Tommy Thompson had had a long day. The secretary of Health and Human Services had been on Capitol Hill since morning, trying to persuade conservatives in the House and Senate to vote for a prescription drug bill he described as good policy, good medicine and good politics.

Now he had to speak to a room full of conservative codgers at a banquet celebrating the 10th Anniversary of the “60-Plus Association,” a lobbying group that is a conservative alternative to the American Association of Retired Persons. The “60-Plus” members were not in a mood to cheer a prescription for prescription drugs that expands entitlements in a government program already heavy at the top. Nevertheless, he waded in, insisting that his friends in the hall face the facts of the moment, for better and for worse.

Health and Human Services is an agency that has grown big and fat. It has 65,000 employees and an annual budget of $525 billion. In fact, this budget is bigger than the entire budgets of all but five nations (the United States, Britain, Germany, Japan and Italy). The U.S. Defense spending is puny by comparison: “We spend 23 cents of every federal dollar.”

That’s only part of the story. “We regulate the foods that you take, the medicines that you take, the health care you have,” he said. “We run the largest research organizations in medicine and infectious disease. Plus we run Medicare, the largest health insurance program in the world, with 42 million Americans enrolled.”

At this point the diners lost the buzz of the cocktail hour. Then he seized their attention with a question. “Medicare was created in 1965,” he said. “Does anyone know what movie and what actress won Academy Awards that year? A collective senior moment ran through the ballroom. No one could raise his hand.

“It was ‘The Sound of Music,’ with Julie Andrews,” the secretary reminded them. “Since then movies have changed. Music has changed. But Medicare is still the same.”

Medicine has changed, too, and Medicare hasn’t reacted to the changes. Back in 1965, the elderly expected to rely on extended hospital care when they became seriously ill. Prevention was something only vaguely understood. Medicare pays for a heart transplant, but it won’t pay for medicines that prevent heart disease. Tommy Thompson sees prescription drugs under Medicare as the first rung on the ladder to a much larger Medicare reform.

“This is the first step in a competitive nature,” he said, ticking off the options in the legislation seniors can choose for getting their prescription drugs. The formula isn’t perfect, he concedes. The administration wants more competition in Medicare reform across the board. But he thinks it’s a beginning that enables a focus on what’s wrong with Medicare so it can be opened to greater competitive health care programs later.

Congressional Republicans who signed up for the plan note that Thompson’s welfare reform plan in Wisconsin radically reduced welfare rolls. They think he can create a similar miracle with Medicare reform.

Prescription drug benefits fit into the framework of a healthier nation managing and preventing disease. So does an awareness of changing life styles. The secretary calculates the cost of smoking, diabetes and obesity at $400 billion a year.

“I put the whole department on a diet, including myself,” he says. “I lost 15 pounds. If we’re going to represent the Department of Health, we have to look the part.”

As difficult as it is to reduce Medicare spending, persuading Americans to diet and exercise will likely be far more difficult. The secretary had given the “60-Plus” seniors lots to think about. The next day, however, Capitol Hill was alive with the sound of new music.

Suzanne Fields is a syndicated columnist, lecturer and author.