It’s been nearly six years since President Barack Obama signed the Affordable Care Act into law and almost four years since the U.S. Supreme Court upheld it.

The goals of “Obamacare” are to provide more Americans with access to quality health insurance and to curtail spending on U.S. health care. Despite vehement partisan objections and an imperfect rollout, more Americans have more health insurance, and the growth in the cost of U.S. health care has been affected, albeit modestly. Much remains to be done to fully deliver on the promise of Obamacare, and there are still powerful political forces that would roll it back. The results of the presidential election will be a major factor in what happens next.

The U.S. stands out as the only sizable, modern industrial country that does not have national health care. The U.S. also spends a much larger percentage — 16 percent of gross domestic product — on health care than other countries. The biggest spenders in Europe are at 11 percent, and the average among most developed countries is 8.9 percent. At an estimated $10,000 per person, or a total of $3.207 trillion for 2015, the cost of health care in America ranks between the total GDP of Germany and Britain. In other words, if the cost of health care in America represented the total GDP of a country, it would rank fourth in the world.

There are many who believe that the ACA is part of the slippery slope toward nationalizing American medicine. To be sure, under the act, not only are more Americans now covered by government-sponsored insurance, the government also now carries more sway in the business of medicine. In other developed countries, although national health care is dominant, private health care remains available. Despite features in common, the businesses of American health care always will be uniquely American.

Sen. Ted Kennedy considered health care reform the raison d’etre of his professional life. He fought for universal comprehensive coverage on 15 occasions in the U.S. Senate over 47 years. Sadly, he died from brain cancer not long before the ACA was signed into law.

The ACA was designed to expand the affordability, quality and availability of private and public health insurance through consumer protections, regulations, subsidies, taxes, insurance exchanges and other reforms. The degree and manner of its implementation has been divided largely along red and blue states. Hawaii is a special case.

First, even before the ACA, when compared with the rest of the country, a disproportionately high percentage of Hawaii residents already had health insurance. This was the result of the Hawaii Prepaid Health Care Act of 1974, which set a minimum standard of health care benefits for workers. An even larger share of Hawaii residents became insured with the rollout of the Quest program, which was formed in the 1990s when Dr. Jack Lewin was director of health.

In an effort to promptly comply with the ACA and to do so in a manner sensitive to the needs of the local population, Hawaii elected to form its own Hawaii Health Connector. Unfortunately, after a period of mismanagement and a substantial loss of precious funds, the HHC was shut down, and, effective Jan. 1, qualifying Hawaii residents began to go directly to the federal platform for access to health insurance. For more information and to get health insurance, go to obamacarefacts.com.

During the most recent debate for the Republican presidential nomination, Marco Rubio hammered on front-runner Donald Trump for his lack of a health care plan should he win and follow through on his promise to repeal Obamacare. Despite various ideas on what should come next, all of the remaining competitors for the Republican nomination have promised to repeal the ACA despite it having been in place for six years.

Turning to the Democratic nomination, Bernie Sanders has taken the opposite position. “Health care is a right, not a privilege,” says Sanders, who promises Medicare-for-all universal coverage. Hillary Clinton, front-runner for the Democratic nomination, has spent the most time studying the question of health care in America. During Bill Clinton’s two terms as president, health care was her signature issue as first lady. Despite broad-based support from Democrats, ultimately “Hillarycare” was unsuccessful.

The best chance for the Affordable Care Act to remain in place would be if Hillary Clinton wins the presidency. She has promised to work with it, refine it and make it better. Her stated objectives include a crackdown on the excessive drug prices charged by pharmaceutical companies. Obamacare is far from perfect, but creating better access to quality health care for the American people while managing costs is the right thing to do.

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.