Although Congress has been reluctant to reform the unsustainable Medicare program, largely fearing a backlash from its beneficiaries, turns out seniors are considerably more willing to make tradeoffs than we’re usually led to believe.

The center for Healthcare Decision asked 810 California seniors to design a new Medicare program—not just for themselves but for current and future generations. They were given 100 markers and asked to allocate them among 12 categories of health benefits to determine which should receive more resources and which could be reduced or dropped. Seniors left only two of the 12 categories intact and suggested significant reforms for the others.

In all, the participants wanted more benefits but would limit access to what experts call “low-value care,” limit doctor choices and sharply curtail “final stage” care. Overwhelmingly, the seniors also wanted to add a long-term care benefit to the Medicare program, an expensive benefit now covered, by default, in the Medicaid program for those who qualify. They said patients at the end of life should enroll in a hospice program and not be covered for visits to an intensive care unit.

Robert Moffit, a senior fellow in healthcare policy at The Heritage Foundation, said he was not surprised seniors wanted more benefits but was struck by the fact that 82 percent favored provider networks over the unlimited provider access they have today. Historically, seniors overwhelmingly opposed any managed care restrictions on physician choice, but now it appears—at least based on this survey—that more seniors seem willing to tolerate a managed care referral system where the primary care physician acts as a “gatekeeper” to specialists.

Moffit, who appeared last Friday at the American Enterprise Institute on a panel to discuss the findings with Kavita Patel of the Brookings Institution and John Rother of the National Coalition on Health Care, said the survey was a breakthrough on Medicare public opinion research because it forced respondents to make real world trade-offs that recognized neither Medicare patients nor taxpayers have unlimited resources.

He warned medical science is not as precise as physics or engineering, and Americans should oppose the imposition of a powerful regulatory regime, such as Medicare, defining “high-” or “low-” value medical care. Value changes with medical advancements, medicine is not a static science, and it is not something that can be divorced from individual patient needs, Moffit added.

Patel agreed Americans don’t want Medicare regulations trying to define “low-value care” and said this survey seemed to indicate seniors trust their doctors and don’t want the government to “try and curb or infringe my doctor.”

Moffit said this survey should be repeated, but instead of the numerical markers, respondents should have to make trade-offs with dollars and cents, so their decisions would be more directly apparent in the impact on their premiums, deductibles and taxes. This type of decision making at the margin is extremely valuable, he said. And although the survey did not focus on broader Medicare reform, Moffit argued again the best option for seniors is a Medicare premium support system where they directly control both the Medicare dollars and the health care decisions.