It’s getting harder and harder to defend the Affordable Care Act.

That difficulty underscores the fact that health care in our society is not a right but a commodity. Recent observers have noted that President Obama has backed away from moral arguments for health care reform in favor of transactional ones. That seems to me to spell defeat for the very idea of the ACA as reform in the humanitarian sense we still hoped for six years ago.

I recently wrote that I think the intention and potential of the ACA were and would be to improve our present system of private insurance, to increase coverage and ensure greater fairness. But yesterday’s Washington Post reported that

Thousands of primary-care doctors and specialists across the country have been terminated from privately run Medicare Advantage plans, sparking a battle between doctors who say patient care is being threatened and insurers that insist they have to reduce costs and streamline their operations.

After the Supreme Court decision that allowed states to opt out of Medicaid expansion, many states, though not a majority, did so—and led by the American Legislative Exchange Council have now enacted and/or proposed a host of repressive state laws designed to deny health care to as many citizens as possible. Then with the rollout of the new health care exchanges, insurance carriers began to cancel plans that didn’t meet new federal guidelines for minimum coverage and blamed their bad faith on the government, spawning a spate of horror stories that made perfect raw material for the Republican hate-Obama industry. Then some large low-wage employers ceased to provide health insurance for their workers, dumping them into the new health care exchanges and plans that require government subsidies to be “affordable.” Not to mention those large employers who for one reason or other have sought “religious” exemptions from the parts of the ACA affecting women’s health. And now this: thousands of doctors terminated from perfectly good Medicare Advantage plans providing medical care for the frail and the elderly, cutting them off from access to their doctors, interrupting years old doctor-patient relationships.

It’s unconscionable, but to Jack Larson, United Healthcare chief executive for Medicare and retirement, the Medicare Advantage provider making the largest cuts in its physician network, these changes are business as usual.

I’m not diminishing at all the short-term disruption when someone loses access to their physician. That’s a hard thing. . . . But we do believe that to have a quality health-care system we need to seek those physicians who have exceptional quality related to cost.

For years Medicare Advantage programs were a cash cow for insurance providers bacause the government paid these plans more per patient than it spent on regular medicare patients. But the ACA cuts payments to Medicare Advantage by $156 billion over the next decade and uses the savings to pay for other parts of the new system. Physicians are protesting individually and through the AMA and other medical organizations. Patients’ groups will likely organize as well. I’m joining the first one that comes to my door.

Thus far I’ve received no notice of any changes in my Medicare Advantage plan. However, I have received several letters from my provider offering me the opportunity to participate in an “entirely voluntary” program of home visits by doctors working for a subcontractor. I’ve not responded and don’t intend to respond. I’ve done some research on the subcontractor and it appears that it is a company that employs problematic physicians (hacks at worst) and that the intent is to get my insurance provider in between me and my own physician. I’m already bombarded by questionnaires after every doctor’s visit, checking up on my experience. I always respond to these because I don’t want any failure of mine to compromise my doctor. I think all this is worse than insidious, but it is likely the best face of present-day managed care. For various reasons my Advantage plan is a very good one.

Returning to the health-care arguments that animated the Clinton/Obama debates prior to the election of 2008 is a bit like returning (assuming that one could do such a thing) to Prague Spring after its brutal suppression. And the ACA? What began as a noble effort to provide access to health care for all Americans became in the working out of it a Rube Goldberg contraption full of unexamined assumptions and naïve expectations about how the strengths of the American capitalist establishment could be marshaled in a good cause requiring action through the state. There may have been a time when such a thing could have worked in America to promote the general welfare, but not now. What has been created in fact is a new complex of opportunities for gaming the system in the interest of predatory capital; with of course the usual losers, in this case physicians as well as patients.

The reasons why the ACA didn’t include a public option get clearer and clearer. They are the same as the reasons why a single-payer system is impossible in this country and why Medicare was designed and is administered for inadequacy—and of course that inadequacy has created the presently large market for supplements and PPOs. In a recent press conference the President was heard to say that we adopted the ACA as the least disruptive of alternatives for health care reform. So far “least disruptive” looks pretty disruptive, and it’s clear that the intent was not to disrupt the patrons of the system: clients (physicians and patients) pretty much be damned.

So how do we measure the success of this program? Sure, you can’t now be turned down for coverage for preexisting conditions, and parents can keep their children on parental policies for a longer time. But the cancellations of recent weeks and months are just as arbitrary as rescissions (now supposedly illegal) were in the former dispensation, and it’s now reasonable to ask, I think, whether in the final analysis the ACA will have been worth its human cost when it will end up leaving 31m people still uninsured.

I think the ACA will survive, and in some as yet to be foreseen future perhaps it can be made better. A popular left wing source seems to indicate that public approval is growing. On balance these are probably good things; but given the ACA’s flaws, with ALEC and the Republican party attempting to sabotage it on every hand and large insurers gaming it in order to continue their present obscene profit growth, it’s hard to imagine that it has the slightest chance to become the universal health care system we once imagined.