The road ahead for U.S. health care remains highly uncertain. The Affordable Care Act, also known as Obamacare, quickly covered approximately half of those who previously were uninsured. However, while fine-tuning to deliver its central aims of access to quality care at reasonable cost, all three branches of government have posed troublesome challenges. Multiple efforts to repeal and replace the ACA have failed, and instead, its foundation has been actively weakened.

What’s next? While the majority of the public is opposed to a repeal of the ACA, intense uncertainty has spawned a range of competing initiatives for the future of U.S. health care.

Medicare-for-all: Under this scheme, the U.S. would move toward a government-­run, national health care system more consistent with that of the majority of modern nations. Of note, during the recent Democratic primary elections, the majority of the candidates who prevailed are moderate-­leaning and their support of Medicare-for-all is far from assured. The benefit of Medicare-for-all is that legal residents and citizens would all have access to care, something the ACA has not yet fully achieved. With greater government oversight, costs also may go down, possibly bringing the U.S. more in line with all other national health systems which spend considerably less per capita. The downside is that care would become more homogenized and access to expensive new and life-saving treatments is sure to be more limited.

Repeal and replace, or just continue to erode: Multiple attempts by Congress during the past two years to quit the ACA have failed. It remains unclear what would replace it. While full repeal is now unlikely, continued efforts to erode the current system may continue. Examples include the elimination of the health care mandate. That is, the unworried can opt out of insurance participation without tax effect. This increases premiums because those who do participate represent a higher risk population. Medicaid block grants to states shift costs and the burden of responsibility away from the federal government. “Skinny plans,” one more blow to the ACA, enable participants to reduce premiums by reducing the menu of coverage.

Improve the Affordable Care Act: In contrast, another real possibility is that the country will get back to the work of refining and improving the ACA in a manner that continues to increase access to quality care, and reduces cost while improving efficiency. Efforts must be directed to stabilize insurance markets and bring premiums under control.

End-around by private sector: Recently, JPMorgan, Berkshire Hathaway and Amazon announced that they would collaborate to build a separate health care system for their employees. Remember, however, that the responsibility of a publicly traded company is to its stockholders, not its patients. While a new private system might offer lower prescription drug costs; greater efficiencies; and more technological solutions to access, diagnostics and treatment, would this work toward the best interests of those who are sick? Increasingly, our personal data is hijacked as we access search engines, communicate via social networks, and buy online.

Hawaii buffered: While Hawaii is not immune to any of the above initiatives, it is somewhat buffered. The Prepaid Healthcare Act ensures that employees who work 20 hours per week for four consecutive weeks are offered health insurance by their employer. Quest, a unique insurance product that combines federal and state dollars, has for years optimized the number of covered lives in Hawaii. The late Sen. Daniel Inouye ensured that Hawaii would not be made to accept any provisions of the ACA if they were less favorable than what already exists. Finally, the state Legislature has signaled its determination to create a backstop to the prospect of a repeal of Obamacare.

Uncertainty about the future of American health care is uncomfortable for all, including patients, providers, payers and governments. It is comparable to the downward pressure of uncertainty in the stock market. We live in interesting times.

Ira “Kawika” Zunin, MD, MPH, MBA, 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. His column appears the first Saturday of every month. Please submit your questions to info@manakaiomalama.com or for more information go to: manakaiomalama.com.