For President Obama, the consequences of health care may still be fatal to his re-election hopes. The choice to go all-in on reform was the most important call of the Obama presidency, and from a purely political perspective it has proved the most disastrous one. Thursday’s decision won’t change this reality: Victory at the Supreme Court was obviously preferable to defeat, but the chief justice’s grudging imprimatur is unlikely to make a deeply unpopular piece of legislation suddenly popular instead. Liberals have persuaded themselves that this unpopularity is largely the product of conservative misinformation and voter ignorance. But it’s really a result of the gulf that opened in 2009 between the public’s priorities and the president’s agenda. By turning from economic crisis management to sweeping social legislation before the crisis had actually abated, Obama made himself look more ideological than practical and more liberal than pragmatic. By continuing to push for the largest possible bill even after the public backlash had elected a Republican senator in Massachusetts, he made himself look wildly out of touch as well. This was not a mistake the icons of the liberal past made. Franklin Delano Roosevelt spent two years defining himself as a Depression-fighter before he set out to establish Social Security; Lyndon Johnson pushed through the Great Society amid an economic boom. Had Obama followed Roosevelt’s first-term example, the initial stimulus bill might have been broken up into smaller (and perhaps more popular) components, financial reform and perhaps tax reform would have preceded health care reform, and the kinds of jobs bills the White House demanded of a recalcitrant Republican Congress in 2011 might have been sought from a Democratic Congress in 2009 and 2010 instead. Even if this policy approach didn’t dramatically accelerate the recovery, it would have given independent voters more confidence that the president had their economic interests rather than his history-making ambitions uppermost in mind. But the Obama White House was convinced that it could fight the recession and rewrite the social compact all at once. And when the administration’s economic policies didn’t deliver as promised, it was almost inevitable that the focus on health care would cost Obama approval ratings, cost his party House seats — and perhaps help cost him a second term as well. Obama is not the only politician whose health care choices have been potentially damaging to his cause, however. Among Congressional Republicans, the decision was made early not only to oppose the White House’s health care push, but to offer almost nothing in the way of policy alternatives. There was no meaningful Republican plan for reform during the heat of the original debate, and for all the notional talk about repealing and replacing, much the same void exists today. Individual conservative politicians and policy wonks have plans, but the party leadership has deemed it too risky to counter the Democratic legislation with anything save boilerplate. Paul Ryan has personally proposed a health care alternative, but his House budgets have conspicuously lacked one. This “just say no” approach made a certain amount of political sense, for many of the same reasons the White House’s “all in” approach turned out to be so politically risky. But it left the Republicans with no leverage on policy: they had nothing to offer wavering Congressional Democrats (from Ben Nelson to Bart Stupak) who had problems with the legislation but wanted to vote for some kind of reform, and they had nothing substantial to put forward when Scott Brown’s victory seemed as if it might force the White House back to the negotiating table. As a result, now that the bill has been passed and the Supreme Court has declined to do their work for them, the Republicans are left to thread a very narrow needle. First they need to take the Senate as well as the White House, and then they need to find a way to pass a party-line repeal bill while lacking any clear consensus on a replacement. Otherwise they will have combined a political victory with a once-in-a-generation policy defeat. Neither the victory nor the defeat is inevitable: there’s still time for Mitt Romney to lead his party to some kind of consensus on a health care alternative, just as there’s still time for President Obama to pull out his re-election bid. But for now, our leaders’ health care moves seem as if they could easily produce the following endgame: The Democratic president is vanquished at the polls, but his Republican opponents are ultimately defeated on the policy.