Medicare would bear no resemblance to its current iteration, transformed from a program in which the government directly pays doctor and hospital bills to a system of vouchers in which future seniors receive subsidies to shop the market and buy health insurance.
The issue has touched off a flurry of ads and accusations in the presidential race, shifting the focus from the fierce talk about President Barack Obama's record on jobs and the economy. Medicare now also stands at the forefront of congressional races as candidates seek an edge with 11 weeks to the Nov. 6 elections.
Republicans have a tight grip on control of the House—240 seats to 190 for the Democrats with five vacancies. Democrats need a net of 25 seats to reclaim control, but the bold talk from earlier this year has been replaced by the number-crunching reality that the results could largely be a wash.
Republicans and Democrats alike see the GOP maintaining control of the House, with Democrats perhaps gaining upwards of 10 seats or Republicans picking up a handful.
New York, including Hayworth's seat, Illinois and California offer the most political promise for the Democrats. New York has eight competitive races, half held by Republicans swept into office in the tea party wave of 2010. The once-in-a-decade redrawing of some New York congressional districts has added more Democratic voters for GOP incumbents, raising the party's hopes.
Democrats also are counting on a boost in turnout in a presidential year and with Obama at the top of the ticket. In New York, turnout in the 2010 nonpresidential elections was a dismal 36 percent. In 2004 and 2008, two presidential years, it was around 59 percent of eligible voters, according to research by Michael McDonald at the United States Elections Project.
Illinois has six competitive seats while California has about a dozen. But within those numbers are several vulnerable Democrats and the party needs them to prevail in November to offset likely losses in Oklahoma, Arkansas and North Carolina, where Republicans dictated the reconfigured districts.
Whether imperiled Democrats in Georgia and Kentucky survive could be the coda on white Southern Democrats nearly 50 years after the Civil Rights Act and the Voting Rights Act. Racial politics have dramatically altered the South, with Republicans dominating across a large swath.
This election offers no signs of the wave that hit in 2010 when Republicans grabbed a net of 63 seats or 2006 when Democrats took control. But both parties have seized on Medicare to pummel candidates and have the money to back it up. The House Republican campaign committee has $41 million cash on hand for the final stretch, while the Democrats have $33 million. Combined, the two have spent more than $100 million.
The National Republican Campaign Committee is airing an independent expenditure ad hitting Democratic Rep. Mark Critz for his votes against repealing Obama's health care law. The spot seizes on the law's $700 billion cut in reimbursements to hospitals, drug companies and other providers, and says Critz put "850,000 Pennsylvania seniors at risk of losing some of their benefits. Mark Critz, he's clearly not on our side."
What the ad doesn't mention is that Ryan's budget also calls for cuts in Medicare of $700 billion.
The Democratic Congressional Campaign Committee is airing an independent expenditure ad against Republican Rep. Dan Benishek in Michigan that uses a grainy image of the first-term congressman as he says "privatizing Social Security and Medicare is the only way to do it." Benishek backed the Ryan budget. The ad ends with the words "Congressman Ben's fishing in troubled waters."
The committees and outside groups are making automated phone calls in dozens of districts on the Medicare issue.
Democrats insist that the Ryan plan for the government-run health care program will unnerve Americans, especially seniors who vote in significant numbers. Republicans counter that Obama has cut the entitlement program in his unpopular health care law, and the GOP is the only party willing to tackle the issue of Medicare's solvency, which would run out in 2024.
The coming weeks will determine who wins on the issue.
In New York's reconfigured 19th Congressional District, Hayworth faces more Democratic voters as the boundaries now include the cities of Poughkeepsie and Newburgh. The first-term lawmaker easily outdistances Maloney in fundraising, with $1.5 million cash on hand to his $264,364.
Enter a Democratic-leaning group, the House Majority PAC, which has reserved $1.2 million in ad time in the district and says Republicans like Hayworth will have to answer for the Ryan budget.
"It is a lie to say Republicans are seeking to end Medicare. Nothing could be further from the truth," Hayworth said, adding, "It's really about doing what's best for the American people, and I know that Paul Ryan is a man of conviction and principle and strength of character who said let's talk about this together."
Maloney, who worked in the Clinton White House and has the backing of the former president, left no doubt he would link the congresswoman to all elements of the Ryan budget.
"The congresswoman has praised Paul Ryan with language my mom usually reserves for the Pope. That means she wants the Ryan plan to be the law of the land. I do not," Maloney said. "You bet the choice is now should we end Medicare so multimillionaires like Nan Hayworth can keep getting huge tax cuts and new tax cuts. That is now the No. 1 issue in this campaign."