In the 1992 elections, the need for healthcare reform was an overriding issue as presidential candidate Bill Clinton set the hook for his domestic agenda.
But by the 1994 congressional races, the consequences of Clinton's failed gambit to overhaul the system created choppy seas for many Democratic candidates.
In this year's contests, healthcare reform has slipped just below the water line, replaced by the great white shark known as Medicare.
"Medicare is a huge election issue," said Thomas Scully, president of the Federation of American Health Systems, which represents investor-owned hospitals. "The Democrats are basing their whole strategy on arguing that the Republicans want to cut benefits to the elderly to give tax breaks to the rich.
"I can't imagine a Democratic campaign anywhere in the country where Medicare won't be the No. 1 issue," Scully added.
Voters around the country already are being bombarded with advertisements about Medicare and entitlement reform from Democrats and Republicans alike.
There is evidence the ads, combined with the highly publicized fights over Medicare reform and various balanced-budget plans, have helped make Medicare a significant issue in the minds of voters.
A poll released late last month by the Kaiser-Harvard Program on the Public and Health/Social Policy found that 7.5% of respondents mentioned Medicare as the most significant issue in the election. It ranked fourth behind the economy (14% of respondents), candidate character (10%) and the federal budget deficit (8%).
That spells trouble for Republicans as they head into their nominating convention this week in San Diego.
"(Medicare) is a very difficult thing for (presumed GOP presidential candidate Bob) Dole and other Republicans to contend with," said Doug Bailey, political consultant and publisher of Hotline, a health and politics newsletter.
Said one Republican aide, "You probably won't hear much about Medicare reform at the convention, but you will hear about balancing the budget."
For Democrats, the message began to take shape more than a year ago when Republican leaders proposed and passed a budget that would have reduced projected Medicare spending by $270 billion over seven years. At the same time, the Medicare program would have been fundamentally changed to give seniors a menu of fee-for-service and managed-care options.
Again and again, Democrats hammered on the plan, complaining Medicare was being savaged to pay for a huge tax cut for the richest citizens.
Not surprisingly, the Democrats' message resonated with older Americans, who worried they would be unable to find a doctor still willing to accept Medicare payment rates.
Martin Corry, a lobbyist with the American Association of Retired Persons, said that during the course of the past year AARP polls have shown that seniors became "more and more uneasy" as they learned the details of the GOP budget proposal. Corry added that since budget talks between President Clinton and GOP leaders collapsed, making it obvious spending cuts wouldn't be implemented, seniors' concern "has abated, but it has definitely not gone away."
Data gathered by Democratic pollsters echoed the AARP poll, but they also revealed an unexpected surprise, one that made it clear Democrats had a winner.
Middle-class baby boomers, worried that they would have to assume the healthcare bills of their aging parents, also were susceptible to the pitch that the GOP budget was too extreme.
"We found it was a strong message across age groups and income levels," said one Democratic aide who asked not to be identified.
Given the opening, Democrats and traditional Democratic supporters have exploited the Medicare issue masterfully.
Last year, the Democratic National Committee spent more than $1 million on ads attacking House Speaker Newt Gingrich (R-Ga.) for suggesting Medicare should be transformed into a "new system."
Beginning last month, the AFL-CIO launched an advertising campaign of its own that fit hand-in-glove with the DNC ads. The AFL-CIO will spend about $20 million on the ads between now and the Nov. 5 election, a spokeswoman said. The labor group will spend an additional $14 million on grass-roots efforts.
Labor is targeting 70 Republican House members, all of whom voted for the GOP balanced-budget plan. The first ad in the series was similar to the DNC ad attacking Gingrich. The second follows an elderly couple named Joseph and Margaret, a throwback to the "Harry and Louise" ads run by the Health Insurance Association of America during the 1994 debate over the Clinton health reform plan. The ad closes with the line, "Call (GOP lawmaker's name) and tell (him/her) not to destroy Medicare. Tell (him/her) this time we're watching."
Republicans point out that under their plan, Medicare spending per person would have risen to more than $7,100 in 2002 from $4,600 in 1996, which hardly constitutes destroying the program. They say the AFL-CIO ads are false and misleading and have threatened television stations with lawsuits if they continue to air them. According to a spokesman at the National Republican Congressional Committee, several stations have acquiesced; however, more than 175 continue to air the AFL-CIO ads.
Republicans also argue that an overhaul of the Medicare system is necessary because the Medicare Part A trust fund is going broke. That fund primarily pays for inpatient hospital care.
As proof, Republicans have cited a report from the Medicare trust fund's trustees released last April. Absent changes, the report predicted the fund would be insolvent in 2001.
What's more, Republicans say, Clinton, despite his protestations to the contrary, also proposed a budget that slowed the rate of growth in Medicare by only about one percentage point less than the GOP plan.
According to Democratic pollster Peter Harris of Harris & Associates, the American public isn't persuaded.
"Since the Democrats first said that the (Medicare) cuts were too high, Republicans have tried to make those arguments up one wall and down another, and they have just gotten creamed," Harris said.
All that adds up to a tough bout for some Republican candidates.
"Just as Clinton over-interpreted his mandate and proposed a (healthcare reform) plan that was too big and had too much government intervention, so too did
the Republicans over-interpret their mandate," said Hotline's Bailey. "(Republicans) seemed to think that their mandate included significant changes in Medicare and Medicaid, but they did not present those changes very carefully and got themselves into a bind by seeming to want to scale back Medicare and Medicaid benefits."
While the rhetoric over Medicare has been heated, discussion of healthcare reform has been simmering quietly.
According to the Kaiser-Harvard study, healthcare reform, specifically controlling costs, is still high on voters' radar screens, although it generates little passion among candidates.
And the hottest healthcare topic in Congress recently-the insurance reform bill sponsored by Sens. Nancy Kassebaum (R-Kan.) and Edward Kennedy (D-Mass.)-doesn't even register as a blip among voters. Some 56% of those surveyed had neither heard nor read about the reform bill Congress passed two weeks ago.
"I am astonished at how little (health insurance reform) is acknowledged by the electorate," said Tom Nickels, vice president of federal relations for the American Hospital Association. "Unless someone spends a lot of money and time getting the public to pay attention, it is just going to be a second-tier issue."
Stephen Cooper, a lobbyist with the Washington lobbying firm of Downey Chandler, agreed.
"Interest in healthcare reform is cyclical," Cooper said. "When there is a recession, people care about it; but when the economy is doing well, like it is now, no one cares."