President Obama’s welcome home from his latest successful overseas trip is clouded by the growing doubts about his most important domestic initiative, the overhaul of the dysfunctional U.S. health-care system.

On the surface, things went well for the No. 1 project on his list while he was away. Hospitals pledged to find $155 billion in savings that could be applied to expanding coverage to more of the uninsured.

The chairmen of three House committees that share jurisdiction over health care prepared to unveil a single proposal — a step the Clintons were never able to achieve in their effort at reform. Insurers, doctors and other key interest groups continued to negotiate with the administration, rather than launching broadsides against its plans.

But if you probe a little deeper, what you find are growing questions among insiders — the kind of fault lines that could spread to threaten public support for the ambitious overhaul Obama has in mind and the political coalitions needed to move it through Congress.

Veterans of previous health-care battles whom I interviewed this past week are still mainly of the view that Obama can succeed. Dissatisfaction with the status quo pervades much of business leadership, the ranks of state government and millions of households. Obama is widely praised among the insiders for staying flexible and keeping himself available to negotiate the needed compromises.

But on several fronts, forces have been moving against him, leaving even some of his allies uncertain whether he will prevail.

The staggering economy and the continued uncertainty about the timing and strength of a recovery have sapped public confidence in Washington’s ability to pull off big ventures. Growing talk that unemployment may top 10 percent and require another stimulus bill could complicate the task of finding a trillion dollars over the next 10 years to finance expanded health-care coverage to the millions of uninsured.

Increasingly, Republicans on Capitol Hill and even some Democrats are voicing doubts about adding to the already enormous budget deficits. Obama has long insisted that his reform can be paid for without increasing the debt, but as the legislative process has unfolded, the question of where the offsetting savings will come from has become more urgent.

Democratic Sen. Ron Wyden of Oregon, the co-author of the one bipartisan bill already scored as saving money, told me, “As you look at what is being proposed [in two Senate committees] you don’t see savings in the 10-year budget. That’s why the discussion has shifted to finding new money to finance expanded coverage. But at home, when you tell people we’re already spending $2.5 trillion a year on health care and now we’re going to spend $1 trillion more, it just doesn’t add up.”

The realization is spreading in Congress that to achieve significant cost controls, a fundamental restructuring of health-care delivery will be needed. But Rep. Jim Cooper of Tennessee, a veteran of the failed Clinton effort and the leader of conservative “blue dog” Democrats on health reform, told me that the proposals under discussion “are weak on delivery system reform.”

Obama, he said, clearly gets the need for drastic change. The president has been citing the June 1 New Yorker article by Dr. Atul Gawande pointing out the extraordinary differences in the cost of health care between El Paso and McAllen, Tex. El Paso has reorganized its medical services into cooperative networks of practitioners, delivering quality care at low cost. McAllen, like most American cities, relies on an unstructured collection of individual physicians and hospitals, competing for business and raking in as much money as they can.

Many others who have worked in the system argue similar points, and some of them have begun to suggest that before attempting to reorganize the whole health-care system, Congress should rationalize Medicare, where costs are soaring in McAllen-like fashion.

But Congress shows no sign of having the will or the skill to challenge the myriad, well-entrenched and influential players in the current delivery system. Unless he can prod it to act differently, Obama may find himself signing a bill that condemns us to continued medical inflation.

Two vastly different public officials — Robert McNamara and Sarah Palin — shared the spotlight this past week, triggering fresh thoughts about one of the classic dilemmas of governmental careers: When and how do you quit?

McNamara, the defense secretary for John Kennedy and Lyndon Johnson and later the president of the World Bank, died at 93, ushered out by lengthy obituaries recalling the controversies of the 1960s, including the furor over his unexplained “resignation” at the height of the Vietnam War.

A few days earlier, Palin, the 2008 Republican vice presidential candidate, had stunned her state of Alaska and the entire political world by announcing that she was leaving the governorship 18 months before the end of her term.

More opposite characters you could not imagine. McNamara, the owlish, frighteningly smart, statistically sophisticated, emotionally fragile executive, was the coldest fish in the exotic aquarium of the New Frontier.

Palin, the most colorful and charismatic figure to pop up in the GOP since Ronald Reagan, has displayed in equally vivid terms her brimming self-confidence and her striking ignorance of public policy.

Had they ever met, they would not have known what to make of each other. But they teach a couple of important lessons about the way to handle exits from high office.

McNamara, the principal architect of the American buildup in Vietnam, was slow to recognize that escalation would not yield victory. But by 1967, his sixth year at the Pentagon, he had come to the conclusion that putting in more troops and expanding the air war against North Vietnam would not halt the Viet Cong. He wrote Johnson privately that it was time to negotiate with the enemy — and thereby end the growing domestic division over the war.

Johnson would not hear of it. He summoned McNamara to the White House, and while the weary defense chief later commented that he was never sure whether he had resigned or been fired, he silently accepted Johnson’s decision to send him to the World Bank.

It was not until 1995, when he was again a private citizen, that McNamara published an apologetic memoir, revealing for the first time that he had harbored the gravest doubts about the war that took 58,000 American lives. The public reaction was harsh. Opponents of the war said that if McNamara had made the reason for his “resignation” public at the time, Johnson might have been forced to end the war — and thousands who died over the next seven years might have been saved.

McNamara said he had never seen himself in the role of whistleblower. As an appointee of the president, he said he owed Johnson his loyalty. The voters had chosen Johnson; his judgment deserved deference. It foreshadowed the similar decision by Secretary of State Colin Powell not to go public with his reservations about the Iraq war.

These are hard calls, and those of us on the outside, who can only imagine the pressures of public office, can show some sympathy for the people who have to wrestle with the conflict between their conscience and their sense of obligation to the administration in which they serve.

But resignation on a matter of principle is never a bad thing, and it can have salutary effects. This country would be better off if it happened more often.

By comparison, Palin’s decision to abandon her gubernatorial duties is much harder to understand or justify. Whether this is a prelude to a presidential bid in 2012, preparation for a high-paying media career or just a return to private life in Wasilla, the puzzlement and derision Palin has encountered are well justified.

One of the traditional values for which conservatives are supposed to stand is: Finish what you started. Meet your responsibilities.

This looks like a wholly selfish decision on her part, with no large principles at stake.

McNamara stayed too long and left too quietly. Palin is bailing out on her people far too soon. Neither can serve as an example for those in government wrestling with the decision of when to quit.

Now that the Minnesota Supreme Court has ended the long count on the 2008 Senate race by awarding the seat to Al Franken, Democrats — at least on paper — have the power to pass whatever bills they want, without a single Republican vote.

Nothing would be a bigger mistake.

Franken, the loud-mouthed former comedian, will be the 60th member of the Senate Democratic caucus — just enough for them to cut off any filibuster threat if they can muster all their members. With solid majorities in both houses, the Democratic leaders, Harry Reid and Nancy Pelosi, could dismiss Republican objections to any bill without a second thought.

Yet that would not only contradict President Obama’s promise to change the partisan climate in Washington but would also entail unnecessary risks to Obama’s ambitious policy goals.

Many who have heard Republican leaders in Congress proclaim their opposition to almost every piece of Obama’s program are saying, “To hell with them.” Instead of seeking to enlist Republican support, they urge Obama to tailor everything to the wishes of his Democratic allies.

Yet when it comes to the big initiatives — energy, health care and the rest — the risks of such a choice are obvious. When no Republican votes are in play, the price individual Democratic legislators can extract from the White House goes up. We saw plenty of that with the stimulus bill and the energy bill, both of which were weakened substantively by the concessions Obama had to make to get the last Democratic votes.

Scholars will also make the point that when such complex legislation is being shaped, the substance is likely to be improved when both sides of the aisle contribute ideas. And they will argue that public acceptance of the mandated changes in such programs will be greater if the law comes with the imprimatur of both parties.

These are theoretical arguments, not likely to carry much weight among congressional Democrats. The stronger evidence can be found in the experience with Obama’s early initiatives.

That record has been clouded by a fog of rhetoric — especially the excesses of Republicans decrying the president’s “socialist” schemes and the Democrats calling the GOP the “party of no.”

The simple fact is that White House outreach to Republicans has not failed. It has yielded two of Obama’s most important victories. In February, when the White House was searching for 60 votes to end debate on the economic stimulus bill, Obama was rescued by three Republicans — Olympia Snowe and Susan Collins of Maine and Arlen Specter of Pennsylvania, who later switched to the Democratic Party.

That vote, 60 to 38, with not a single one to spare, gave Obama an important early win. Had he failed, or suffered a lengthy delay, his presidency would have been off to an awful start.

The second big win came just days ago, when the House for the first time passed an energy bill limiting discharges of environmentally dangerous carbon. The vote — after days of frantic bargaining — was 219 to 212.

For all the attention paid to the concessions made to hold the Democratic defections down to 44, few noticed that if Obama had not been helped by eight Republicans, his margin might have been wiped out. Those eight who defied their own leadership are among the few surviving GOP moderates, and, with their Senate counterparts, they will be crucial again on health care.

To ignore them would be really dumb.

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The saga of South Carolina Gov. Mark Sanford and his Argentine romance has been such ripe fodder for the gossip mills that the essential governmental question has almost been forgotten.

Whether Sanford can resolve the mess he has made of his personal life is of little concern to anyone but the people involved.

But when he disappeared for five days, telling no one in his administration or even his security detail where he had gone, he did something totally irresponsible. Had any kind of emergency occurred, South Carolina would have been leaderless.

At the moment Sanford abandoned his duties in secret pursuit of private pleasure, he in effect tendered his resignation.

The implicit message, delivered by the Supreme Court majority in two of the most important decisions of the term that ended this week, is that racial discrimination is no longer as big a problem as we once thought.

Neither the voting rights case out of Texas nor the affirmative action hiring case out of New Haven, Conn., said that explicitly. But the link between the two is the assumption or assertion that this society has largely healed itself and does not need the race-conscious remedies that the previous generation of politicians thought necessary.

If that reading of the court’s majority is correct, then two things are clear. Judge Sonia Sotomayor will certainly challenge the prevailing view if she is confirmed by the Senate to join that bench. And over a longer period, President Obama is likely to find himself in conflict with the court on the question of race.

In the voting rights case decided on June 22, Chief Justice John Roberts signaled that he thinks time has run out on the remedy that Congress concocted in 1965 to overcome the historical pattern of denying blacks access to the ballot box in much of the South. A central provision of the Voting Rights Act, passed originally for five years and repeatedly extended, requires covered jurisdictions to get approval from Washington for any change, no matter how trivial, to its voting procedures.

As Roberts wrote in his opinion, “the historic accomplishments of the Voting Rights Act are undeniable. . . . [But] things have changed in the South. Voter turnout and registration rates now approach parity. Blatantly discriminatory evasions of federal decrees are rare. And minority candidates hold office at unprecedented levels.”

Given all that, he said, it is hard to justify the constitutionality of treating one set of states differently from all the others. The Voting Rights Act was spared only by the court’s discovery that the statute could be interpreted in a way that gives the Texas district involved in the case a chance to be exempted from its terms. So the court deferred judgment on the constitutional question.

Seven justices agreed with Roberts. The eighth, Clarence Thomas, wanted to rule it unconstitutional right now.

In the New Haven firefighters’ case, Justice Anthony Kennedy, writing for a 5-to-4 majority, ruled that protesting white firefighters had been victims of reverse discrimination when the city scrapped an exam on which none of the African Americans who took the test scored well enough to win immediate promotion. In doing so, he put a new and severe limitation on the Civil Rights Act of 1964, passed to open the job market to blacks.

Justice Ruth Bader Ginsburg, in dissent, noted that New Haven, now estimated to be nearly 40 percent black, has only one African American among its 21 fire captains. But, unlike in 1964, when blacks were being beaten for seeking their rights, the court — and perhaps the country — now shows as much or more sympathy for the white victims of the reverse discrimination it finds in affirmative-action programs.

Injecting Sotomayor into this epochal debate when her confirmation hearings begin in a couple of weeks will introduce a passionate and committed advocate of affirmative action. In her professional life and in her many speeches, the woman who would be the first Hispanic justice has repeatedly signaled that she does not believe the wounds of racial discrimination are completely healed or that the remedies of the past are no longer needed.

In that, she is joined by Obama, who rejects the notion that his election signaled the advent of some “post-racial” age. In his great address in Philadelphia in March 2008, candidate Obama said, “Race is an issue that I believe this nation cannot afford to ignore right now. . . . As William Faulkner once wrote, ‘The past isn’t dead and buried. In fact, it isn’t even past.’ ” He argued that the wounds of slavery and segregation are still being felt, noting that because “blacks were excluded from unions, or the police force, or fire department meant that black families could not amass any meaningful wealth to bequeath to future generations.”

You have to believe that as Obama has the opportunity over time to reshape the Supreme Court, there will be more Sotomayors — and more of a challenge to those who wish to dispute the continuing damage that segregation has done to this country and the continuing need for race-conscious remedies.

In a conversation the other day with a White House official, I heard something I’d never expected from an employee of Barack Obama’s. “I wish,” he said, “George Bush would speak up a little more.”

In the five months since he left the presidency, Bush has immersed himself in his memoir. He has stayed home in Texas and rarely spoken publicly. The result has been that he has largely disappeared from the news and — the point the Obama aide was making — pretty much has been forgotten.

Bush’s silence has made it harder for Obama to keep the public focused on Bush as being responsible for our present difficulties — the weak economy, the unsettled wars, the scandals of Guantanamo and the detainee program.

It is not for lack of trying. Obama regularly reminds the public in his speeches and news conferences of all the problems he inherited from his predecessor. But to reporters covering the White House, those reminders have become familiar boilerplate. And since Bush won’t fight back, they rarely get much coverage.

Five months into his tenure, Obama has become the only president the American people think about. And a series of polls last week showed that when Americans think about Obama, they are becoming increasingly critical.

The Wall Street Journal-NBC, the New York Times-CBS and the Pew Research Center polls all reported similar findings. Barack Obama retains his personal popularity, with overall job approval scores at upward of 60 percent. But when asked about specific important policies of the administration, the scores are much lower — or even negative.

In Andrew Kohut’s survey for Pew, the share of voters applauding Obama’s handling of the economy declined from 60 percent in April to 52 percent now. He barely broke even on his approach to the General Motors and Chrysler bailouts, with 47 percent approving and 44 percent disapproving. By a 22-point margin, those polled disagree with spending billions to keep the companies operating.

For weeks, polls have consistently registered opposition to Obama’s decision to close the prison at Guantanamo Bay. His speech blaming Bush for opening the prison apparently did little to ease the political fallout.

The New York Times-CBS poll had more worrisome news. As the size of the budget deficits has become more evident, concerns about the budget policies of the administration have grown. By a 2-1 margin, this survey found that voters answered negatively when asked if Obama has developed a clear plan for dealing with the deficit. A 52 percent to 41 percent majority rejected the Obama priority for stimulating the economy at the cost of higher deficits. They said the focus should be on reducing the deficit.

Health care, Obama’s latest and biggest fight, will provide another test of his leadership, with indications in several polls that Republicans and Democrats are taking opposing stands, despite the president’s calls for a bipartisan bill.

At least until Iran exploded in popular protest against what appears to have been a rigged presidential election, there was broad approval here at home for Obama’s handling of foreign policy. But the White House expects more criticism of the troop buildup in Afghanistan, with the summer likely to produce more fighting and higher casualties.

In sum, Obama has probably extracted most of the political benefit available from the high pitch of activity at home and abroad that has marked the early months of his presidency. Now people are starting to take a more critical look at the decisions he has made. And they are waiting, with varying degrees of patience, to see how the big policy gambles of the early days play out.

Obama is fortunate that the public does not see a clear alternative coming from congressional Republicans. But he misses being compared on a daily basis with his predecessor. Thus, the irony of Obama people saying, “Bring back Bush.”

Fifteen years ago, when Democratic Sen. Tom Daschle was running interference for the Clintons’ effort at health-care reform, his goal in life was to enlist Sen. Bob Dole, the hugely influential Republican leader, as a co-sponsor. Daschle never got him, and the enterprise crashed and burned.

When I did an interview with the two of them this week, Dole remarked that “we started out working together, and then it fell apart” — the victim of a massive lobbying campaign, a bunch of tactical errors by the president and first lady, and Dole’s presidential ambitions, which moved him into the camp of the Republican naysayers.

Now Daschle and Dole, along with another former Republican leader, Howard Baker, have come together with a report outlining the provisions of a possible bipartisan health bill and strong recommendations on how to pass it. (The fourth original member of this Bipartisan Policy Center board, former Senate Democratic leader George Mitchell, dropped out to become President Obama’s special envoy to the Middle East.)

In a phone conversation the day before their report was released, Daschle and Dole agreed that prospects for enactment of major reform are far better now than in 1994 — and better than they would have been even two years ago. “The situation is far more dire on costs and quality and access to care,” Daschle said. Added Dole: “You have business, labor and a whole cross section of people saying, ‘We have to have reform.’ “

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But it will still be a heavy lift. Like Obama, Daschle and Dole estimate the cost of insuring the 46 million without health coverage to be $1.2 trillion over 10 years, and they say that at least half will have to come from new revenue, if the Obama goal of budget neutrality is to be met.

To raise it, they would assess large companies that do not offer employees health insurance a fee based on their payrolls — a mandate that Dole acknowledges would be hard for many Republicans to swallow. And they would impose taxes for the first time on the so-called Cadillac policies paid for by employers — a change opposed by many Democrats, by unions and by Obama when John McCain advocated it during last year’s election campaign.

But that is only the beginning of the bitter medicine Dole and Daschle are asking their fellow partisans to choke down.

Acknowledging that there is little chance for bipartisanship in the House, Dole urged Senate Republicans to give up any thought of filibustering the health bill. “We need a group of Republicans who will give an early demonstration that bipartisanship is possible,” he said.

Daschle, in turn, said he thinks the Democrats should not attempt to ram a health bill through the Senate by using the budget reconciliation device to pass it with 51 votes, rather than the 60 votes most legislation requires.

Daschle, who would have been Obama’s point man on health reform had his recent tax returns not caused him problems, made the point that a reform of this magnitude should not be forced through on a narrow majority. Australia, he said, “passed and repealed health reform several times before they got a strong enough vote to sustain it.”

It is significant that the Daschle-Dole plan sidesteps the raging controversy over whether there should be a government-sponsored plan to compete with private insurers. Obama and most other Democrats are demanding it; Republicans and conservative Democrats call it a deal-breaker.

Daschle reluctantly agreed that there would be no federal-government plan. Instead, states that want it could include such a plan on the menu for their residents, with technical help from the feds in setting it up. Five years from now, if a demand for such an option still exists, the president could recommend it, and Congress would have to vote on it.

It was damned hard for Dole and Daschle, neither of whom faces the voters or the lobbyists, to agree. It will be much harder to extract a bipartisan bill from Congress