By BBC News Online's Steve Schifferes

Health care is the hidden issue of the 2000 campaign.

After his election in 1992, President Clinton attempted to make the reform of the entire health care system a major plank of his first Administration.

But his defeat on health care helped pave the way for the Republicans to control Congress in 1994, and led all politicians to shy away from the highly charged issue.

Now, as the 2000 election approaches, pressure groups and local initiatives are seeking to put the health care issue back on the agenda, forcing both Presidential candidates and Congressmen to respond.

Earlier health care reform focused on two issues: the lack of coverage by millions of Americans, and the high costs of maintaining a system of insurance-based care.

These problems have not gone away, but now reforms are focused on a less comprehensive agenda, and are targeting more specific problems.

The most high-profile is an attempt to cover the high cost of prescription drugs.

President Bill Clinton and Vice President Gore have proposed an extension of in Medicare, the government-fumded health care system for retired people, to cover prescription drug costs.

Drug companies on the attack

The proposal for a drugs benefit is attacked by the drugs industry, which fears that if the government is going to pay for the costs of prescription medicine, it will also want to restrict the prices that drug companies can charge.

They cite the tight regulations on fees for doctors who participate in the Medicare programme.

The cuts in prices and prices, they say, would lead to reductions in research budgets which would ultimately be counter-productive. Companies would not be able to avoid the long and expensive process of testing and developing new drugs if they could not gain an adequate return from their sale.

But momentum for a prescription benefit is growing, with the backing of the powerful American Association of Retired People, (AARP), which represents the grey lobby.

And even Republicans in Congress are beginning to concede that something needs to be done about the cost of prescription drugs, even if they favour an extension of the private insurance system.

Managed care worries

Another issue which has become increasingly contentious is the spread of "managed care," a system of group health care where beneficiaries have to go through a "care manager", usually a nurse, before they can gain access to a doctor.

Many private plans run by companies for their workers have converted to this system. (Ironically, it was the universal model proposed and rejected in the early Clinton health care reform plan.)

And even those in the current government scheme are being encouraged to join health maintenance organisations. So far, not many have done so voluntarily.

Patients and doctors are both unhappy over the limitations the system imposes on their choices. Doctors are limited in what care they can offer, and patients have little redress if they feel they did not get the care they wanted. Now grass roots initiatives are beginning to try and restore patients' rights to choice.

In Massachusetts, a coalition of doctors groups, labour unions, and groups representing the retired is trying to force a state-wide health reform referendum on the ballot in the autumn.

The initiative would require the state to formulate a plan to provide health care for all citizens by 2002, and would guarantee the rights of patients to chose his or her own doctors, and the right of doctor to choose the right treatment for each patient.

And other states, including Washington, Arizona, Arkansas, and Oklahoma, are also considering ballots in November.

The moves comes after a year of increasing deadlock in Congress, with Republicans and Democrats split over what kind of patients' bill of rights legislation to implement.

Democrats have backed plans to allow patients to sue their managed care organisations, and even to allow doctors to unionise, while republican plans are more modest.

But according to Dr Bernard Lown, one of the organisers of the Massachusetts initiative, "what is happening is an enormous backlash by the public" who are fed up with the delays.

Looming questions

The problem with these initiatives is that they will increase the cost of the US health care system, which is already the most expensive in the world, at more than $1 trillion per year.

And the goverment contributions to the health care system are rapidly becoming unsustainable, even more quickly than social security payments.

Al Gore would like to earmark more funds from the budget surplus to the health care system, as well as extending benefits to children of poor families.

And he would like to do more to support mental health services, the Cinderella of the health care system.

At the same time, there is another huge area of expenditure that could require more government support - long term care.

The care of elderly people in nursing homes, or long-term nursing care in their homes, is not covered by current health care insurance, and many people are forced to spend all their resources before they become eligible for means-tested assistance.

Bodies representing the elderly are pressing for any reform to include the cost of home helps as well, pointing out that 22m US households have an unpaid carer.

But the mechanisms for financing such an increase have barely been discussed.

The Commission appointed by President Clinton to look into the long-term future of Medicare funding split three ways, with proposals for more private funding vying with a major increase in government support.