Donald Trump was elected. We continue to have a Republican House of Representatives and Senate in Washington. What does that mean for health and health care in the United States?

Since its inception, the Republicans have railed against the Patient Protection and Affordable Care Act, more commonly known as the ACA or Obamacare. This could have been expected since it was passed unilaterally by a House and Senate controlled at that time by Democrats. Although the idea was based on a plan originally conceived by a Republican-leaning think tank, it was hated from the beginning by the party not in power at the time.

Now that party is in power.

Despising something and doing something about it are two different things.

Think of a dog chasing a bus. If it catches the bus, then what? We heard the phrase “repeal and replace” frequently without seeing a consistently structured plan. The majority party now finally is trying to do something, but what? How different and how effective can it be? The Republican alternative, The American Health Care Plan, or Ryancare/Trumpcare, was passed unilaterally by a House controlled by Republicans and now faces a Senate also controlled by Republicans. What can be expected? Will it improve things, or simply push the soap around the bathtub, resulting in little?

Don’t forget that the tremendous forces of lobbyists representing medical professions, facilities, pharmaceuticals and insurance will fight to assure their place on the gravy train. These are among the best funded and most effective lobbyists in Washington and our state capitols. They will make effective action by Congress difficult. Hence, we can expect little change.

My best guess is we will muddle on with continued controversy until we agree on what we want to do. As a nation, we really have not decided just what the legislation is intended to do. Is health care a basic right for all Americans? Is legislation needed to assure health for Americans? Is an act of Congress needed to assure access to health care services? Is it needed to assure access to health insurance coverage? Is it intended to shield people from the potential of ruinous charges for health care services? Is it intended to protect the public sector from having individuals bankrupted and subsequently falling upon publicly funded social welfare programs? Is it an attempt to assure social justice for all? Is the legislation a way to meet a perceived right to health care? Do we need to protect ourselves from others whose disregard for health can adversely impact us (think anti-vaccinators or financial deadbeats whose unpaid bills get shifted to others)? Do we need protection from practices of insurers that work against us?

What are they trying to do in Washington?

Obamacare and Trumpcare are both flawed because they concentrate mainly on access to health insurance coverage. As such, the question is simply who pays and how much? Do individuals foot the costs or does the government participate? This has become the political question.

Americans are expected to obtain health insurance coverage either by themselves, through an employer or through the government. Insisting on this through a mandate is intended to give financial access to more people.

In theory, having more people covered also has the potential to halt the shifting of the charges for care of the under-insured and uninsured along to the insured in the form of higher charges for those who could pay. Cost shifting by health care providers commonly is in the form of charges at least 25 percent to 33 percent higher than needed.

Health care providers function as surrogate tax-collectors, overcharging many to cover costs of others. However, any mandate to obtain coverage doesn’t control the cost of insurance. It relies on competition among insurers to keep costs in check, but this leaves out the role of health care providers.

Health care providers have been given a free ride and many realized a bonanza under Obamacare that will continue under Trumpcare. Either way, with more people being covered, fewer bills are unpaid. However, providers have not reduced their charges accordingly. In fact, ever-increasing charges became one big reason for insurance costs to continue to increase.

When a large company like Aetna leaves the marketplace because it is not profitable enough, have people wondered why? People objected to insurance price rises under Obamacare, but the increasing costs were a big issue long before Obamacare. In fact, the “good old days” weren’t so good. Health insurance costs were ever increasing, and employers and citizens were caught in a trap of insurance costs increasing faster than inflation.

But insurance costs often reflect provider charges. The lack of a focus on costs and provider charges is a major flaw in both Obamacare and Trumpcare. Incorporating action on costs would require joint action by our Congress and President Trump. Any plan, without Congressional willingness to improve it, is doomed. Something might be enacted, but will it work?

There are those who believe that we need to let old-fashioned competition and free enterprise work their magical effects in the health arena. This won’t work since our health care sector is uncontrolled by competition. Too many providers enjoy monopolies of various kinds and there often is not a choice among alternative providers.

People do not shop for services among alternatives, even if they are available. People and their providers are usually unaware of the charges for services; certainly they are unaware of the real costs. Health care simply is not purchased like soap, autos or other consumer goods or services. People — and especially our legislators — are confused by the different uses of terms like “price,” “charge,” “cost,” and “reimbursement,” and hence cannot intelligently discuss financial matters.

Generally, the only part of the competitive system that operates freely is the desire of providers to charge what the market will bear, in one form or another.

Quality is mildly addressed by Obamacare and Trumpcare. The American health care system does not produce the best results. Several other countries have far better outcomes on many measures such as life expectancy, maternal and child death rates and disease rates. In fact, our system often focuses on care that is episodic, expensive, high tech, end of life and esoteric. Our “care” often kills many patients. Medical errors and poor care are not uncommon. Any look at health care should incorporate consideration of the value of the care that is paid. For those who say this is not a role for the government, consider that well over one-half of all care already is paid by the government through Medicare, Medicaid and veterans’ benefits.

Taxpayers have a right to expect the biggest possible bang for their buck. However, providers have learned that the easiest way to stop a serious discussion is to simply ask “… but what about the quality?” Uninformed people cannot proceed beyond this to engage in a meaningful discussion.

Going back to access, consideration of the supply of providers largely has been ignored. We need enough providers distributed throughout our population to assure that people have a provider reasonably available to them. Hopefully more providers could lead to some price competition among them and help reduce costs. However, there is evidence that the more hospital beds you have, the higher the charges are — despite the supply.

The supply of medical personnel and facilities has not been addressed in Washington. There is an inherent assumption that if you have insurance, you have access to providers. Tell this to residents of poor inner-city neighborhoods or rural areas. There is poor distribution of our providers, and this will not improve.

Most careful observers believe that we are simply waiting for all current governmental attempts in health care to simply collapse. When that happens, we will need a major overhaul of our policies on health and heath care. Most agree we will evolve to some form of single payer system, with a single payer large enough to demand reform, or a form of a national health service to control the providers of care.

The health system has evolved over the decades. It does some great things, but it has many inherent flaws. Like "Topsy" in “Uncle Tom’s Cabin” observed when she was asked who made her, she replied, “I 'spect I jest growed.” Similarly, our health systems just grew. Addressing this constructively will require us to decide what we want, what we need to do and when we need to do it.

The road ahead will have many twists and turns.