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. …

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. …

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.