Anyone who remembers how the last Democratic effort on health care went down in flames -- dividing the party and leading to the Republican takeover of the Congress in 1994 -- remembers the infamous "Harry and Louise" attack ad. What fewer people remember is why the ad worked.

The television ad was created by the health insurance lobby, and ran in swing congressional districts. The ad was nothing fancy -- just a typical middle class couple discussing the Clinton health care reform legislation. The strategic brilliance was in what the couple talked about: how the plan would take away personal choice and give it to the government.

Those who were involved in creating and pushing the 1994 Clinton plan tend to lament how the "Harry and Louise" ad was misleading, and point to polling that showed that the specific content of the Clinton plan remained popular to the bitter end.

The problem is that voters do not make up their minds based on the specific content of policies but rather on their impression of what the policies will do. Voters in 1994, confused by the complexity of the proposal, feared it would result in less, not more, choice, and higher, not lower, costs. If Democrats are to going to win on health care reform, they must avoid this trap. And that means understanding how middle-class voters -- "Harry and Louise" -- think about health care reform.

1. Recognize that Most Voters Have Health Insurance

Advocates of health care reform have spent much of the last 15 years talking to the 260 million Americans who have insurance about the 40 million Americans who don't.

Insured voters -- who are 95 percent of all voters -- see rising costs, the denial of care due to pre-existing conditions, the lack of portability, obstacles to seeing specialists, and other problems as a result of profiteering by insurers and drug companies -- not the result of there being so many uninsured. Their intuitive solution is to demand that "somebody do something" to protect consumers -- namely through restraining drug companies and insurers.

2. Solve the consumer crisis first -- it will inspire greater sympathy toward the uninsured

In the past, progressives and Democrats have sought to emphasize to insured Americans that they are at risk of losing their coverage or are in some other way insecure.

But when Harry and Louise get scared -- watch out. Fear-based appeals overwhelmingly tend to trigger a zero-sum, conservative reaction -- not a generous and progressive one. When voters are worried about losing or paying more, they become change averse.

But the opposite is also true: when voters believe a health care reform proposal would address the problems that they care about, they are more likely to embrace efforts to extend coverage to the uninsured. Only after insured voters believe their own needs will be met do they turn a compassionate eye toward the uninsured.

A reform proposal that protects the insured so that they a) have access to basic services, b) can't be denied insurance due to a pre-existing condition, c) can keep insurance if they lose or change jobs, d) can't be discriminated against by insurers due to their age and health, and e) are protected from price gouging, will create the psychological conditions for voters to secure, and thus more compassionate and more generous toward the uninsured.

3. Embrace personal responsibility

When voters talk among themselves about covering the uninsured, the conversation quickly turns to whether or not the uninsured are themselves to blame for their situation. This is something that is missed in most polling, which doesn't allow the space for these concerns to emerge.

Voters do not want to pay more in insurance, copays, or taxes to cover those they consider to be "undeserving," such as illegal immigrants, people who refuse to work, people who do not take good care of their children, people who do not take good care of their health, and people who have enough money to pay for insurance but are irresponsible.

To feel positive about any reform proposal, voters need to be reassured that the new system will inspire greater personal responsibility. To this end, voters respond positively to new rules, such as the notion that "everybody should have to pay something" for their health care. Voters are quick to qualify this belief with a recognition that what people pay should depend on their means. Voters strongly embraced the progressive notion of a "sliding scale," where people pay what is fair to their income levels.

In Sum

Public cynicism toward government has long driven concerns that a government-run health care system could be worse than our current private health insurance system. Voters support government insurance for seniors and children -- but not necessarily for themselves.

To win reform we need to propose legislation that voters perceive as solving the consumer crisis. Then, and only then, will Harry and Louise be in the mood for comprehensive reform that covers the uninsured.

This article was based on research we conducted with Lake Research Partners for the Herndon Alliance. The views expressed here are our own.