The landmark Patient Protection and Affordable Care Act, passed in the early years of the Obama administration, was seen by many as a significant step toward putting medical services within reach of more Americans. Indeed, some 20 million more people have coverage today than in 2010.

But there are flaws in what’s more popularly called the ACA or “Obamacare.” Any major legislation of this kind should be seen as the start of the reform process, requiring refinement in the succeeding years.

Unfortunately, because of the political standoff at the time of enactment — a partisan chasm that has only widened since enactment — there were no revisions, with Democrats unable to stomach another fight.

Now the Republicans have full control of government, and it looks as if they are poised to repeat history. So far, their only legislative response falls far short of a solution, and while President Donald Trump is vowing to negotiate a settlement, his success is anything but assured.

This stalemate leaves many states, including Hawaii, in a cloud of uncertainty, many people fearing more instability for their health coverage costs. There’s enough fear that the Legislature is moving a measure to save key provisions of the ACA under state law.

The American Health Care Act has emerged as the vehicle for fulfilling the GOP’s years of clamoring for repeal and, more recently, the party’s realization that it will need a replacement program at the same time.

After failed attempts to woo even marginal Republican support for the bill, the ACA ultimately passed through “budget reconciliation” in the Senate, requiring only 51 votes, all Democrats.

House Speaker Paul Ryan’s American Health Care Act will follow the same partisan reconciliation path to passage. It’s called a “repeal and replace,” but in fact many nonbudgetary elements of Obamacare will remain in place, because lawmakers would need 60 votes to strike them.

Nationally, consumers who have to contend with the fallout of legislation are hoping for further revision. Many critics fret about the proposed dialback of the Medicaid expansion a few years down the road, and about a system of tax credits that will offer much less help to the lower-income groups in purchasing insurance.

Governors of both parties, most of whom signed onto the Medicaid expansion to cover more of their poorer citizens, are rightly concerned about what will happen when those funds dry up, and many people are dropped from insurance.

It will be back to emergency-room care for them. Uncompensated care again will weigh on the hospitals and providers, whose industry representatives have loudly protested the bill.

All of these people await what they expect to be a broad revision of the measure, once the nonpartisan Congressional Budget Office analyzes its costs and consequences.

Even without the score, other expert observers, including the Kaiser Family Foundation, offer some dreary prognostications about the bill. Kaiser’s home page displays an interactive map comparing the assistance the new bill will offer and what consumers have through the ACA.

In many counties nationally, according to the foundation, there would be more losers than winners.

Hawaii purchasers of ACA plans fare relatively well under the new bill’s tax credits, according to the foundation, which projects an 8 percent increase in aid for purchasing insurance. But in the final analysis, the overall picture even for this state might not be so pretty.

About 600,000 in Hawaii get coverage from employer-provided plans, said state Insurance Commissioner Gordon Ito. That’s likely because of the state’s Prepaid Health Care Act, which has enforced employer-based coverage for four decades.

But about 350,000 are covered by Medicaid, a group that grew substantially due to Medicaid expansion now at risk. Officials are concerned what could happen to that group, and to the level of subsidy that those buying coverage individually will owe if the ACA is repealed.

Ideas for improving the existing law have been floated, include enabling early enrollment of Medicare members to lessen the burden of older patients on the private markets.

Democrats favor a public insurance option to compete with the private; on the right, Trump is pressing for negotiating prices of prescription drugs for those in federal programs.

In an ideal world, debate would center on continuing the reform process like this, not a myopic obsession with repeal. But this is not an ideal world, and unless there’s a course correction, America will pay a heavy price for this grave error by its elected leaders.