Numerous surveys have shown that a majority of Americans believe the Affordable Care Act (ACA), commonly called Obamacare, is faltering and is in serious trouble. Compounding the problem is the contention that President Trump and the Republicans have no realistic replacement alternative.

As the debate rages we realize health insurance is not the same as health care. Complicating the situation is the fact no solution will appease everyone and all likely solutions will be unacceptable to most. No plan is perfect for everyone. That puts us between a rock and a hard place.

The ACA is plagued with double-digit premium increases, a defiant uninsured public, rising health care costs and the fact some large insurers are pulling out of the individual markets. The longer we delay making changes will only make the corrective actions more painful.

Those who buy policies on the exchanges often find that even with subsidies, they can’t afford to use the coverage because of mounting deductibles…$6,000 for individual Bronze plans. Cost-wise, we can’t have poor, uninsured people using the emergency room for their primary care. Face it, there is nothing affordable when it comes to health care.

Expanding access to health care is only part of the puzzle. Controlling the soaring costs, and allowing for a constant stream of innovative procedures, is the other half as we struggle to find ways to sustain the exploding health care system.

Young and healthy people don’t think they should be forced to buy expensive health insurance. They are already struggling to pay off other living expenses. Older people between the ages of 50 and 65 are starting to contend with age-related health issues, job insecurity and soaring health insurance premiums, which they cannot afford.

Replacement proposals, like the American Health Care Act (AHCA) will ask older, poorer and sicker people to pay significantly higher premiums and deductibles. Opponents of the AHCA says it delivers tax benefits to the wealthy on the backs of lower and middle-income Americans.

There’s no good answer to the problem when only a small segment of the population can afford to pay for health care and an aging segment of the population is lining up to receive an expanding menu of health care therapies that have soaring costs.

Marcia Angell thinks it is time to replace Obamacare with Medicare for All. As I said before, no proposed solution to this puzzle contains all the pieces and every solution has stiff opposition.

Angell is a former editor of the New England Journal of Medicine and is a corresponding member of the Faculty of Global Health and Social Medicine at Harvard. She recently wrote an op-ed piece in USA Today.

As it currently stands, 65% of health costs are paid by the federal government in one way or another, Angell wrote. Health policy experts estimate this would increase to 80% with Medicare for All.

In 2010 when Obamacare was enacted, about 50 million Americans (16%) were without health insurance. The U.S. was then spending $2.6 trillion a year on health care. In 2015, about 29 million (9%) remained uninsured, and we spent $3.2 trillion on health care.

Medicare is essentially a single-payer system for those older than 65…government financed but privately delivered. To be sustainable, Medicare needs some reforms such as shifting hospitals and other providers to a non-profit delivery system, Angell says. This controversial idea would likely be opposed by free-market Republicans.

Any program and any changes to Medicare for All would be expensive. Medicare and Medicaid are already grossly underfunded. Medicare for All would require a massive increase in taxes…perhaps an earmarked progressive income tax which Angell says would be offset by the elimination of premiums and out-of-pocket costs, and the slowing of inflation that stems from our market-based system.

Angell suggests switching to universal Medicare for All one decade at a time, starting by dropping the eligibility age from 65 to 55. Whatever is done in the coming years, we don’t want to replace the ACA with a system that is inadequate, doesn’t serve the uninsurable and threatens to bankrupt the country.