Yet passing this ambitious reform on a party-line vote by questionable tactics may also lead to political disaster. Headed into a midterm election, Obama has managed to alienate many senior citizens, concerned that cuts in their Medicare will be used to finance someone else's entitlement, and many independents, whose general disgust with the political process has been reinforced. The intensity of opposition to health care reform remains higher than the intensity of support. Solid majorities of Americans believe that reform will increase their own costs and reduce the quality of their care. No amount of presidential speechmaking between now and November is likely to change those views -- particularly because the past year of presidential speechmaking actually has been counterproductive.
The immediate political judgment on Obama is likely to be harsh. The historical judgment is, by nature, uncertain. Obama can (correctly) comfort himself that he has altered the health care debate in America forever. When Republicans eventually return to power, they will attempt to modify the package through the introduction of more market-oriented elements. They will not attempt to abolish health care reform. What Republican would want to campaign on a return to the exclusion of insurance coverage because of pre-existing conditions? Obama has created legislative facts on the ground that will shape every future health care debate.
But the value of this achievement will be determined by another historical judgment. If this health care reform had passed in, say, 1994, it might have been just another burden borne by a growing economy, and later refined as the predictable, unintended consequences of the law became evident -- an economic drag, but not a disaster. Yet if the American government is headed toward a general entitlement crisis, Obama's health reform will be seen as historically irresponsible. He is adding a massive new entitlement on top of a structure of entitlements that is already precarious. The costs of this new commitment are projected to grow at about 8 percent a year -- faster than the economy or tax revenues. And this new entitlement is substantially funded by the easiest cuts in current entitlements -- money that now cannot be used to honor existing, unfunded entitlement promises.
In this historical scenario, the irony will be thick. Having seen Wall Street court disaster with highly leveraged risks and many Americans ruined by overextended borrowing, Obama's main response to the economic crisis has been to repeat the excesses of both on a grand scale.
It is possible for a president to be strong -- and badly wrong.