WASHINGTON — It is the health-care equivalent of President Nixon's going to China: The biggest expansion of Medicare since its inception has been approved on the watch of a Republican Congress and a Republican president.
This implausible product from the party of limited government is the culmination of years of snowballing pressure on Congress to provide drug coverage to senior citizens, who often face crippling pharmaceutical bills.
The party that called for major reductions in the growth of Medicare in the mid-1990s under House Speaker Newt Gingrich of Georgia is now eagerly embracing the addition, at a cost of nearly $400 billion over 10 years, of prescription drug coverage to the program that was a cornerstone of President Lyndon B. Johnson's Great Society.
The bill makes good on myriad campaign promises made by GOP candidates over the last five years -- including President Bush, who now heads into his 2004 reelection campaign claiming credit for breaking a years-long deadlock over prescription drug coverage.
It marks the end of a long chapter in the 38-year history of Medicare, in which the growing clamor for drug coverage topped the charts of voters' domestic policy concerns, dominated health debates in Congress and became a fixture of political campaigns.
But it is not the end of the book on Medicare: The bill, an amalgam of federal and private-sector approaches to providing drug benefits, includes a groundbreaking, but limited, experiment in introducing more market competition to the program's basic services.
The question of which approach will dominate Medicare in the long run may hinge on which party prevails in the next few elections.
"If Democrats win, they will build on the drug benefit, trying to make it more generous, and ignore -- if not pare back -- the pro-competition provisions," said Drew Altman, president of the Henry J. Kaiser Family Foundation. "If Republicans win, they will build on the private market mechanisms."
The drug coverage issue has been part of a much broader debate over the years about how to modernize Medicare and prepare for the retirement of the baby boomers -- those born between 1946 and 1964.
Drugs have become enormously more important since Medicare was established in 1965. The most common and costly medicines that are now central to treating older Americans -- such as Lipitor, a widely used anti-cholesterol drug -- were not even a gleam in a scientist's eye when the program was being hatched.
