The midterm elections are over and the Democrats will control the U.S. House of Representatives in the next Congress. Republicans gained several seats in the U.S. Senate and, of course, President Trump remains in the White House.

For several months prior to the election, polls showed that health care was the most important issue to American voters. Polls also revealed that voters trusted Democrats more than Republicans to deal with health care. Some of this trust is historic, but a lot of it reflects Republicans lack of message and lack of an alternative to Obamacare.

Remember that no Republican voted for the Affordable Care Act in 2009. Included in these “no” votes were Senators John McCain (R-AZ), Susan Collins (R-ME), and Lisa Murkowski (R-AK), all of whom voted against repealing Obamacare in 2017. It is no wonder why voters don’t trust Republicans to handle health care.

Midterm voters in three very red states chose to expand Medicaid as allowed under the ACA– Utah, Idaho, and Nebraska. People were convinced that having any health insurance was the same as having timely access to quality health care, even though existing Medicaid patients have trouble seeing doctors because of poor provider reimbursements.

There is no question that some people have been helped by Obamacare. Yet, 60 percent of those who were uninsured in 2010 when the ACA became law remain uninsured. Obamacare has done absolutely nothing to control ever-rising health care costs in the U.S. Likewise, it forced hundreds of thousands of Americans to lose their existing health insurance plans and pay more for government-approved plans. Its largest accomplishment has been to expand the poor-quality Medicaid entitlement to 10 million able-bodied individuals, ages 18 to 64 years old.

The most popular midterm health care campaign talking-point was the ACA’s pre-existing condition mandate. Voters liked this idea, even though they were never told that this mandate was one of the main reasons health insurance premiums continue to dramatically increase for everyone. Repeal of Obamacare would eliminate this clause, but Republicans could not explain the better alternative of high-risk pools for people with high-cost pre-existing conditions.

With Democrats in control of the U.S. House, no significant health care legislation will become law for the next two years. However, health care will remain an important campaign issue in the 2020 presidential election. Those liberal Democrats who have already indicated an interest in running for president, are talking about a single-payer health care system, or “Medicare for All.” Moderate Democrats will undoubtedly take a more gradual approach, with the expansion of Medicare and Medicaid as well as a public option in the Obamacare exchanges. Price controls on drugs will also be in the mix.

It is unclear how Republican lawmakers will approach the health care issue in the future. They missed their chance for the repeal and replacement of Obamacare in 2017 and couldn’t coalesce around a health care message in 2018. Many Republicans have already supported the Medicaid expansion and have lost credibility on anything other than more government control of our health care system.

There are several wild cards in the health care debate, however.

First is the fact that half of all Americans receive their health insurance from their employer or their spouse’s employer. Any significant overhaul of the health delivery system will need to address the fact that the majority of people with employer-paid insurance and their employers view this arrangement favorably.

Second is the lawsuit brought by Republican Attorneys General. The major tax reform of 2017 included the repeal of the Obamacare “tax” on not owning health insurance. This repeal essentially made the individual mandate in the ACA unconstitutional. The ACA does not have a severability clause, so if any part of the law is found to be unconstitutional, the entire law must be struck down. The AG lawsuit is currently working its way through the courts and represents one last chance to repeal Obamacare.

Undoubtedly, the Trump Administration will continue to allow small changes and reforms to our health care delivery system outside of the ACA. However, whether voters understand or not, the midterm election gives government more control over our health care.