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Defining Medical Necessity under the Patient Protection and Affordable Care Act


  • Daniel Skinner is assistant professor of political science, specializing in political theory, at Capital University in Columbus, Ohio. His scholarly projects engage the intersections of the politics of medicine and health care and political rhetoric. He is currently developing a book manuscript that examines the politics of the concept of medical necessity in American health care debates. His work has appeared in journals such as Review of Politics; Health, Culture and Society; Politics and Gender; Polity; and Law, Culture, and the Humanities. E-mail:


While the Patient Protection and Affordable Care Act (ACA) of 2010 promises to expand care to millions of Americans, how the bill will determine the meaning of medical necessity—the concept that continues to serve as the key means for regulating the utilization of health care services—remains an open question. Instead of detailing what is and is not considered medically necessary, the ACA charges the U.S. Secretary of Health and Human Services with overseeing the processes by which these critical determinations will be made. This article considers a series of “meta-questions” regarding the place of medical necessity determinations within the context of the ACA. It does so by examining the policy challenges presented by a bill that attempts to balance government regulation, physician autonomy, and the various market forces driving managed care. The result is an understanding of the inherently political nature of medical necessity determinations under the ACA.