The rise and fall of managed care.

The managed care backlash is analyzed as a collective behavioral response led by attacks from threatened professional, provider, and special interest communities. Central to the backlash was the middle class's repudiation of explicit rationing at the point of service adopted by Health Maintenance Organizations (HMOs) and other managed care plans. Americans are accustomed to choice and autonomy in their health care utilization and reacted negatively to restrictions. Assisted by negative anecdotes in the media and allegations of the denial of needed services, opponents built a negative picture of managed care often inconsistent with the empirical evidence. They succeeded in arousing public anxiety that appropriate health care might not be available when people most needed it. The private centralization of large health plans made them an easy target for the media, politicians, and provider groups in opposition. These attacks and regulatory initiatives succeeded in diluting strong utilization management controls contributing to current difficulties of containing large health cost increases.