President Obama staked the initial reputation of his administration on the wisdom, restraint and economic innovation of House Speaker Nancy Pelosi and the rest of the Democratic congressional leadership. It was a mistake. The legislation they produced plugged the fiscal holes in state budgets and Medicaid, and it indulged eight years of pent-up Democratic spending demands on priorities from education to child care to Amtrak. The package did little to promote investment, job creation or economic growth. By one estimate, about 12 cents of every dollar spent was devoted to genuine economic stimulus. While Obama himself remains popular, support for his largest legislative achievement now stands at 34 percent.

This massive expenditure became the political context for the health-care debate. Because the national debt has increased by more than $1 trillion since Obama took office, the president was forced to make his case for health reform based on long-term cost savings. An immediate increase in spending, he argued, would be more than offset by eventual reductions in federal health spending.

But this case collapsed in a series of Congressional Budget Office estimates stating that both House and Senate health approaches would expand deficits during the current 10-year budget window and beyond.