Decision Points

Majority Leader Bill Frist and Finance Committee Chairman Chuck Grassley of Iowa. Chuck wisely brought two key Democratic counterparts, Senators Max Baucus of Montana and John Breaux of Louisiana, into the drafting process. They produced a solid bill that garnered support from thirty-five Democrats. The Senate passed 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 , Majority Leader Tom DeLay , and Ways and Means Committee Chairman Bill Thomas built a fragile coalition to pass 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 coupledlow-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 , 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 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 . 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 , 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 friendship 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 embassy 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
    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 divorcée. 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