WASHINGTON — While President Bush and Republican leaders hail emerging Medicare legislation as a landmark accomplishment for the party, many in its most conservative ranks are cringing at the effort to provide a costly new prescription drug benefit.
A small but potentially crucial band of embittered conservatives says that the compromise crafted by GOP leaders does too little to introduce private-sector competition into health care for the elderly and to control the program's burgeoning costs.
Unless more concessions are made as leaders apply the finishing touches, conservative critics say, the bill will squander a once-in-a-generation opportunity to fundamentally change a program that is on the path to insolvency when baby boomers retire.
That means House Republican leaders are grappling with the opposite problem confronting their Senate counterparts. Party leaders in the Senate worry about a filibuster by liberal Democrats who believe the bill provides too little for the elderly.
In the House, GOP leaders are laboring to stem defections by conservative Republicans who only grudgingly voted for the original House bill -- which passed by a single vote.
Party leaders are trying to sway their right wing by touting provisions taken straight from the conservative wish list, including a new scheme for allowing Americans of all ages to save for health-care expenses in tax-sheltered accounts.
Conservatives long have promoted such accounts as a way to encourage more cost-conscious consumption of medical care.
But many conservatives are not buying that line, arguing that the market-oriented reforms included in the bill do not go far enough to justify the expense of $400 billion over 10 years and the creation of a new entitlement benefit.
"A Republican president and a Republican Congress are poised to create the largest entitlement since 1965," said Rep. Mike Pence (R-Ind.), who announced his opposition to the bill on the House floor Tuesday despite pressure from GOP leaders to keep his stance quiet. "I can't be part of that."
The issue is so seminal that the American Conservative Union, the group whose ratings of lawmakers' records is widely cited as a measure of ideology, has announced it will give double weight to the Medicare vote in making its assessments this year.
GOP leaders are confident that conservative opposition will not be so widespread that the bill will be rejected, if only because it would be a humiliating defeat for Bush.
But to be safe, they have mounted an all-out effort to lobby the rank and file -- a process that amounts to getting die-hard conservatives to do what they often find difficult: accept half a loaf.
"This is the best that we can get," said House Majority Leader Tom DeLay (R-Texas), a conservative who is taking a leading role in selling the Medicare bill. "This is a piece of legislation that complies with my principles as a conservative."
To the extent that Republican conservatives defect, party leaders will have to resort to a rarely used tactic in the deeply partisan House -- counting on Democrats to help pass the bill. Republican leaders are trying to build support for the compromise among conservative Democrats, many of whom come from rural areas that will get special benefits under the bill.
The marquee purpose of the bill is to provide a new prescription drug benefit for the elderly.
But it is also the culmination of a decades-long debate between liberals and conservatives about whether the traditional Medicare program -- which provides direct government subsidies for hospitals and doctors chosen by patients -- is the best way to finance health care for the elderly at a time of spiraling costs and the baby boom generation's nearing retirement.
Conservatives have argued that allowing more competition from private health plans would not only give consumers more choice in their coverage, but would also drive down prices in the scramble to attract patients.
Advocates of traditional Medicare say that such competition would subject the elderly to the vagaries of the marketplace and risk saddling them with unaffordable premiums or inadequate coverage.
Conservatives scored their biggest victory when the House passed its initial version of the Medicare bill, which would have required the traditional program to compete directly with private insurers after 2010.
But even with that provision, many conservatives were not happy with the legislation, objecting to the effort to expand the program without making more dramatic changes to shore up and reorient it.
Nineteen Republicans voted against the original House bill in June. Others voted for it only reluctantly; 13 of them later wrote to House Speaker J. Dennis Hastert (R-Ill.) threatening to oppose the bill if it did not include provisions to control program costs, foster free-market competition and provide tax-free health savings accounts.