Updated 10 a.m., Oct. 21.

A Republican Congress — and Nate Silver puts the odds of a Republican House at 73 percent — may seem as if it would do more to reduce Medicare spending growth than a Democratic one. Republicans, after all, opposed Medicare when it began in the 1960s. Ronald Reagan, then starting his political career, called it the first step toward socialism.

“One of these days,” he said in 1963, as the spokesman for the American Medical Association campaigning against Medicare, “you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.”

But the more recent political history of Medicare has been quite different. If anything, Republicans have been less fiscally conservative toward Medicare than Democrats.

In the 1990s, a Republican-controlled Congress eliminated the Office of Technology Assessment, which had been doing cost-effectiveness studies of medical technologies. The office, says Dana Goldman, director of the University of Southern California’s Leonard D. Schaeffer Center for Health Policy and Economics, says “did a really nice job with some studies, many of which foreshadowed technology choices two decades later.” It was one of the only government agencies Congress eliminated during that time.

Around the same time, Newt Gingrich took steps to prevent Medicare from cracking down on treatments that didn’t appear to improve health. The following comes from Shannon Brownlee, writing in The Washington Monthly:

…a federal office known as the Agency for Health Care Policy and Research (A.H.C.P.R.) impaneled a group of 23 experts in 1993 to draft guidelines to help doctors figure out how best to treat low back pain. The A.H.C.P.R. was created in 1989 during the first Bush administration. Its mandate was to produce evidence-based, clinical-practice guidelines that would help physicians sort through the conflicting data that existed not just for low back pain, but for many other common treatments and tests.



Then, as now, the nation’s medical bill was rising at an alarming rate, in part due to widespread, inappropriate use of unnecessary or useless treatments. Democrats and Republicans alike hoped that the A.H.C.P.R.’s research would help rein in costs by giving doctors better direction, and offering payers—especially Medicare—the ammunition they needed to make evidence-based coverage decisions. More significantly, the agency promised to improve the quality of health care by helping to ensure that doctors would give patients the treatments they really needed — and refrain from giving them care that could harm them. But when the A.H.C.P.R.’s panel concluded that there was little evidence to support surgery as a first-line treatment for low back pain, and that doctors and patients would be wise to try nonsurgical interventions first, back surgeons went wild…. Their arguments found a sympathetic ear in Newt Gingrich’s newly elected Republican majority in the House…. The Republicans saw the A.H.C.P.R. as a wasteful government agency, and in 1995 the House voted to eliminate its funding, calling it the “Agency for High Cost Publications and Research.” Eventually, the agency was rescued with the help of a handful of Republican supporters in the Senate, but it suffered a 21 percent cut of its already meager $159 million budget.

Almost a decade later, under President George W. Bush, a Republican-led Congress, with significant Democratic support, added a drug-prescription benefit to Medicare. Whatever the plan’s benefits, Congress didn’t pay for it with cuts elsewhere or higher taxes. The bill was simply added to Medicare’s long-term shortfall and, in turn, the federal deficit.

Finally, there was the recent debate over health reform. To help pay the cost of expanding health insurance, Democrats cut Medicare spending over the next decade. Michael Steele, the Republican Party chairman, referred to the cuts as a raid on Medicare, and they became a major talking point.

It’s certainly possible that the party will shift directions again. Representative Paul Ryan, the ranking Republican on the House Budget Committee, has put out a plan to cut Medicare spending, though very few other members of his party support it. Ultimately, the basic arithmetic of the deficit — which, over the long term, will be caused more by Medicare than anything else — may force the Republicans to change.

But, for now, the party of small government — the party that opposed the creation of Medicare — is also the party of big Medicare.

Update: An earlier version of this post incorrectly said that the Reagan administration — rather than a Republican-led Congress in the 1990s — eliminated the Office of Technology Assessment.