Chief of Staff Rahm Emanuel had argued for a more incremental approach to health reform. "I begged him not to do this," he later recalled.
The president went ahead, saying "I feel lucky." In March of 2010, Obamacare was passed without a serious recalibration or a single Republican vote.
This choice unleashed a cascade of effects. Obama placed a highly ideological debate on the size and role of government at the center of American politics. He contributed to extreme polarization in Congress and the public. He exhausted his political capital on an issue that had little to do with the immediate economic crisis faced by the country. He invited the backlash midterm election of 2010 -- including the loss of 63 Democratic House seats -- which effectively ended the creative period of his presidency.