Decision Points

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.

    At Buckingham Palace.
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 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 Washington 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 entitlement that will keep growing forever,” he said.
    “So are you for abolishing Medicare?” I responded. “This is an opportunity to introduce competition into the system and hold down costs. Just so you know, this is a helluva lot better deal than you’re going to get from any other president.”
    He wasn’t persuaded. When I landed in Washington, I made another round of calls. We were making some headway, but it was going to betight. When the House voted at 3:00 a.m., the initial count came up short. Speaker 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., 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?”
    He passed 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 passed 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 Constitution Hall. Behind me on the stage was a group of seniors who would benefit from the new law. One was 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 , worked with Medicare Administrator Mark McClellan and his team on a massive 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.
    Ultimately, Medicare modernization was a tradeoff. We created a needed new benefit but spent more money than I wanted. We introduced market-based competition among private drug plans, but we were unable to use the new benefit as leverage to move more seniors from government-run Medicare to private Medicare Advantage plans. We created health savings accounts, but we could not convince Congress to require government-run Medicare to compete on a level playing field with private plans.
    By the time I left office, more than 90 percent of Medicare beneficiaries had coverage for prescription drugs. Ten million were enrolled in private-sector health-care plans through Medicare Advantage. Almostseven million Americans owned health savings accounts, more than a third of whom had not previously owned health insurance.
    Thanks to competition between private-sector plans, the average monthly premium for prescription drug coverage dropped from an initial estimate of $35 to $23 the first year. By 2008, the initial estimate of $634 billion had dropped below $400 billion. The Medicare prescription drug benefit became one of the few government programs ever to come in well under budget. Market