I’ve noticed that some people are grading the performance of the commercial health insurance provisions of the Patient Protection and Affordable Care Act (PPACA) based on whether they like their health coverage, or whether other ordinary people like their health coverage.

I’ve fallen in that trap myself. Because any hard numbers on the actual performance of anything related to PPACA commercial health insurance provisions are so hard to find, I find myself rejoicing at the sight of the occasional bit of PPACA exchange plan or PPACA Medicaid expansion coverage enrollee satisfaction survey data.

But I remembered, while hearing a question about that recently, that even from the perspective of people who worked hard to design and pass PPACA, PPACA is just a temporary measure.

On the one hand, PPACA includes some bits that could help control costs, such as efforts to make health plans easier for consumers to compare. Maybe, as irritating as the bronze-silver-gold-platinum metal level system can be, it really will help consumers squeeze insurers, and push insurers to squeeze providers.

But, on the other hand, the real point of PPACA is just to help poor people and sick people get some coverage, and to avoid the pre-2008 situation, in which just about the only people who bore the brunt of efforts to control health care costs, other than employers, were the sick people and the working-poor people who were shut out of both government health plans and the commercial major medical market.

And, deep down, the real point of helping sick people and the working poor with medical costs is to give the hospitals, clinics and medical practices that care for those people a more predictable, easier to manage revenue stream. 

If PPACA gets providers to give more poor people with diabetes enough care to keep their toes on their feet, and enough care to keep them from going blind, while the country comes up with some kind of health finance system that actually functions, it’s working.

If PPACA is making typical consumers angry at providers, providers and insurers angry at each other, insurers angry at the drug companies, brokers feel like organizing protest marches around local hospitals, and everyone furious at PPACA, it’s also working.

See also: UnitedHealth to avoid 2016 public exchange plan sales

Typical consumers, providers, insurers and brokers all have a great deal more ability to shop, negotiate, and shape public policy than poor people and sick people do. We’re supposed to get mad enough to replace PPACA, and to replace our current health care system.

Maybe the answer will be, “Ayn Rand is right. The best solution, even for poor people and sick people, is to end any government involvement whatsoever in health care, because it just makes things worse.”

If that’s the ultimate answer, then, even in that case, it seems reasonable to me to provide poor people and sick people with temporary access to coverage, because, if the Randian analysis is correct, government interference is partly responsible for how hard it is for them to get affordable care. Get rid of the flawed programs meant to help them for now after we get rid of the laws, regulations and programs that, from a Randian perspective, shut them out of the system.

See also: Scott Walker’s PPACA replacement plan is popular with Republicans—but can it work?

On the third hand, creating any kind of good, stable, self-sustaining health finance system is always impossible, because every self-funded health finance system puts the human passion for mercy in conflict with our passion for fairness and the grim reality of resource limits.

Reporters in any country can do a heart-breaking feature article about how their system fails to cover X, or about how patients in Category A get treated better than patients in Category B.

But, on the fourth hand, one great thing about agents and brokers is that you’re the people who, from time to time, know how to grab on to mercy, fairness and resource limits and make them let the clients get the care they need. You can’t change the laws of the universe, but you can make them wiggle a little to let your clients slip through…