The passage of the Patient Protection and Affordable Care Act (ACA) of 2010 was hailed as a major achievement of the Obama administration. It was touted as legislation that would expand health care coverage for Americans, contain ever-growing health care costs, provide expanded care for behavioral health and mental illness, and require a higher degree of accountability of health care providers regarding cost and quality. Its passage did not fulfill the promise of a public option which Obama made while running for President and thus undermined any genuine movement to attaining the type of universal health care available to countries far less wealthy than ours. In fact, it has since emerged that it was President Obama himself who blocked any public option in order to kowtow to powerful vested interests who would be financially harmed by such a system of care. Nonetheless, despite the Democrats succeeding only in passing health care legislation crafted by a right-wing think tank, there was considerable enthusiasm and hopeful expectations that the ACA would bring with it countless benefits for Americans requiring health care. Behind these illusions was a health care plan carefully crafted to benefit the health care industry and Big Pharma who would experience a much-expanded market and the profits to come with it.

In fairness, some of the benefits promised were realized. The ACA did provide access to health insurance and care to millions of Americans, especially young adults. This was achieved, in part, by extending the age at which children could remain covered by their parents’ health insurance. Another principal strategy of expanding coverage was providing subsidies through the federal government for uninsured lower income Americans. However, millions of Americans still remained without health insurance despite the legislation. For many individuals who purchased coverage, the insurance they were able to acquire, though “affordable”, was of no practical use to them because of high deductibles that had to be satisfied before health insurance companies were financially liable and high levels of co-payment. Americans continued to be unable to seek health care or afford the highly inflated costs of need drugs. Catastrophic illness continued to plummet Americans into bankruptcy. These “bare bones” policies made an utter pretense of access to health care. Over time, some health insurance companies abandoned the marketplace because they found participation not to be sufficiently profitable. Others increased health care premiums while limiting the services, hospitals and physician networks available to subscribers — again placing profit over care.

As time has gone on the ACA can be added to a number of other over-hyped federal blunders aimed at containing health care costs while at the same time continuing to fail to provide universal health care to Americans. As a psychologist who worked in health care settings and then taught and trained doctoral level psychologists, I watched as managed care, health maintenance organizations, diagnostic related groups and a plethora of other misguided, half-baked ideas emerged from Washington as solutions to problems which legislators and policy-makers failed utterly to understand and lacked to political will to sincerely tackle. This is because none of these “solutions” actually critically examined the flawed assumptions and values and models of care that continue to dominate health care delivery in the U.S.

Just prior to the passage of the ACA national health care spending was $2.5 trillion annually, $8,086 per person or 17.6 percent of the U.S. Gross National Product. In 2016, spending in the U.S. reached $3.3 trillion, $10,348 per person or 17.9 percent of the GNP. The evidence is clear that the ACA failed to reduce health care costs. Moreover, despite the U.S. spending more per person than virtually all other industrial nations, it has a substantially lower average life expectancy (a little over eighty years). For example, in 2011 Japan spent $2,878 per person and had an average life expectancy of 83.4 years. Overall, ACA neither made health care affordable nor did it protect patients from the depredations and greed of the health care and pharmacology industries.

These profit-obsessed corporations were the real winners as one clear outcome of the implementation of the ACA has been the continued expansion of the healthcare industries. This is no accident as the payment structure of the ACA has ensured this growth believing that only hospitals or large-scale health care providers can achieve the type of integration of services to promote efficiency and make the necessary investment in health care technology. For example, in 2014 Medicare paid $453 for an echocardiogram to a hospital-based practice versus $189 to an independently employed physician. Not surprisingly, this has led to an ever-shrinking number of independently practicing physicians as the become forced to become employees of hospital systems (48.5% independent practitioners in 2012) compared to 33% in 2016). At the same time the ongoing mergers of health care systems do not actually result in greater efficiencies and cost containment but will result in a 6% increase in health care costs in the coming year.

Health Care is NOT a Commodity

A fundamental flaw inherent in the ACA can be found in the glaring contradiction found in its title. The goal of making health care accessible to US citizens should not be to make health care “affordable”. This is because health care is not — and can never be — a commodity. People do not think of or utilize health care like automobiles, electronics or vacations. An abundance of literature utterly belies conceptualizing health care as a commodity. To assert this is anathema to the dominant neoliberal hegemony that has a stranglehold on every aspect of life. An essential principle of neoliberal ideology is that the “market” exists as a natural and inevitable entity subject to laws independent of all human intervention. As a result, humans must refrain from trying to influence or interfere with the market, but instead submit themselves to its working. All social goods, including health, are commodities subject to deregulation, privatization and competition. The pursuit of profit is a natural outcome of this process. This naturalization and reification of the “market” is not only a fairy tale in which a purely human construct is treated as if it were a concrete entity. More importantly, it is a form of mystification intended to deceive those individuals — particularly those who are oppressed and exploited by this myth — to fail to see how it is used by the powerful and the elite to maintain their power and to deprive others the dignity and respect owed them.

As the philosophers, Amartya Sen and Martha Nussbaum, argue, health is a fundamental human good due to all individuals without consideration to station or merit. For Sen, health is one of the five forms of instrumental freedom. Like the other instrumental freedoms, health promotes our development at all levels, makes our lives richer, and enables us to realize our potentials. Health plays a critical role in enabling all individuals to exercise choice, interact and forge relations with others and expand the range of their capabilities. Similarly, Nussbaum adopts Aristotle’s idea of eudaimonia or flourishing as the ideal for all human beings to pursue. There are certain elements of human life that are critical to making it a life worth living and health is certainly one of them. Depriving human beings of the ability to achieve and sustain health is equivalent to depriving them of their very humanity. It is not surprising that an ideology that reduces everything to a commodity, sees human beings as objects as well — subject to exploitation in the interests of the acquisition of wealth.

The Persistence of Dis-Integrated Care

Another count on which the ACA has failed is in promoting a form of care that attends compassionately and respectfully to all the various facets of the human person. At the time of the passage of the ACA, there was a flurry of enthusiasm because it was based on the premise that the provision of integrated care was pivotal to cost containment and better health care outcomes. The type of integrated care was exemplified by the Patient-Centered Medical Home (PCMH) model advanced by family practitioners. Within this model, all the various needs of patients would be provided in one location and be given attention by an interdisciplinary team of providers headed by a primary care physician. This could include areas such as psychology, diet, exercise, nursing, and social services. The providers would essentially constitute a patient’s “medical home” — a place where he or she can be seen by his or her personal physician and where he or she was familiar to the treatment team. The care would thus combine the qualities of being accessible, comprehensive, patient-centered, coordinated, and cost-effective.

The need for this type of integrated care is well documented. For example, looking at it from the perspective of my profession of psychology, research has found that 70% of all visits to primary care providers involve issues related to mental or behavioral health issues. This includes mood and anxiety disorders as well as substance abuse issues. The inclusion of a psychologist or behavioral health provider to primary care helps to ensure that these emotional issues are better identified while conveniently providing care for them in the same setting. Even in those cases in which patients are experiencing a medical condition, it is not uncommon for that medical condition to be accompanied by an emotional disorder. For example, patients with a chronic medical condition are two to three times more likely to also have a medical condition. For patients with depression, 85% are likely to seek assistance from their primary care provider. Unfortunately, about 50% of the time this depression goes undiagnosed and treated. When integrated and coordinated care is not provided to such patients, not only are treatment outcomes less likely to be positive, but the costs of care tend to be higher.

While the evidence for the value of integrated care is substantial, the ACA has not succeeded to its goal of making this care more available to patients. Think for a moment about your own experiences going to your primary care physician. Was this type of coordinated, comprehensive and holistic care available to you? The failure of health care reform to treat the whole person is once more not surprising given that these “reforms” have done nothing to challenge the basic assumptions, the prevailing models and the vested interests that have long dominated health care. The traditional medical model continues to see human beings in terms of a mind-body dualism in which the primacy is placed on biological factors as responsible for illness and distress. This materialistic bias is particularly advantageous to the pharmaceutical industry that reaps obscene profits by promising a chemical cure for a host of human ills. Moreover, within the neoliberal ideology, the individual is seen as the only valid unit of focus and analysis. This gives rise to another disastrous split that misrepresents the reasons for why some people have a greater likelihood of becoming ill and are more likely to die.

Utter Neglect of the Social Determinants of Health

The final failing of health care in the US is its turning a blind eye to the fact that human beings are not self-contained units who bear principal responsibility for whether they are healthy or ill. Rather human beings are social to their very core and a wide range of social factors have definitively been demonstrated as having a tremendous bearing on their well-being. These are called the social determinants of health which have been extensively studied by public health. Social determinants are those conditions into which human beings are born, grow, work and age. These include things such as neighborhood and physical environment (safety, housing and transportation), food (access to healthy food and sufficiency of food), employment, education, community, and health care. The reality is that millions of Americans are born into conditions which exert a cumulative deleterious impact on their well-being and give rise to a host of medical and psychological disorders that diminish the quality of their lives. The poisonous water supply in Flint, Michigan — found in many other locations throughout the US — is just one example. Another is living in areas called food desserts where access to affordable and healthy food is absent or limited. The prevalence of violence, high levels of toxic chemicals, a lack of recreational facilities and decent schools, and little opportunity for gainful employment that is the daily experience of many Americans cannot help by exert a host of harmful impacts on their well-being.

What the research on social determinants of health makes clear is that economic policy is inescapably also health care policy. The research on social determinants has elucidated that inequality is correlated in a large number of indicators of ill health and social woes. The experience of inequality is accompanied by higher levels of stress associated with the imbalance between the demands placed upon individuals and their ability to exert control over those circumstances. This stress steadily eats away at them on a biological and psychological level. It also is associated with higher levels of teenage pregnancies, incarceration, substance and drug abuse, lower levels of trust, and higher levels of violence.

So long as the neoliberal ideology that dictates health care policy, there can be no hope of substantial progress being made in creating a society where individuals can thrive and in which they will be treated with the dignity and respect they deserve. A world that worships greed, that elevates competition as the sole means to success, that undermines the social bonds critical to human compassion, and that sacrifices human lives to the impersonal dictates of a “market” behind which the elite hide their indifference and cruelty wants us to all believe we can buy health. It is a lie — a cruel and insidious deception. We must expose it, condemn it and reject it utterly. Health is indeed a human right.