Decision Points Part 17

Had Saddam followed through on that intention, the world would likely have witnessed a nuclear arms race between Iraq and Iran. Saddam could have turned to Sunni terrorist groups like al Qaeda-a marriage of convenience, not ideology-as surrogates in an attempt to match Iran's use of s.h.i.+a terrorist groups like Hezbollah. The chance of biological, chemical, or nuclear weapons falling into the hands of terrorists would have increased. The pressure on our friends in the region-especially Israel, Kuwait, Saudi Arabia, and the United Arab Emirates-would have been intense. And the American people would be much less secure today.

Instead, as a result of our actions in Iraq, one of America's most committed and dangerous enemies stopped threatening us forever. The most volatile region in the world lost one of its greatest sources of violence and mayhem. Hostile nations around the world saw the cost of supporting terror and pursuing WMD. And in the s.p.a.ce of nine months, twenty-five million Iraqis went from living under a dictators.h.i.+p of fear to seeing the prospect of a peaceful, functioning democracy. In December 2003, the Iraqis were still a long way from that dream. But they had a chance, and that was a lot more than they'd had before.

The hardest days of the war were still ahead. In January 2004, our troops intercepted a letter from Zarqawi to senior al Qaeda al Qaeda leaders. He wrote about the growing pressure he was feeling and laid out his plan for survival. "We need to bring the s.h.i.+a into the battle," he wrote, "because it is the only way to prolong the duration of the fight between the infidels and us." He set a new goal for the jihadists in Iraq-igniting "a sectarian war." leaders. He wrote about the growing pressure he was feeling and laid out his plan for survival. "We need to bring the s.h.i.+a into the battle," he wrote, "because it is the only way to prolong the duration of the fight between the infidels and us." He set a new goal for the jihadists in Iraq-igniting "a sectarian war."

*The s.h.i.+a, a Muslim sect, make up about 60 percent of Iraq's population. Kurds, who are mostly Muslim but identify primarily by their ethnic group, comprise about 20 percent. Sunni Arabs, the Muslim sect that enjoyed privileged status under Saddam, account for 15 percent. Christians, Yezidis, Mandaeans, Jews, and others make up the rest.

**At the same ceremony, I presented the Medal of Freedom to Prime Minister John Howard John Howard of Australia, who I called a "man of steel," and to President Alvaro Uribe, the courageous leader of Colombia. of Australia, who I called a "man of steel," and to President Alvaro Uribe, the courageous leader of Colombia.

***Tragically, Lieutenant Commander Zellem died in a training accident in 2004.

onight in this hall, we resolve to be the party not of repose but of reform. We will write not footnotes but chapters in the American story. We will add the work of our hands to the inheritance of our fathers and mothers and leave this nation greater than we found it....If you give me your trust, I will honor it. Grant me a mandate, I will use it. Give me the opportunity to lead this nation, and I will lead."

I meant the words I spoke at the Republican National Convention Republican National Convention in 2000. When I entered politics, I made a decision: I would confront problems, not pa.s.s them on to future generations. I admired presidents who used their time in office to enact transformative change. I had studied in 2000. When I entered politics, I made a decision: I would confront problems, not pa.s.s them on to future generations. I admired presidents who used their time in office to enact transformative change. I had studied Theodore Roosevelt Theodore Roosevelt, who served in the White House almost exactly a century before me. He had taken on the financial trusts, built a powerful Navy, and launched the conservation movement. I also learned from Ronald Reagan Ronald Reagan, who combined an optimistic demeanor with the moral clarity and conviction to cut taxes, strengthen the military, and face down the Soviet Union despite withering criticism throughout his presidency.

One of the lessons I took from Roosevelt and Reagan was to lead the public, not chase the opinion polls. I decided to push for sweeping reforms, not tinker with the status quo. As I told my advisers, "I didn't take this job to play small ball."

Two weeks after we moved into the White House, Laura and I held our first movie night in the Family Theater. Situated on the ground floor of the White House, the theater features forty-six comfortable chairs and a ninety-three-square-foot projection screen. The Motion Picture a.s.sociation of America, led for years by a fascinating Texan, Jack Valenti Jack Valenti, generously made movies available to the first family. We never had to sit through coming attractions.

For our first screening, Laura and I chose Thirteen Days Thirteen Days, about President Kennedy's handling of the Cuban Missile Crisis. The movie was a fitting choice for our guest of honor, Senator Ted Kennedy Ted Kennedy of Ma.s.sachusetts. of Ma.s.sachusetts.

On the surface, Ted and I didn't have a whole lot in common. He was liberal; I was conservative. He grew up on Cape Cod; I was raised in West Texas. He had spent almost forty years on Capitol Hill; I was relatively new to town.

With Senator Ted Kennedy in early 2001. White House/Eric Draper White House/Eric Draper Ted and I did share what Laura called the family business. My grandfather Prescott Bush Prescott Bush had represented Connecticut in the Senate at the same time had represented Connecticut in the Senate at the same time John F. Kennedy John F. Kennedy had represented Ma.s.sachusetts. Laura and I enjoyed meeting Ted's wife, Vicki; son Patrick, a congressman from Rhode Island; and niece had represented Ma.s.sachusetts. Laura and I enjoyed meeting Ted's wife, Vicki; son Patrick, a congressman from Rhode Island; and niece Kathleen Kennedy Townsend Kathleen Kennedy Townsend, the lieutenant governor of Maryland, along with her daughter Kate.

Ted was friendly, gracious, and full of life. He had the trademark Kennedy accent and a great Irish glow. His smile came easily and often gave way to a big, warm laugh. I felt a connection to history as we watched a movie about how his brothers had defused a crisis from the West Wing.

The movie hadn't been my only purpose for inviting Ted. He was the ranking Democrat on the Senate committee that drafted education legislation. He had sent signals that he was interested in my school reform proposal, No Child Left Behind.

Ted and I were both appalled by the results coming from our public schools. In the compet.i.tive global economy, good jobs demanded knowledge and skills. But American students routinely trailed their peers in key subjects. On an international math test comparing twenty-one countries, America's high school seniors placed ahead of only Cyprus and South Africa.

Part of the problem was that millions of children were shuffled from one grade to the next without anybody asking what they had learned. Many came from poor and minority backgrounds. In 2000, nearly 70 percent of fourth-graders from high-poverty backgrounds couldn't read at grade level. Some 40 percent of minority students failed to finish high school in four years. How could a society that promised equal opportunity for all quit on its neediest citizens? Starting in the 2000 campaign I had called the problem "the soft bigotry of low expectations." I had promised to take on the big issues. This was sure one of them.

In recent years, the national education debate had bogged down in modest proposals like school uniforms and unrealistic calls to abolish the Department of Education. Success was often defined by dollars spent, not results achieved. I had come from a world where accountability was a daily reality. In baseball baseball, any interested party can open the newspaper, a.n.a.lyze your performance in a box score, and demand change. "More pitching, Bus.h.!.+" was a familiar refrain. Education was a lot more important than baseball, yet most people had no idea how their schools were performing.

As governor, I worked with the legislature to pa.s.s a law requiring schools to test students on the basics every year, report the results publicly, and allow parents to transfer their children out of underperforming schools. Between 1994 and 1998, the percentage of third-graders performing at grade level grew from 58 to 76. Minority students showed the largest gains, closing the achievement gap with their white peers.

When I ran for president, I decided to propose federal legislation that set clear goals-every child would learn to read and do math at grade level-and held schools accountable for progress. Under No Child Left Behind, states would test students in reading and math every year between third and eighth grade, and once in high school. Schools would post scores publicly, broken down by ethnicity, income level, and other subcategories. The data would allow parents and concerned citizens to evaluate schools, teachers, and curricula. Schools that scored below standards would receive extra help at first, including money for students to attend after-school tutoring, public or private. But if schools repeatedly failed to make adequate progress, there would be consequences. Parents would have the option to transfer their child to a better-performing public or charter school. The principle was straightforward: You cannot solve a problem until you diagnose it. Accountability would serve as a catalyst for reform.

I highlighted No Child Left Behind at almost every campaign event, including the NAACP convention. I told reporters I hoped to be known as "the education president." I told Ted Kennedy Ted Kennedy the same thing the night we watched the same thing the night we watched Thirteen Days Thirteen Days. "I don't know about you, but I like to surprise people," I said. "Let's show them Was.h.i.+ngton can still get things done."

The next morning, a letter arrived in the Oval Office: Dear Mr. President,You and Mrs. Bush couldn't have been more gracious and generous to Vicki and me and the members of our family last night and these past few days. I very much appreciate your thoughtful consideration. Like you, I have every intention of getting things done, particularly in education and health care. We will have a difference or two along the way, but I look forward to some important Rose Garden signings.Warm Regards,Ted Kennedy I was excited. No Child Left Behind stood a much better chance of becoming law with support from the Lion of the Senate. It was the beginning of my most unlikely partners.h.i.+p in Was.h.i.+ngton.

Ted Kennedy was not the only legislator I courted. Over my first two weeks in office, I met with more than 150 members of Congress from both parties. I hoped to replicate the productive relations.h.i.+p I'd forged with Bob Bullock, Pete Laney, and other legislators in Texas. One news story began, "If relations between Congress and the White House soon deteriorate into bitterness-as-usual, it won't be for lack of effort to avoid that by President Bush." Another suggested that I was conducting "the biggest charm offensive of any modern chief executive."

Whatever the press called my effort, both houses of Congress soon took up No Child Left Behind. By March, the Senate education committee had completed a bill that included all the key elements of my proposal. The House moved next. Congressman John Boehner John Boehner of Ohio, the skilled Republican chairman of the House Education Committee, collaborated on a solid bill with Congressman of Ohio, the skilled Republican chairman of the House Education Committee, collaborated on a solid bill with Congressman George Miller George Miller of California, one of the chamber's most liberal members. The House pa.s.sed it by a vote of 384 to 45. of California, one of the chamber's most liberal members. The House pa.s.sed it by a vote of 384 to 45.

The process of reconciling the House and Senate bills dragged through the summer. When Congress returned from recess in early September, I set out to reenergize the debate with two days of school visits in Florida. Laura agreed to give her first-ever testimony on Capitol Hill. As a teacher and librarian, she had great credibility on education. Her appearance was scheduled for September 11, 2001.

By the end of that morning, it was clear I would not be the education president. I was a war president. Throughout the fall, I urged Congress to finish No Child Left Behind. Ted Kennedy Ted Kennedy gave a courageous speech defending accountability in front of the National Education a.s.sociation, a teachers' group that contributed heavily to Democrats and strongly opposed the bill. Senator gave a courageous speech defending accountability in front of the National Education a.s.sociation, a teachers' group that contributed heavily to Democrats and strongly opposed the bill. Senator Judd Gregg Judd Gregg and Congressman Boehner, once an advocate of abolis.h.i.+ng the Education Department, rallied Republicans who were anxious about the federal role in education. Like me, they argued that if we were going to spend money on schools, we ought to know the results it produced. A week before Christmas, Congress pa.s.sed No Child Left Behind by a bipartisan landslide. and Congressman Boehner, once an advocate of abolis.h.i.+ng the Education Department, rallied Republicans who were anxious about the federal role in education. Like me, they argued that if we were going to spend money on schools, we ought to know the results it produced. A week before Christmas, Congress pa.s.sed No Child Left Behind by a bipartisan landslide.

Over the years, No Child Left Behind prompted plenty of controversy. Governors and state education officials complained that the bureaucracy was too rigid and that too many schools were labeled as failing. When Margaret Spellings Margaret Spellings became education secretary in 2005, she modified bureaucratic restrictions and increased flexibility for states. But we both made clear we would not dilute the accountability measures. The purpose of the law was to reveal the truth, even when it was unpleasant. became education secretary in 2005, she modified bureaucratic restrictions and increased flexibility for states. But we both made clear we would not dilute the accountability measures. The purpose of the law was to reveal the truth, even when it was unpleasant.

Some critics said it was unfair to test students every year. I thought it was unfair not to. Measuring progress was the only way to find out which students needed help. Others complained about what they called "teaching to the test." But if the test was well designed to measure knowledge of a subject, all the schools had to do was teach that subject.

Another common claim was that No Child Left Behind was underfunded. That's hard to believe, given that we raised federal education spending by 39 percent over my eight years in office, with much of the extra money going to the poorest students and schools.*

On a more fundamental level, the critics who complained about the money missed the point of No Child Left Behind. The premise of the law is that success cannot be measured by dollars spent; it has to be judged by results achieved.

By the time I left office, fourth- and eighth-grade math scores had reached their highest levels in history. So had fourth-grade reading scores. Hispanic and African American students set new records in multiple categories. The gap had narrowed in exactly the way we wanted: All students improved, but minority students improved the most.

In January 2008, I visited Horace Greeley Elementary School in Chicago to mark the sixth anniversary of No Child Left Behind. The school, named for the nineteenth-century abolitionist, was 70 percent Hispanic and 92 percent poor. It had outperformed most public schools in Chicago. Student proficiency in reading had risen from 51 percent in 2003 to 76 percent in 2007. Math proficiency had improved from 59 percent to 86 percent.

At Horace Greeley Elementary School. White House/Joyce Boghosian White House/Joyce Boghosian It was uplifting to see a school full of low-income minority students thrive. A sixth-grader, Yesenia Adame Yesenia Adame, said she enjoyed taking tests. "Then your teachers can know what you need help on," she explained. At the end of my visit, I told students, parents, and the press what I had long believed: No Child Left Behind is a piece of civil rights legislation.

I used to quip that I was a product of a faith-based program. By 1986, faith had changed my heart, and I had quit drinking. Ten years later, my eyes opened to the potential of faith-based programs faith-based programs to transform public policy. to transform public policy.

In June 1996, two African American churches in the town of Greenville, Texas, were burned. Until 1965, a sign on the town's main street had advertised "The Blackest Land, The Whitest People." As governor, I feared we were witnessing a surge in old-time racism.

I traveled to Greenville to condemn the burnings. A mixed-race crowd of about four thousand people turned out in the football stadium. "From time to time, Texans boast that ours is a big state." I said. "But as big as this state is, it has no room for cowardice and hatred and bigotry." Then I gave the microphone to Tony Evans Tony Evans, a dynamic African American pastor from Oak Cliff Bible Fellows.h.i.+p in Dallas. He told a story about a house with a crack in the wall. The owner hired a plasterer to cover the crack. A week later, the crack reappeared. So he hired another plasterer. A week later, the crack was back again. Finally the homeowner called an old painter, who took one look and said, "Son, first fix the foundation and then you can fix the crack in the wall."

The crowd nodded and clapped. Then Tony turned to me. "Governor, I have something to say to you," he said.

Uh-oh, I thought. Where is this headed? Where is this headed?

"We need to fix the foundations," he said, "and your old government programs aren't doing the job." He said he had a better alternative. It was the most effective welfare system in the world. It had buildings on many street corners, a list of willing workers, and regular meetings to study the perfect manual for saving lives.

He was talking about houses of wors.h.i.+p. And he was right. Faith-based programs had the potential to change lives in ways secular ones never could. "Government can hand out money," I said, "but it cannot put hope in a person's heart or a sense of purpose in a person's life."

I looked for ways for Texas to partner with faith-based organizations. I met with Chuck Colson Chuck Colson, Richard Nixon's White House counsel, who had spent time in a federal penitentiary and found redemption. Chuck had founded an organization devoted to spreading the Gospel behind bars. We agreed to start a faith-based program in one wing of a Texas prison. Chuck's program, the InnerChange Freedom Initiative InnerChange Freedom Initiative, would provide instructors for Bible study and a life lessons course. The program would be optional and open to prisoners near the end of their sentences. Each inmate who partic.i.p.ated would be connected with a mentor and welcomed into a church congregation upon release.

In October 1997, I visited the Jester II prison near Sugar Land, Texas, where several dozen inmates had enrolled in InnerChange. At the end of the tour, a group of men in white jumpsuits filed into the courtyard. They formed a semicircle and struck up "Amazing Grace." After a few stanzas, I joined the chorus.

The next morning, Karen Hughes Karen Hughes brought me the brought me the Houston Chronicle Houston Chronicle. There I was on the front page, shoulder to shoulder with the prison choir. The story noted that the man next to me, George Mason George Mason, had pled guilty to killing a woman twelve years earlier. That day in the prison yard, he did not seem like a murderer. He had a gentle manner and a kind smile. No question he had become a spirit-filled man.

When I ran for president, I decided to make a nationwide faith-based initiative faith-based initiative a central part of my campaign. In my first major policy speech, delivered in Indianapolis, I said, "In every instance where my administration sees a responsibility to help people, we will look first to faith-based organizations, to charities, and to community groups." a central part of my campaign. In my first major policy speech, delivered in Indianapolis, I said, "In every instance where my administration sees a responsibility to help people, we will look first to faith-based organizations, to charities, and to community groups."

Nine days after my inauguration, I issued executive orders creating an Office of Faith-Based and Community Initiatives in the White House and in five Cabinet departments. The offices changed regulations and broke down barriers that had prevented faith-based charities from accessing the federal grant-making process. To emphasize the initiative's nonpartisan nature, I appointed Democrats to serve as the first two directors. One was John Dilulio John Dilulio, an innovative professor from the University of Pennsylvania. The other was Jim Towey Jim Towey, a thoroughly decent man who had led Florida's social services department and served as Mother Teresa's lawyer. I used to tell Towey that we sure have a litigious society if Mother Teresa needed a lawyer.

Some said the faith-based initiative blurred the line between church and state. I took that concern seriously. Government should never impose religion. Every citizen has the right to wors.h.i.+p as he or she wishes, or not to wors.h.i.+p at all. I was always wary of people who used faith as a political weapon, suggesting they were more righteous than their opponents. My favorite Bible verse for politicians is Matthew 7:3-"Why do you see the speck that is in your brother's eye, but do not notice the log that is in your own eye?"

At the same time, government need not fear religion. If social service programs run by people of faith did not proselytize or discriminate against people receiving services, I thought they deserved a chance to compete for taxpayer dollars. The government should ask which organization would deliver the best results, not whether they had a cross, a crescent, or a Star of David on their wall.

The initiative opened up roughly $20 billion a year in federal funding to compet.i.tion from faith-based groups. Many of these organizations had no experience interfacing with government, so we held forty conferences and more than four hundred grant-writing seminars to help them apply for funding. Ultimately, more than five thousand faith-based and community organizations, mostly small gra.s.sroots charities, received federal grants.

In January 2008, I visited the Jericho Program Jericho Program of East Baltimore. Operated by Episcopal Community Services of Maryland and funded by a grant from the Department of Labor, the program provided mentoring, counseling, and job training services to recently released adult male convicts. The nine men from Jericho were quiet when I walked into the room. I detected a fair amount of skepticism. "I drank too much at one point in my life," I said to break the ice, "and I understand how a changed heart can help you deal with addiction." of East Baltimore. Operated by Episcopal Community Services of Maryland and funded by a grant from the Department of Labor, the program provided mentoring, counseling, and job training services to recently released adult male convicts. The nine men from Jericho were quiet when I walked into the room. I detected a fair amount of skepticism. "I drank too much at one point in my life," I said to break the ice, "and I understand how a changed heart can help you deal with addiction."

The men opened up and told their stories. One had been convicted of selling drugs, another of cocaine possession, another of theft. Many had been in and out of prison several times and had abandoned their families. Thanks to the services they received at Jericho, they had begun to find purpose in their lives. One man emotionally explained how thrilled he was to have reunited with his three daughters. "Six months ago, I was broken down," he said. "Now I am shaking hands with the president." Another told me proudly that he had received two job offers. "Drugs have always been a problem in my life, up until now," he said. "Thanks to Jericho," he said, "I got my groove."

The Jericho Program's recidivism rate was 22 percent, less than half of Baltimore's overall rate. The men I met that day were among fifteen thousand who had benefited from the Prisoner Reentry Initiative we launched in 2004. Their recidivism rate was 15 percent, one third of the national average.

My most extraordinary meeting on faith-based initiatives took place right across the hall from the Oval Office. In June 2003, I had convened a roundtable discussion with faith-based leaders. Chuck Colson Chuck Colson and several members of InnerChange attended. When I stepped into the Roosevelt Room, I spotted a familiar-looking African American man. I walked over and gave him a big hug. "I'm sure glad you're here," I said. and several members of InnerChange attended. When I stepped into the Roosevelt Room, I spotted a familiar-looking African American man. I walked over and gave him a big hug. "I'm sure glad you're here," I said.

It was George Mason George Mason, the man from the prison choir in Sugar Land. Upon release, he had earned a job as a janitor at his church. He also led a Bible study and served as a mentor for others leaving prison. What a testimony to the redemptive power of Christ: George Mason and George W. Bush together in the West Wing.

With George Mason. White House/Tina Hager White House/Tina Hager

Created by President Johnson in 1965, Medicare had helped countless seniors enjoy healthier lives. But while medicine had advanced, Medicare had not. Benefits were determined by a government bureaucracy that was wasteful and very slow to change. When private insurers added mammogram coverage to protect against breast cancer, it took Medicare ten years and an act of Congress to catch up.

Medicare's most antiquated feature was that it did not cover prescription drugs. The program would pay $28,000 for ulcer surgery, but not $500 a year for pills that would prevent most ulcers.

I was struck by the stories of older Americans who had to choose between buying groceries and medicine. One sixty-nine-year-old woman I met, Mary Jane Jones Mary Jane Jones of Virginia, had to work twenty hours a week just to afford her nearly $500-a-month bill for prescription drugs and insulin. She told me she sometimes used needles three or four times to save money. of Virginia, had to work twenty hours a week just to afford her nearly $500-a-month bill for prescription drugs and insulin. She told me she sometimes used needles three or four times to save money.

Medicare wasn't just outdated; it was going broke. The combination of rising health costs and the upcoming retirement of the Baby Boom generation had created a $13 trillion unfunded liability. The next generation would get stuck with the bill.

The rising costs bankrupting Medicare affected the whole health-care system. America's health spending had doubled from about 7.5 percent of GDP in 1972 to more than 15 percent in 2002. Part of the explanation was the cost of new medical technology. Junk lawsuits also played a role. But the primary cause was a fundamental flaw in the system: Most people had no idea what their health care cost.

Seniors and the poor had their bills paid by the government through Medicare and Medicaid. Most working Americans received coverage through their employers and relied on a third party, an insurance company, to negotiate prices and determine payments. Many self-employed Americans couldn't afford health insurance because the tax code disadvantaged them and regulations prohibited small business owners from pooling risk across jurisdictional boundaries.

What the system lacked was market forces. There was no sense of consumerism or ability to shop around for the best deal, no compet.i.tion for customers' business, and no transparency about quality and price. As a result, there was little incentive for doctors or patients to limit the resources they consumed, which was crucial to holding down costs.

I saw reforming Medicare as a way to solve two problems. First, by adding a prescription drug benefit, we would modernize the program and provide seniors with the quality health care their government had promised. Second, by delivering the drug benefit through private insurance plans that compete for seniors' business, we could inject market forces into the health care system. Reforming the program would also create an opportunity to expand Medicare Plus Choice, later renamed Medicare Advantage, which allowed seniors to obtain all their health care through flexible, affordable private insurance plans.

I knew Medicare reform Medicare reform would be a tough political issue. Introducing market forces into a government health program would upset the left. Adding an expensive prescription drug benefit would be unpopular with the right. But I decided to take on the challenge. would be a tough political issue. Introducing market forces into a government health program would upset the left. Adding an expensive prescription drug benefit would be unpopular with the right. But I decided to take on the challenge.

Under our plan, seniors who wanted the new prescription drug benefit would have to choose private plans instead of government-run Medicare. We would change Medicare's funding formula so that the government-run program had to compete with private plans on a level playing field. Both reforms would introduce more market forces and help address the rising costs of health care.

Before announcing my plan publicly, I previewed it with Republican leaders in the House. They told me my proposal didn't stand a chance on Capitol Hill. Democrats would never support a bill that required seniors to give up their government-run Medicare coverage to receive a prescription drug benefit. Some Republicans wouldn't either.

I faced a tough decision. I could fight for a lost cause or make a compromise. I decided to propose a prescription drug benefit that would be administered by private health plans but open to all seniors, including those who wanted to keep government-run Medicare coverage.

My Medicare team** worked closely with Senate Majority Leader worked closely with Senate Majority Leader Bill Frist Bill Frist and Finance Committee Chairman and Finance Committee Chairman Chuck Gra.s.sley Chuck Gra.s.sley of Iowa. Chuck wisely brought two key Democratic counterparts, Senators of Iowa. Chuck wisely brought two key Democratic counterparts, Senators Max Baucus Max Baucus of Montana and of Montana and John Breaux John Breaux of Louisiana, into the drafting process. They produced a solid bill that garnered support from thirty-five Democrats. The Senate pa.s.sed the bill in June by a vote of 76 to 21. of Louisiana, into the drafting process. They produced a solid bill that garnered support from thirty-five Democrats. The Senate pa.s.sed the bill in June by a vote of 76 to 21.

In the House, some conservatives balked at the cost of the drug benefit, which we eventually estimated at $634 billion over ten years. But Speaker Denny Hastert Denny Hastert, Majority Leader Tom DeLay Tom DeLay, and Ways and Means Committee Chairman Bill Thomas Bill Thomas built a fragile coalition to pa.s.s the bill 216 to 215. Just nine House Democrats voted for a benefit they had demanded for years. The rest voted no. During the debate on the floor of Congress, not a single Democrat criticized the Medicare bill for costing too much. Most wanted to spend more money. built a fragile coalition to pa.s.s the bill 216 to 215. Just nine House Democrats voted for a benefit they had demanded for years. The rest voted no. During the debate on the floor of Congress, not a single Democrat criticized the Medicare bill for costing too much. Most wanted to spend more money.

The razor-thin House margin made it essential that the House and Senate bills be combined in a way that retained Republican support. To address cost concerns, we included a so-called trigger provision that would take effect if Medicare spending rose faster than expected. Congress would then be required to make reforms to address the problem.***

We also highlighted health savings accounts, an innovative new health insurance product created by the House bill. Designed to make coverage affordable for small businesses and individuals, HSAs coupled low-premium, high-deductible insurance against catastrophic illness with a tax-free savings account to pay routine medical expenses. Employers or individuals could contribute to the account, which belonged to the individual and could be taken from job to job. Because HSA owners paid their own health-care expenses and kept any money left over, they had incentives to stay healthy, shop for good deals, and negotiate better prices.

In mid-November, AARP AARP, the influential seniors' advocacy group, endorsed the compromise bill. "This is not a perfect bill, but America cannot wait for the perfect," CEO Bill Novelli Bill Novelli said. He was then excoriated by Democratic leaders, labor unions, and liberal editorial pages. But his stand went a long way with wavering members of Congress. said. He was then excoriated by Democratic leaders, labor unions, and liberal editorial pages. But his stand went a long way with wavering members of Congress.

The decisive vote came on November 21, 2003. Laura and I had long been scheduled to spend that day in Great Britain, as part of the first official state visit there by an American president since Woodrow Wilson Woodrow Wilson. Some suggested postponing the trip. I refused. "They have phones in London, you know," I reminded the team.

Laura and I enjoyed spending time with Queen Elizabeth II Queen Elizabeth II, a gracious, charming woman with a keen sense of humor. In 2007, Her Majesty and Prince Philip came to celebrate the four hundredth anniversary of the Jamestown settlement. In my welcoming remarks before seven thousand people on the South Lawn, I thanked the queen for her long friends.h.i.+p with America. "You helped our nation celebrate its bicentennial in 17..." I caught myself before I could finish the date, 1776, a rough year in U.S.-British relations and an unflattering commentary on the queen's longevity. The eighty-one-year-old monarch glanced at me with a wry smile. "She gave me a look that only a mother could give a child," I said. At a dinner at the British emba.s.sy the next night, Her Majesty said, "I wondered whether I should start this toast by saying, 'When I was here in 1776...'"

With Queen Elizabeth and Prince Philip. White House/Joyce Boghosian White House/Joyce Boghosian Queen Elizabeth's hospitality at Buckingham Palace during our 2003 state visit was exquisite. We received a forty-one-gun salute, inspected the royal troops in the courtyard, and slept in the immaculately appointed Belgian Suite. Our room had been occupied by Queen Elizabeth's uncle, King Edward VIII, before he abdicated the throne in 1936 to marry an American divorcee. It included a three-hundred-year-old mirror, some 10 million British pounds'-$15 million-worth of antiques, and a beautiful view of the palace gardens. At our afternoon tea with Her Majesty and Prince Philip, I asked the queen about her dogs. A few minutes later, a royal footman appeared with her famous corgis. They were friendly and polite. My only hope was that if Barney ever met the queen, he would behave as well as they did-and not bark for Scottish independence.

That evening, Her Majesty and Prince Philip gave an elegant state banquet in our honor. Our places were set with ten pieces of silverware and seven crystal wine goblets. Evidently, word hadn't reached the royal pantry that I had quit drinking. Before I stood to make my toast in white tie and tails, I looked over at Laura in her beautiful burgundy gown. I wondered if she was thinking what I was: We've come a long way from that backyard barbecue in Midland. We've come a long way from that backyard barbecue in Midland.

At Buckingham Palace. White House/Eric Draper White House/Eric Draper

The stateliness of Buckingham Palace marked a stark contrast to what awaited on the flight home. As Air Force One took off, legislative director David Hobbs David Hobbs called me with a list of about a dozen wavering House members, mostly conservatives. I started dialing for votes over the Atlantic. Several congressmen were unavailable to take my call. One junior member did answer. "I didn't come to Was.h.i.+ngton to increase the size of government," he told me. called me with a list of about a dozen wavering House members, mostly conservatives. I started dialing for votes over the Atlantic. Several congressmen were unavailable to take my call. One junior member did answer. "I didn't come to Was.h.i.+ngton to increase the size of government," he told me.

"You know what, I didn't, either," I answered. "I came to make sure the government works. If we're going to have a Medicare program, it ought to be modern, not broken."

"This is just another ent.i.tlement that will keep growing forever," he said.

"So are you for abolis.h.i.+ng Medicare?" I responded. "This is an opportunity to introduce compet.i.tion into the system and hold down costs. Just so you know, this is a h.e.l.luva lot better deal than you're going to get from any other president."

He wasn't persuaded. When I landed in Was.h.i.+ngton, I made another round of calls. We were making some headway, but it was going to be tight. When the House voted at 3:00 a.m., the initial count came up short. Speaker Denny Hastert Denny Hastert took the rare step of holding the vote open in the hope he could persuade a few congressmen to change their votes. Just before 5:00 a.m., took the rare step of holding the vote open in the hope he could persuade a few congressmen to change their votes. Just before 5:00 a.m., David Hobbs David Hobbs woke me up with a call from the Capitol. "We need two more votes," he said. "Can you talk to a few more members?" woke me up with a call from the Capitol. "We need two more votes," he said. "Can you talk to a few more members?"

He pa.s.sed his cell phone around to several Republicans who might be persuaded to change their minds. I argued the case as best I could, given my jet lag. David called back a little while later. Miracle of miracles, the House had pa.s.sed the bill, 220 to 215. The Senate followed a few days later. I signed the Medicare Modernization Act of 2003 on December 8, 2003, at Const.i.tution Hall. Behind me on the stage was a group of seniors who would benefit from the new law. One was Mary Jane Jones Mary Jane Jones, the woman from Virginia who had to reuse her needles to afford insulin. The prescription drug benefit would save her an estimated $2,700 a year.

The new law called for the prescription drug benefit to take effect on January 1, 2006. Skeptics said that seniors would have trouble picking from all the competing private options. I disagreed. I believed that seniors were plenty capable of making decisions about their lives, and that the government ought to trust them to do so.

My effective secretary of health and human services, Mike Leavitt Mike Leavitt, worked with Medicare Administrator Mark McClellan Mark McClellan and his team on a ma.s.sive public outreach campaign. It paid off. More than 22 million seniors signed up for a prescription drug benefit during the initial five-month enrollment period. In a 2008 survey, 90 percent of Medicare prescription drug recipients-and 95 percent of low-income beneficiaries-said they were satisfied with the program. and his team on a ma.s.sive public outreach campaign. It paid off. More than 22 million seniors signed up for a prescription drug benefit during the initial five-month enrollment period. In a 2008 survey, 90 percent of Medicare prescription drug recipients-and 95 percent of low-income beneficiaries-said they were satisfied with the program.