Although far from perfect, for now, Hawaii remains among the best states for quality and access to health care, but these are uncertain times. President Donald Trump campaigned that he would repeal Obamacare on Day One, but on Day 43, Trumpscare was dead on arrival. No effort had been made to secure support from the House Democrats, and no middle ground could be found to bring together both conservative and moderate Republicans. Without enough votes, the bill was pulled. Meanwhile, Hawaii state legislators rallied and introduced House Bill 552 in an effort to shelter Hawaii from ill effects of potential federal legislation.

“Nobody knew health care could be so complicated,” said Trump when first briefed in advance of committing to legislation that would replace Obamacare, otherwise known as the Affordable Care Act. Indeed, the American health care industry is highly complex and in a state of flux. In contrast, virtually all other developed nations formed single-payer health care systems early on. While the U.S. is consistently the leader in advancing the science of medicine, U.S. health care stands out as by far the most expensive in the world, with population outcomes — such as infant mortality, suicide, drug abuse, obesity and life expectancy — that are relatively poor.

Sen. Ted Kennedy, among the longest-serving and most influential legislators this country has known, worked his entire political career to improve access by changing the structure of American health care. It didn’t happen. During their time in the White House, President Bill Clinton and Hillary Clinton dedicated great effort and political capital to restructure health care, to no avail.

How did President Obama pull it off? It was his routine to retire to his study, after dinner with the family, and spend four to six hours studiously pouring over briefings and then writing out questions and decisions for staffers who would pick them up in the morning. He learned from past failures of others and carefully evaluated how best to balance special interests and garner support from Congress. He also possesses emotional stability and the ability to speak thoughtfully and in a manner that inspires. In the end he delivered the ACA, which, despite being far from perfect, cut the number of uninsured in half.

Quality care and cost control are still a work in progress, as is insuring those who still go without. There remains much to do. If Hillary Clinton had won the presidency, she may have failed in her efforts to refine the ACA for the same reason: inability to unify the party. There remains a big rift between the Bernie Sanders camp, which is in favor of a single-payer system, and the moderate Democrats who would improve what is now in place. In fact, after the Republicans failed to repeal and replace Obamacare and decided to table the effort indefinitely, there has been talk about a bipartisan effort driven by moderates from each party.

The Aloha State has been a national outlier since the Hawaii Prepaid Health Care Act of 1974, which mandates that employers cover premiums for health insurance for those who consistently work 20 hours or more. In the ’90s the formation of Quest, which is funded through a combination of federal Medicaid and state dollars, further ensured that more of the local population would have access to health care. In this spirit, Sen. Dan Inouye inserted a clause in the ACA stating that while Hawaii would comply with beneficial aspects of the ACA, it would not compromise access. In this way he protected the two provisions just mentioned. Along this vein, state legislators recently introduced HB 552 in an effort to insulate the people of Hawaii from the fallout of any changes to ACA. For example, a proposed structural change in federal Medicaid funding toward block grants to states would result in a $223 million cut and cause 110,000, or roughly one-third of the current Hawaii Quest population, to lose coverage. The notion is that HB 552 would serve as a financial backstop to such federal funding cuts.

Nevertheless, even in Hawaii, health care is far from perfect for patients, providers and carriers. Many physicians are still being driven out of practice by the many administrative requirements that might improve some aspects of public health but cut at the heart of personalized, customized health care, shifting both cost and risk to providers. Still, Hawaii has achieved and remains committed to the single most important feature of quality health care: Almost everyone is covered.

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.