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The Affordable Care Act, if honestly represented, is a redistribution-of-wealth program that significantly altered the private health insurance market with a primary goal of providing greater subsidized coverage for lower-income individuals.As with all wealth redistribution plans, there are clear winners and there are clear losers. Is the average American a clear winner or a clear loser? While valid arguments could be made either way, I think the balance of data suggests to me that middle-class Americans – average US household income is around $51,000 – are hurt through much higher out-of-pocket costs, much narrower choices and disruption, plan cancellations, extra tax forms, being forced to pay for unwanted services in some cases, and high downstream unfunded costs. And for those not on it (which is likely for the average American, given only 12 of 350 million citizens are), it explodes state Medicaid budgets and fiscal liabilities at the federal level, so they are hurt by it too. This negative view is bolstered by the fact that it has never been majority-popular by any significant margin, and more people disapprove than approve of it, several years in.One middle-class American explained it this way: “Unless I’m catastrophically ill, I’m now required to spend $12,000 for the privilege of spending another $10,000 per year out of pocket on medical care.” That sums it up for our family too – though $12,000 per year is cheaper than what we're paying.Most important, perhaps: the entire program is at high risk of actuarial failure in the next ten years if nothing is done.Secretary Clinton confidently asserts that the ACA is “clearly working.” It seems to me we first need to understand how she defines “working.”When I pay for a refrigerator, computer, or service, I decide whether it's working based not solely upon what these products happen to do when I get them –the unexpected new features and whatnot – I also compare what I got to the representations that were repeatedly and earnestly made by its salespeople. A noisy refrigerator with a broken freezer compartment isn’t “working” if I was repeatedly sold on it with promises of it being quiet and ice cream-ready.In essence, I ask myself, “Was the advertising honest?” We all do.To that end, these promises were repeatedly made about the ACA:“If you like your healthcare plan, you can keep your plan, period.”“If you like your doctor, you can keep your doctor, period.”“The typical family of 4 will save about $2500/year.”“We can do all this without adding one dime to the deficit.”“A site as easy to use as Amazon.”“We predict 21 million people insured by the ACA in 2016.”“23 government-sponsored healthcare co-ops will help deliver better access to care.”“This is not a tax.”These are not minor representations about how the ACA would work. They were, and are, important commitments that were repeatedly made. They were repeated so often because they resonated. They mattered to people. People who dared raise questions about any one of them were scoffed at, even mocked.The president even said before both houses of Congress, “If you misrepresent what's in this plan, we will call you out.”No doubt these repeated, forceful assurances caused some of us to go from opposition to support – though it remained highly divisive and still never earned significant-majority popular support.Some of us likely reasoned that surely, the biggest representations, many made after the details of the ACA were known, couldn't possibly be so blatantly lied about. After all, in many instances when these assurances were made, the ACA was either in final statute form or even already law.It's late 2015. Here's the tally:Broken. Called “Lie of the Year”, in fact.Broken.Broken.Broken.Nope.It's a year away, so we don't yet know, but enrollment predictions have just been halved to 10-11 million.12 of the 23 have already declared bankruptcy, taking with them billions of dollars in taxpayer-funded loan guarantees.Broken (see Supreme Court.)On each of these important representations, the ACA is most definitely not working.Yes, there are several laudable goals and even accomplishments of the ACA. And even if you subtract out the millions of people who involuntarily had their healthcare insurance cancelled on them (including my family of five), it does look like it has net-expanded the number of people that have gotten insurance, at a price.On the flip side, about 70% of new ACA enrollees are under Medicaid, which is 100% subsidized; they essentially pay nothing to support it. Many of the remaining 30% also get some form of subsidy. A 2015 McKinsey study indicates that insurers are currently taking $2.5 billion in annual losses through the program. UnitedHealth, the largest participant in the ACA marketplace has said their losses are about half a billion dollars and are unsustainable, indicating they will likely exit the market next year. Cigna, another large insurer, also confirmed that they are taking losses with the program. Two significant sources of revenue – the “Cadillac Tax” and the Medical Device Tax – are likely going to be repealed soon, primarily at Democrats' urging.So, given the above, can you help me understand the math that still makes this program work, while also adhering to promise #4 above? I realize it’s complex – Professor Gruber might even say it’s opaque, or remind me that I’m stupid – but even I just can’t grasp the basic math that keeps this program afloat in the long term to foot without continued massive increases in deductibles, out-of-pocket costs, narrowing of choices, or expansion of the federal debt.Yes, the ACA has removed the legality of plan cancellations based upon pre-existing conditions, a huge and largely positive change in isolation.Secretary Clinton, to be honest, I think your characterization that it’s “clearly” working at a minimum has to be balanced against whether it’s actually delivering on the repeated promises that were made about it when it was put forward. And doing so, it's far from clear that the ACA is “working” as promised or even as represented.As mentioned above, the ACA, if honestly represented, is a redistribution of wealth law that reshapes the health insurance market. There are winners and losers. Many of those of us in the latter camp do support the notion of improving America's healthcare, but we also wish we weren’t so blatantly and repeatedly lied to, inconvenienced, price-hiked and insulted. We’re footing the bill for much of this, and at a minimum deserve a little respect – which starts with honesty. And then maybe even if any ACA fans are so inclined, a bit of gratitude.Secretary Clinton, I appreciate you (or your staff) participating directly on Quora.If you're a reader and some of my thoughts above resonate with you, and you aren’t too busy figuring out where to spend your $2500 savings this year, I’d be honored if you added your voice by clicking the “Upvote” button.Related reading:Obamacare Is Now on Life SupportObamacare Enrollees Are Reeling from High DeductiblesLatest ObamaCare Flop: Enrollment Will Be Way Below PlanThe Biggest Threat To Obamacare Is Already Written Into Law: No Insurance Industry Bailoutshttp://www.newsweek.com/obamacare-will-ditch-two-million-jobs-over-ten-years-403033

In the question's description, the questioner wonders aloud about lack of popular support for the ACA, breezily assuming that it is nothing-but-beneficial and downside-free. Americans are patriotic, Americans care about their fellow citizens, so why not broadly support the Affordable Care Act? This is a pretty big leap in logic.The truth is that at its core, the Affordable Care Act (ACA) is a wealth redistribution and reform plan targeting the health insurance market. As such, there are clear winners and clear losers. Someone might support greater health resources for those who need it and yet, as I do, strongly feel the ACA is the wrong way to do it. There were far better ways to go by expanding and strengthening Medicare, for instance, in the case of low income or demonstrated hardship.In addition to arguments about inefficiency, the plan was disruptive (and actively detrimental) to many people who had healthcare beforehand, in several different ways, including the dimensions of cost, liberty, access and quality.The ACA is, and pretty much always has been, majority-unpopular. So at this writing, it's not just some but most Americans that have a negative view of it.Gallup: Americans Tilt More Negative Toward Affordable Care Act.This majority-disapproval is remarkable not just for its strength and duration, but also because an eye-popping 70% of current enrollees are on Medicaid, which is 100% subsidized. That is, 70% of enrollees essentially pay nothing for the benefits they receive, and a decent percentage of the remaining 30% also get subsidy. So why all the hate?This dislike has many drivers. Most opponents express some combination of these concerns:Higher out-of-pocket costs than prior coverageDispleasure with being repeatedly, deliberately lied-to during the selling phaseConcern about its long-term actuarial implosionFrustration with the partisan manner in which it was passedAnger with the incompetent, wasteful manner in which it was rolled outBeing forced to participate in a marketBeing forced to pay for undesired benefitsNarrowing of choice, options and freedom to forgo participationCancellations of plans, limitations on doctor networks, in some cases lowering of care and/or preventing access to desired, previously-available facilitiesConcern that the way it's been modified on the fly isn't ConstitutionalAdditional complexity added to people's livesReduced payouts to doctorsFailure of healthcare co-ops and waste of billions of dollarsDisagreement about the proper level of government involvement in our livesPolitical displeasure with the administration on other matters, which rubs off on its signature programIt's far more expensive than alternative ways to cover the uninsuredNegative associations with existing health-insurance problems (complexity, denial of some types of coverage, long wait times, etc.) which carry over(from the left) Falling far short of a more ideal single-payer solutionThe Affordable Care Act, if honestly represented, is a redistribution-of-wealth program that significantly altered the private health insurance market with a primary goal of providing greater subsidized coverage for lower-income individuals.As with all wealth redistribution plans, there are clear winners and there are clear losers.Is the average American a clear winner or a clear loser? While valid arguments could be made either way, I think the balance of data suggests to me that middle-class Americans – average US household income is around $51,000 – are hurt through much higher out-of-pocket costs, much narrower choices and disruption, plan cancellations, extra tax forms, being forced to pay for unwanted services in some cases, and high downstream unfunded costs. And for those not on it (which is likely for the average American, given only 12 of 350 million citizens are), it explodes state Medicaid budgets and fiscal liabilities at the federal level, so they are hurt by it too. This negative view is bolstered by the fact that it has never been majority-popular by any significant margin, and more people disapprove than approve of it, several years in.One middle-class American explained it this way: “Unless I’m catastrophically ill, I’m now required to spend $12,000 for the privilege of spending another $10,000 per year out of pocket on medical care.” That sums it up for our family too – though $12,000 per year is cheaper than what we're paying.Most important, perhaps: the entire program is at high risk of actuarial failure in the next ten years if nothing is done.Secretary Clinton confidently asserts that the ACA is “clearly working.” It seems to me we first need to understand how she defines “working.”When I pay for a refrigerator, computer, or service, I decide whether it's working based not solely upon what these products happen to do when I get them –the unexpected new features and whatnot – I also compare what I got to the representations that were repeatedly and earnestly made by their salespeople. A noisy refrigerator with a broken freezer compartment isn’t “working” if I was repeatedly sold it on with promises of it being quiet and ice cream-ready.In essence, I ask myself, “Was the advertising honest?” We all do.To that end, these promises were repeatedly made about the ACA:“If you like your healthcare plan, you can keep your plan, period.”“If you like your doctor, you can keep your doctor, period.”“The typical family of 4 will save about $2500/year.”“We can do all this without adding one dime to the deficit.”“A site as easy to use as Amazon.”“We predict 21 million people insured by the ACA in 2016.”“23 government-sponsored healthcare co-ops will help deliver better access to care.”“This is not a tax.”These are not minor representations about how the ACA would work. They were, and are, important commitments that were repeatedly made. They were repeated so often because they resonated. They mattered to people. People who dared raise questions about any one of them were scoffed at, even mocked.The president even said before both houses of Congress, “If you misrepresent what's in this plan, we will call you out.”No doubt these repeated, forceful assurances caused some of us to go from opposition to support – though it remained highly divisive and still never earned significant-majority popular support.Some of us likely reasoned that surely, the biggest representations, many made after the details of the ACA were known, couldn't possibly be so blatantly lied about. After all, in many instances when these assurances were made, the ACA was either in final statute form or even already law.It's January 2016. Here's the tally:Broken. Called “Lie of the Year”, in fact.Broken.Broken.Broken.Nope.It's a year away, so we don't yet know, but enrollment predictions have just been halved to 10-11 million.12 of the 23 have already declared bankruptcy, taking with them billions of dollars in taxpayer-funded loan guarantees.Broken (see Supreme Court.)On each of these important representations, the ACA is most definitely not working.In fact, has there ever been a social program of such scale or impact in US history that has been so blatantly misrepresented in its sales phase? I cannot think of one. Not Medicare. Not Medicaid. Not Social Security. Not Civil Rights. Not the EPA. Not the Clean Water Act.Given how it was passed in the narrowest of votes, through a "budget reconciliation" process deliberately to avoid a sure-to-lose final vote in the Senate, one might ask: "What if the ACA were honestly represented in its sales phase? Would it still have passed?"Yes, there are several laudable goals and even accomplishments of the ACA. And even if you subtract out the millions of people who involuntarily had their healthcare insurance cancelled on them (including my family of five), it does look like it has net-expanded the number of people that have gotten insurance, at a price.On the flip side, about 70% of new ACA enrollees are under Medicaid, which is 100% subsidized; they essentially pay nothing to support it. Many of the remaining 30% also get some form of subsidy. A 2015 McKinsey study indicates that insurers are currently taking $2.5 billion in annual losses through the program. UnitedHealth, the largest participant in the ACA marketplace has said their losses are about half a billion dollars and are unsustainable, indicating they will likely exit the market next year. Cigna, another large insurer, also confirmed that they are taking losses with the program. Two significant sources of revenue – the “Cadillac Tax” and the Medical Device Tax – are likely going to be repealed soon, primarily at Democrats' urging.So, given the above, can you help me understand the math that still makes this program work, while also adhering to promise #4 above? I realize it’s complex – Professor Gruber might even say it’s opaque, or remind me that I’m stupid – but even I just can’t grasp the basic math that keeps this program afloat in the long term without continued massive increases in deductibles, out-of-pocket costs, narrowing of choices, or expansion of the federal debt.Yes, the ACA has removed the legality of plan cancellations based upon pre-existing conditions, a huge and largely positive change in isolation.As mentioned above, the ACA, if honestly represented, is a redistribution of wealth law that reshapes the health insurance market. There are winners and losers. Many of those of us in the latter camp do support the notion of improving America's healthcare, but we also wish we weren’t so blatantly and repeatedly lied to, inconvenienced, price-hiked and insulted. We’re footing the bill for much of this, and at a minimum deserve a little respect – which starts with honesty. And then maybe even if any ACA fans are so inclined, a bit of gratitude.If you're a reader and some of my thoughts above resonate with you, and you aren’t too busy figuring out where to spend your $2500 savings this year, I’d be honored if you added your voice by clicking the “Upvote” button.Related reading:Obamacare Is Now on Life SupportObamacare Enrollees Are Reeling from High DeductiblesThe Biggest Threat To Obamacare Is Already Written Into Law: No Insurance Industry Bailoutshttp://www.newsweek.com/obamacare-will-ditch-two-million-jobs-over-ten-years-403033Aetna Joins Growing Chorus Warning About ObamaCare Failing

Interesting Question. So let’s start with How the term “Medically Necessary” is defined, and When those specific Clients, or patients, or user group conditions, meet the current, defined Eligibility Requirements, for 3 well-known agencies … a Branded, well-known HMO, Medicaid and Medicare. It’s Complicated … on so many levels, and Do Not “expect” that any form of Government insurance program is going to cover, not only the Elective surgery, but also provide coverage for any Future issues or problems, as you will surely read about further down.A. Cigna HealthCare (HMO) - Definition of Medical Necessity for Physicians -"Medically Necessary" or "Medical Necessity" shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:1. in accordance with the generally accepted standards of medical practice;2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and3. not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.For these purposes, "generally accepted standards of medical practice" means:• standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community;• Physician Specialty Society recommendations;• the views of Physicians practicing in the relevant clinical area; and• any other relevant factors.Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.B. Medicaid (State)Medicaid can deny a service or treatment for you if it finds it's not "medically necessary."State Medicaid programs can deny coverage for a particular treatment if the treatment is not medically necessary. Each state has defined the term "medical necessity" differently in their laws and regulations; the federal Medicaid Act doesn't have a definition of medical necessity. Below we'll discuss how some states define medical necessity, but ultimately, your treating physician's opinion about whether a particular treatment is medically necessary will be the most important factor in getting Medicaid to pay for the treatment.What Is Medical Necessity?No state has a definition of medical necessity that says a treatment is medically necessary just because a doctor says it is. All states have some other constraints built into their definitions of medical necessity.Many states have cost restrictions built into their definitions, in an effort to reduce their Medicaid costs by limiting patients to the least expensive treatment.For example, Florida limits patients to the least expensive treatment that is effective. Other common restrictions on states' definitions of medical necessity are prohibitions against experimental treatments, requirements that the treatment provide a significant benefit to the patient, and requirements that the treatment not be provided primarily for the patient's or doctor's convenience.Other states define medical necessity more broadly, giving the opinion of the treating physician more weight.For example, California's Medi-Cal program defines a treatment as medically necessary simply when it is reasonable and necessary to prevent significant illness or disability, relieve severe pain, or save someone's life.C. MedicareMedicare normally covers services deemed medically necessary.According to the official U.S. government site for Medicare, “medically necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” In any of those circumstances, if your condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat those.Is Transgender Surgery "Medically Necessary", or an “Elective Procedure”??Transgender Surgery - is currently defined as an “Elective Procedure”, which may not, or will not meet the Eligibility Requirements for an HMO, or Medicaid or Medicare. An Elective Procedure - is akin to Breast Augmentation as an example of a surgical procedure (Plastic / Reconstructive) that is not deemed “medically necessary”, so therefore the enroll-e elects to cover all the associated costs, on their own and fully responsible for any and all Future consequences.Transgender Surgery - Is Complex by it’s very own nature, and in order for an HMO, Private coverage vendor, or State Medicaid to extend Partial or FULL “coverage” … there are at least 12 Metrics that would have to be Assessed and Pre-approved (takes time), BEFORE, any complicated surgical procedure is given the Green light, which most People do not understand, nor pay attention to … such as:Age (15 or 22 or 30 or 40 or 50 or 60 or 70 ????)Pre-surgery Psychological analysis reportPost-surgical Psychological servicesMedical + Surgical Clearance reportIdentification of any prior or current High Risk Factor’sFinancial review & any concurrent private insurance coverage assessmentMedical-Surgical Team (Multiple) & Hospital stay + LOC pre-approval assessmentsNumber of Follow-up visits, preapproavlSocial services assessment reportMalpractice Insurance assessment (Surgeons, or Hospital, or the State)Future Revisions or Reversal’s assessments, COST permutations, and risks report (most probable)Potential Health & Medical Disability (Psychological, and/or, Physical) assessmentDeath factor / Risk assessmentEstimated Total Med-Surg Costs + Projected Future Costs?Transgender Surgery - Right now, the US Military (topic on Military.com), is in the process of making assessments and developing policies for current Transgender personnel, for those who are considering Transgender Surgery, and for New Transgender recruits, and using similar Metric’s as above, so that’s an on-going process.Elective procedure - People undergoing Transgender surgery right now, are those that can afford it without Incurring a Debt Load, are most likely to be the Upper-Upper Middle Class and Wealthy cohorts, in the US.Off-shore Affordable Surgery Locations - South Korea, Thailand, and Vietnam (Saigon/ Ho chow mein city), as Saigon currently building brand, new Hospital’s and Plastic Surgery Centers, in Mega-Complex Level.Brazil & Venezuela - are well-known for their Plastic Surgery acumen and favorable, aesthetic results.Of course, if you are one of the Posh … then Switzerland is your Port-of-call … Verstehst du?There you go, Phobe …