A slim majority of Americans appear to support limited health insurance restrictions as a way to help control spiraling costs, a new survey released Wednesday concludes.

The results suggest that younger Americans may be willing to tolerate some of the very limits that made managed care (search) wildly unpopular after its peak in the late 1990s. But support for the measures, which include requiring a primary care physician’s authorization to see a specialist, is weak among older and sicker persons.

Slightly over half of 2,024 adults surveyed in August said that requiring specialist referrals and limiting the list of approved prescription drugs were good ideas if they helped control insurance premiums. Over 75 percent of those in the survey said their insurance premiums went up last year.

Support was weaker for insurance companies that require prior approval for medical procedures, while just 30 percent supported paying doctors bonuses for holding down costs. All of those strategies were common in managed care plans in the 1990s and helped lead to a consumer backlash against HMOs (search) and similar plans.

Managed care practices helped turn the public against the industry, spurring a contentious debate in Congress over patients' bill of rights legislation and even spawning popular Hollywood films like John Q (search).

The results suggest that the American public’s once-intense distaste for managed care may be waning as health care costs continue to rise, says Claudia Schur, a University of Chicago researcher who conducted the survey.

“I think there’s a clear willingness to consider managed care. There’s no blanket refusal,” she says.

Still, only people 18 to 34 years of age consistently supported the restrictions. Schur points out that they are the same people least likely to use health care services or to have had negative experiences with managed care in the last decade. Only 30 percent of those surveyed thought that managed care could hold down costs without hurting health care quality.

In all, only restricting prescription drug formularies -- lists of approved drugs -- maintained majority support among a wide swath of age, income, and racial groups. That is likely because the formularies are still in wide use today and most consumers have had relatively benign experience with them, Schur says.

Managed Care Costs Rise Despite Changes

The results may reflect what insurers already know about U.S. consumers: Some are willing to accept restrictive plans in exchange for lower costs, while others want more freedom even if it means higher prices.

Those preferences gave rise to increasingly popular preferred provider organizations (search) (PPOs), where patients face fewer restrictions and have more choices of doctors. They’ve also led to a market where employees have a much wider choice of differently priced plans than they did 10 years ago, Schur says.

Insurance costs continue to rise despite the changes, helping to grow interest in health savings accounts. The plans allow workers to save money for health care in tax-free accounts but also give consumers more responsibility and more financial risk for their own health decisions.

The plans enjoyed the strong support of President George Bush in the election campaign and have seen a small but growing number of employers offering them, says Jon Gabel, vice president of health systems studies at the Health Research and Educational Trust.

Between 1.5 and 2 million Americans now use the health savings accounts, which were passed by Congress last year.

John Bertko, the chief actuary at the Humana insurance company, says the plans may have cut costs by as much as 5 percent among 100,000 customers who’ve used them this year. Bertko calls the figure “speculative,” noting that it is too early to tell if the accounts can save money while maintaining quality or if consumers will even use them.

Others agree. “We should probably wait a little while before we decide if they’re working or not,” says Gary Claxton, vice president of the Kaiser Family Foundation.

By Todd Zwillich, reviewed by Brunilda Nazario, MD

SOURCES: Heath Affairs, Nov. 10, 2004, pp 516-525. Claudia L. Schur, principle research scientist, NORC, University of Chicago. John Bertko, chief actuary, Humana Inc. Gary Claxton, vice president, Kaiser Family Foundation.