The Affordable Care Act’s Regime of Truth, Surveillance and Control
An overview of the US Affordable Care Act’s key terminology suggests the continued affirmation of allopathic procedures alongside accelerated bureaucratic surveillance, centralization and control. While reinforcing the faith in allopathy, the preponderance of such terms points to processes seeking to reaffirm in the existing human subject a willingness to adapt to new deeds, activities, behaviors, and proficiencies to lay the groundwork for the development of an altogether new form of social control.
The US Supreme Court’s upholding of the Patient Protection and Affordable Care Act (ACA)[1] is no doubt a momentous event. At the same time the ACA is another instance where Americans are prevented from understanding the significance of their lawmakers’ actions given the legislation’s length (the condensed ACA is 955 pages), the opaque legalistic style in which it is written, and the law’s framing and publicity in mainstream media, particularly during a presidential campaign year.
On the whole, liberal pundits and their followers recognize the ACA as a landmark gesture of beneficence toward the country’s less fortunate, while conservatives generally see the legislation as another major step down the road to serfdom.
Certainly the new law will at once strengthen, broaden, and centralize the federal government’s surveillance powers and decision-making apparatus over the medical activities and relationships of providers and patients alike, with an intensified hierarchical bureaucracy given increased decision-making power over the appropriateness of medical procedures and life itself.
Further, under the ACA a specific medical authority and practice is being underlined as the principal mode of illness identification and treatment—one that became the norm only after the formidable influence of the American Medical Association (AMA) and the Rockefeller family ensured that allopathic medicine would supplant homeopathy and other competing approaches by the early 1900s.[2]
Since that time allopathy’s emphasis on surgery and patented synthetic pharmaceuticals has come to be the accepted form of medical discourse and practice in the West. In so doing, it fundamentally constitutes America’s regime of medical truth, imbuing medical science and practice with an aura of precision and integrity that has firmly established its legitimacy in the public mind. “Each society has its regime of truth,” the French philosopher and cultural historian Michel Foucault observes.
that is, the types of discourse which it accepts and makes function as true; the mechanisms and instances which enable one to distinguish true and false statements, the means by which each is sanctioned; the techniques and procedures accorded value in the acquisition of truth; the status of those who are charged with saying what counts as true.[3]
Such truths are created and sustained only through “multiple forms of constraint” exerted by “a few great political and economic apparatuses.”[4] The “truth” of allopathic medicine was assured early on through steadfast advocacy of the AMA’s Council on Medical Education, which alongside state medical boards and the Rockefeller Institute for Medical Research succeeded in closing dozens of medical schools teaching alternative approaches and not urging the use of synthetic drugs. Between the mid-1910s and 1936 $91 million of Rockefeller money went to “a select group of medical schools,” historian Paul Starr notes. “Seven institutions received over two thirds of the funds from the [Rockefeller] General Education Board.” The combination of policies and funding put into play by Rockefeller and other major foundations “determined not so much which institutions would survive as which would dominate, how they would be run, and what ideals would prevail.”[5]
In Foucault’s view the construction of truth plays a central role in the modern liberal state’s exertion of power at a distance. Whereas traditional despotic control wielded itself through deliberate violence or the threat thereof, the new power is bound up with modern institutions themselves, exerting a gentle yet persistent pressure on the individual through the monopoly on truth combined with discipline, surveillance, and constraints on competing realities. “It was a question not of tracking the body en masse, ‘wholesale,’ as if it were an indissociable unity,” Foucault argues, “but of working it ‘retail,’ individually; of exercising upon it a subtle coercion, of obtaining holds upon it at the level of mechanism itself—movements, gestures, attitudes, rapidity: an infinitesimal power over the active body.”[6]
Through such a subtle yet thoroughgoing disciplinary process over time the modern individual is transformed into a submissive subject upon which the politico-scientific leadership may effectively inscribe and disseminate its designated regime of truth.
Having established allopathy’s truth-bearing features over the past century, the accelerated centralization of surveillance and control embodied in the Affordable Care Act arguably seeks to establish new deeds, activities, behaviors, and proficiencies, and in due course to lay the behavioral and institutional groundwork for the continued development of a new kind of social being and control.
In keeping with Foucault’s suggestion that regimes of truth are comprised of the variety of discourses produced and allowed by professional and governing institutions and accepted as true by their subjects, the ACA is an intriguing document, revealing in varying degrees how for the foreseeable future through a government administered medical enterprise human life in the US will be more and more anticipated, surveilled, programmed, and managed.
While a thorough analysis of the ACA’s text is beyond the scope of most citizens as well as this commentary, a good deal may be gleaned on the document’s nature and scope–thus suggesting the architecture its authors intend to implement–by identifying prevalent terms used throughout the text (or their absence) and the frequency with which such terms appear in its 955 pages.
102 Selected Terms and the Frequency of Their Usage in
2010 “Compilation of Patient Protection and Affordable Care Act”[7]
2010 “Compilation of Patient Protection and Affordable Care Act”[7]
| Term Category / Term Bureaucratic Titles and Areas | Times Used in Text |
| “agencies” | 150 |
| “Department of” | 153 |
| “Health and Human Services” | 252 |
| “Secretary” | 3,080 |
| “Secretary of” | 297 |
Surveillance, Centralization, and Control | |
| “$” | 459 |
| “access” | 281 |
| “accountability” | 37 |
| “accountable” | 18 |
| “administrative” | 156 |
| “authorization” | 21 |
| “awareness” | 26 |
| “community” | 453 |
| “contract” | 379 |
| “correct” | 70 |
| “data” | 532 |
| “definition” | 171 |
| “disclosure” | 90 |
| “dollars” | 7 |
| “education” | 397 |
| “electronic health records” | 5 |
| “ethics program” | 5 |
| “fee” | 247 |
| “federal” | 637 |
| “grant” (verb and noun) | 850 |
| “health records” | 7 |
| “income” | 379 |
| “insurance” | 721 |
| “identification” | 42 |
| “internal revenue” | 191 |
| “liability” | 18 |
| “licensed” | 78 |
| “lifestyle” | 16 |
| “management” | 163 |
| “mandatory” | 10 |
| “measurement” | 30 |
| “money” | 35 |
| “monitoring” | 27 |
| “nonprofit” | 76 |
| “orders” | 43 |
| “oversight” | 49 |
| “penalties” | 57 |
| “permitting” | 12 |
| “profit” | 109 |
| “required” | 320 |
| “reporting” | 223 |
| “responsibility” | 65 |
| “Social Security Number” | 5 |
| “standardized” | 36 |
| “State” | 2,145 |
| “surveillance” | 20 |
| “tax” | 684 |
| “team” | 57 |
| “training” | 334 |
Legal / Obfuscative Verbiage | |
| “inserting” | 904 |
| “pursuant” | 140 |
| “redesignating” | 101 |
| “repeal” | 52 |
| “subparagraph” | 1,244 |
| “the following” | 893 |
| Medical Approaches and Philosophies | |
| “allopath” | 5 |
| “alternative medicine” | 3 |
| “behavioral” | 52 |
| “chiropractor” | 4 |
| “complementary” | 0 |
| “counseling” | 45 |
| “dentistry” | 30 |
| “dietician” | 1 |
| “health care” | 793 |
| “illness” | 29 |
| “naturopath” | 0 |
| “nutrition” | 37 |
| “nutritionist” | 2 |
| “osteopath” | 20 |
| “prevention” | 243 |
| “wellness” | 98 |
| “wellness care” | 0 |
Medical Procedures | |
| “abortion” | 24 |
| “alternative treatment” | 1 |
| “assisted suicide” | 4 |
| “birth” | 29 |
| “death” | 15 |
| “evaluation” | 252 |
| “examination” | 31 |
| “hospital” | 893 |
| “imaging” | 18 |
| “immunization” | 33 |
| “nursing home” | 39 |
Medicinal Substances | |
| “drug” | 535 |
| “genetically modified” | 0 |
| “herb” | 0 |
| “holistic” | 0 |
| “medicine” | 116 |
| “mineral” | 0 |
| “pharmacy” | 73 |
| “pharmaceutical” | 14 |
| “toxicity” | 1 |
| “vaccine” | 14 |
| “vaccine injury” | 0 |
| “vitamin” | 0 |
| Misc. | |
| “enhanced” | 33 |
| “infant” | 15 |
Notes
[1] US 111th Congress, 2nd Session, Compilation of Patient Protection and Affordable Care Act, Washington DC, 2010. Available athttp://www.healthcare.gov/law/
[2] Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1984).
[3] Paul Rabinow and Michel Foucault, “Truth and Power,” in The Foucault Reader, ed., Paul Rabinow (New York: Pantheon, 1984), 73.
[4] Rabinow and Foucault, “Truth and Power,” 72-73.
[5] Starr, The Social Transformation of American Medicine, 121.
[6] Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan, (New York: Vintage Books, 1977), 136-137; Joseph Rouse, “Power/Knowledge,” in The Cambridge Companion to Foucault, ed. Gary Gutting (New York: Cambridge University Press), 92-114.
[7] US 111th Congress, 2nd Session, Compilation of Patient Protection and Affordable Care Act.
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