The Affordable Care Act of 2010, better known as Obamacare, now insures 20 million lives and covers roughly half of those who were without health insurance prior to its inception. While Obamacare is yet fraught with imperfections that must be addressed, it has fulfilled its conscionable mission: to increase access to health care for Americans. Under the new presidential administration, the number of covered Americans might remain the same, but care will be rationed and quality access is sure to suffer greatly.

Among the battle cries from those opposed to the ACA at inception was that it would mean “pulling the plug on grandma.” Despite campaign promises of the president-elect and the drumbeat of the GOP, which has long intended to repeal the act, neither will succeed in pulling the plug on 20 million Americans. Great fanfare will be made of eradicating the country of Obamacare, but to some extent the changes will be in name only — perhaps to “Trumpscare.” Indeed, the president-elect has promised to retain the prohibition on rejecting coverage based on pre-existing conditions and to maintain the provision for young adults to remain on their parents’ policies.

Nevertheless, despite the distinct absence of a comprehensive, alternative plan to the conundrum of U.S. health care, much could change:

Medicaid: There is an ill-advised plan for Medicaid block grants to states. Under this scheme the federal government will give the states a fixed sum, thereby shifting the cost risk, instead of simply paying for needed services for those patients who qualify.

Medicare: The new administration is in favor of privatizing Medicare by means of a voucher program. Those who qualify will be given vouchers to defray the premiums that they will then pay to private insurers. Having a Medicare voucher will not, by itself, assure that one can obtain insurance. Furthermore, more premium dollars will go to administrative costs for private insurers than under Medicare. Another portion of the premium dollar will go toward profits to private carriers. Medicare does not take a profit. This will result in the financial risk for health care being shifted from the federal government to the individual.

Health savings accounts: For all those other than seniors, the impoverished and the disabled, the new administration likely will encourage health savings accounts (HSAs). As standard premiums continue to increase beyond reach, the alternative will be a scheme whereby premiums are markedly reduced in exchange for a high deductible of several thousand dollars. Participants are required to make monthly contributions so that the deductible amount is in a sequestered account should it be needed. The result will be a distinct financial disincentive to seek necessary care, and these decisions will be made by consumers and not with their providers. The assumption that “I am well because I feel well” does not pass muster for the silent killers that include diabetes, high blood pressure, high cholesterol, heart disease, obesity and early stages of cancer.

Americans should expect to see the IRS penalty lifted for those who choose to defer coverage. This population consists primarily of the young, unworried well who will now instead go to the emergency department when they fall ill.

The late U.S. Sen. Daniel Inouye worked to ensure that under the Affordable Care Act, the people of Hawaii would not be at risk for having a lower standard than that provided by Hawaii law. The Hawaii Prepaid Health Care Act of 1974, for example, set minimum standards such that employees who work more than 20 hours per week for four or more consecutive weeks are entitled to health insurance. It turns out that details of this law preclude HSAs in Hawaii.

The HPHCA, combined with QUEST, which utilizes a combination of federal Medicaid and state funds, has resulted in Hawaii becoming among the states with the lowest percentage of uninsured. That may be about to change. If the ACA is formally repealed, Hawaii’s protections from less favorable federal policies could be at risk.

Under the new presidential administration and with the current makeup of Congress, plans afoot serve, as promised, to make for a smaller federal government that spends less on health care and shifts the cost risk to states and individuals. More Americans could still, in principle, be covered than before Obamacare, but services would be rationed. Although this might achieve modest cost containment, access to quality care would be deeply compromised for the U.S. population — and Hawaii would not be immune.

Ira “Kawika” Zunin, M.D., M.P.H., M.B.A., is a practicing physician. He is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com