Obama’s highly anticipated health care speech did not disappoint, and the shameless heckling from the Republican side of the aisle amounted to icing on the Administration’s public relations cake, so clearly contrasting as it did the President with the political craziness that has aligned itself against him. Obama’s poll numbers will receive a bump – albeit a smaller one than supporters would like to see, as it will primarily come from renewed enthusiasm from the progressive wing of the party which began losing patience with the Administration on this issue (and others) weeks ago.

And praise is coming in by the bucketful. Engaged progressives – from the pundit class to regular citizenry in water-cooler conversations – are using terms such as “turning point” and “game-changer” in describing the success of the speech and the renewed momentum for reform.

Inspired pundits notwithstanding, however, the game has not changed. We are still working the same board with the same pieces and the same rules. What Obama may have done, rather than change the game, is simply hand himself a “get out of jail free” card, enabling him to regain lost ground and political momentum. But there is still a reform bill to be finalized, and the deeper political realities beyond any sense of this week’s ideological momentum remain the same. What matters, of course, is what happens next.

Political reality may be 90% perception, but that remaining 10% is made up of intractable policy realities, and Obama said nothing that mitigates the core political challenge to health care reform.  

Two distinct lines from his speech collectively frame the biggest single problem that remains: “For those individuals and small businesses who still cannot afford the lower-priced insurance available in the exchange, we will provide tax credits, the size of which will be based on your need,” followed a few lines later by “individuals will be required to carry basic health insurance – just as most states require you to carry auto insurance. Likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers.”

Few reformers argue the need to get everyone insured in order to capture savings and increase efficiency in the system, hence the near-universal calls from the left for an individual mandate.

The problem, then, is not whether to have such a mandate, but how to make it work.

A publicly administered and funded insurance option is the simplest, most obvious means to that end. Obama spoke correctly of distinguishing between means and ends, warning against a dogmatic fixation on such a public option by progressives, but the fact is any other means gets sticky, and come down to simply giving people money in some way shape or form, something Washington is loathe to do. And lawmakers should be wary; the notion of simply paying out for individual private insurance without any meaningful regulatory cost controls is an unsustainable, budget-busting gift to an industry already practiced in gouging its clientele.

So without a public option, a fairly straightforward game of policy logic becomes an equation that doesn’t balance easily at all, and despite huzzahs from enthusiastic liberal lawmakers, Obama continued to lay the groundwork for a delicate abandonment of a true public option in his speech. For reform to work without such an option, Congress and the Administration will have to show a willingness to proactively and firmly regulate in a way inconsistent with everything we’ve seen from both up to this point.

If this dynamic that was underway before the speech continues to play out in the direction it had been heading, this meeting of the irresistible force of policy logic with the immovable object of a Congress either chronically confused or simply beholden to insurance and pharmaceutical contributions will leave only one place to balance off the numbers in any final bill; on the backs of middle and working class Americans.

Unless we see more than rhetoric from Obama and Congress – and soon – this debate will continue on the track it has been on for the last week, and could very well still lead to a uniting of the progressive activist base with the far right to defeat a final product seen as doing far more harm than good. Without clearer, firmer and bolder leadership than can be contained in a single speech, we will see a bill, perhaps not as egregious as the abomination that emerged from the mind of Senate Finance Chair Max Baucus, but close enough. A bill that will not provide an immediate, meaningful public option, will still require people to buy insurance, but will only provide assistance to purchase that insurance to the poorest Americans, and in some deferred form – such as tax credits – which will not come when needed.

The middle and working class will again witness what happens when wealthy Congresspeople (especially when looking to make a tough bill’s numbers round out pleasingly) decide what is “affordable” on their behalf. Reform activists still have their work cut out for them if there’s to be a different outcome.