in 1984, should resign from the Senate altogether.
“I still think he should not continue as leader,” Dickerson said. “That doesn’t make me feel the least bit more comfortable with him being in leadership right now. It just don’t."
After McConnell freezes up again, Kentucky GOP mixed on his future
Publicly, comments from McConnell’s conference in Washington have consisted mainly of well wishes.
Joe Biden, a longtime McConnell friend despite their political differences, said he spoke to McConnell by phone this week, said he was "his old self" when the two talked.
The former president frequently disparages McConnell, calling him an "Old Crow" and saying he should be ousted as leader. McConnell has avoided mentioning Trump after saying his actions before the Jan. 6, 2021 riot at the U.S. Capitol, "were a disgraceful, disgraceful dereliction of duty."
Shane Noem, chair of the Kenton County GOP, was one of the attendees at the event where McConnell froze for a second time. He said "as a Republican Party, we are proud of his leadership in making Kentucky a red state over the past 30-plus years.”
Others such as Mike Bryant, who leads the Breathitt County Republican Party, declined to say whether he thought McConnell’s health impeded his ability to serve, but said the incident illustrated the need for term limits in Congress, also taking aim at Sen. Dianne Feinstein, D-Calif., and Biden for their ages.
“McConnell, Feinstein, and even President Biden, among others, have all shown recent signs of a potential lack of mental acuity. I’m not qualified to say whether they are mentally capable of performing their job duties, but I will say this: if congressional term limits were in place, many of these issues would simply be non-existent,” Bryant said in a statement to USA TODAY.
M.J. Haddix, vice chair of the Gallatin County GOP, had similar sentiments on term limits and also pushed for age restrictions in Congress, telling USA TODAY in an interview he thought it would be best for McConnell to step down from his leadership post.
"My question to Mr. McConnell and anyone around him would be how do you run this country as a business whenever you cannot even get up and speak? I don't know how you make conscious decisions, especially when you're in a leadership position in Washington and make good sound decisions for the general population of the United States," Haddix said.
What happens if Mitch McConnell has to step down?
Other Republicans said that while the political stakes matter, the decision should be left up to the senator and his physician.
Republican Trey Grayson, a former secretary of state, acknowledged the Bluegrass State’s senior senator moves and talks slower at public events, but said McConnell remains sharp on every subject from local farm subsidies to federal judicial appointments.
“Of the people who are in the know, I don’t hear talk of resignation in the real sense,” Grayson said. “The only time I hear it is when people start gaming things out, but it's more on the hypothetical side.”
Republicans close to the GOP leader told USA TODAY resigning in the immediate future is out of the question, especially because of questions about how he might be replaced in a state with a Democratic governor in a closely watched off-year election.
Grayson, a former Senate candidate who McConnell encouraged to run in 2010, said state and national Democrats will likely challenge that law in court should a vacancy arise during Gov. Andy Beshear's tenure. He said McConnell, who is always keeping a political calculus, won’t risk such a move ahead of the November election.
“It would absolutely be on my mind,” Grayson said. “It was one of my hesitations when I left (the secretary of state’s office)… and a U.S. Senate seat is way more important because of the national implications.”
Beshear, a popular Democratic incumbent in a red state, has repeatedly dodged questions about what he would do in the event of a Senate vacancy since McConnell’s first incident of freezing in public in late July.
Asked Thursday if voters deserved to know what he would do in the event of a hypothetical vacancy, Beshear again declined to answer, saying, "I respect Senator McConnell and his health enough, first of all, to not sensationalize it."
"And second, there is no vacancy. So he has said he's going to serve out his term and I fully believe him."
But Beshear gave the public a clue about his views on filling Senate vacancies when he vetoed the bill two years ago before the GOP-dominated legislature issued an override, with the governor arguing that the bill violated provisions of both the state and U.S. Constitution — leading to speculation he may legally challenge or defy it should a vacancy occur.
Beshear is facing Republican Attorney General Daniel Cameron — a former protégé of McConnell — in the general election. Should Cameron win and take office in early December, he would almost certainly follow the new appointment procedures should a vacancy occur.
Michael Abate, a constitutional attorney in Kentucky who has represented the state Democratic Party in previous lawsuits, said he hasn’t spoken with the governor or party leadership about a potential challenge to the state’s vacancy law, but thinks it would be "a substantial and viable challenge."
Noting that the federal constitution allows state legislatures to give governors executive appointment authority to fill vacancies, Abate said it comes down to whether legislatures have “the power to condition that appointment in a way that would limit it to one political party.”
“I think there's a serious challenge that says, look, if you're going to give the governor the power to fill the appointment, you have to let the governor exercise their discretion,” he said. “I'm not aware of any case resolving that question and I think it’s something courts would have to wrestle with.”
There are no restrictions on a governor's choice to fill a Senate vacancy in 35 states, while four states do not allow governors to fill vacancies at all, instead triggering special elections to fill the Senate seat.
In just 10 states, including Kentucky, the person appointed by the governor to fill a vacancy must be of the same party as the departed senator.
Tres Watson, a longtime Kentucky political consultant and former GOP spokesman, said state Republicans don’t trust Beshear will follow the new vacancy rules, especially with a razor-thin margin in the Senate.
“I’d say most believe (the governor) will sue to overturn the law,” he said.
Who replaces Mitch McConnell?
Even if McConnell ignores calls to resign, as most confidants assert he will, the recent health scares have forced a conversation about who is best positioned to take over once he leaves the public stage.
Names being batted around in GOP circles include members of the state’s congressional delegation, such as Rep. Andy Barr, who represents a swing district in the central part of the state, and Rep. James Comer, who has led the House oversight panel.
"I’m praying that Senator McConnell’s condition improves. Whether he runs again or completes this term is a decision for McConnell and his family," said Rep. Thomas Massie, R-Ky, who some speculate would seek the seat.
"We have enough trouble picking our Speakers, so I’m reluctant to advise the Senate on their leadership.”
Others mention people outside of politics, such as businesswoman Kelly Craft, who spent millions in a failed bid for governor this year or businessman Nate Morris, a noted Republican fundraiser with close ties to Sen. Rand Paul, of Kentucky.
Watson said speculation on a successor remains premature and that any jockeying won't be too loud until McConnell signals he's ready for a departure.
“I don't think anybody wants to be seen as the person who is pushing (McConnell) out,” Watson said. "There's certainly no lack of candidates. We'd have to see how everything shakes out.”
The more immediate jockeying will be in Washington, which will have to deal with McConnell's momentary paralysis in public once Congress returns from its August recess next week.
Sen. Rick Scott, R-Fla., who challenged McConnell for his leadership position last fall, told CBS News he expects McConnell to remain leader through 2024. Scott said he hopes McConnell, "comes back with all of us on Tuesday and continues to be an active senator and Republican leader."
Those in McConnell's inner circle, however, understand that the Kentucky Republican faces his greatest challenge yet in the coming weeks as the nation pays closer attention to his every move and word.
"They're ambitious people on the Republican side, who will look at this as an opportunity for themselves," the McConnell friend, who spoke to him recently, told USA TODAY. "I regret it but that's just the way politics is."