Republican infighting and the damning CBO scores suggesting Trumpcare would worsen the lives of tens of millions while cutting taxes on upper income taxpayers by billions would seem to put the passage of the program in jeopardy. What’s next?

Possibly nothing but more polarization. Republicans refused to cooperate in designing Obamacare or in its implementation, despite the fact that it was built on a template designed by a Republican think tank and enacted by a Republican governor. When it became law, hatred of big government and a Democratic president trumped the proving of healthcare for those citizens least able to afford it.

The alternative reality the Republicans inhabit continues. On seeing the CBO numbers, the administration said they were fake news that should be ignored. HHS Secretary Price said “nobody will be worse off financially,” possibly because the 24 million losing healthcare will no longer have any healthcare costs. They will be worse off medically, but not financially.

Paul Ryan said of the prospect of those millions of additional uninsured Americans, “I’m not concerned about it.” I guess it’s easy for the comfortable to ignore the afflicted as long as they are succeeding in reaching goal number one — less government, less deficit, less welfare state. Mission accomplished. But a free market that produces more paupers and dying people is a dubious accomplishment.

For their part, Democrats are weirdly oblivious to a glaring fact. Healthcare costs money. In America it costs more than in most other developed countries, often twice as much despite the fact that they cover virtually everyone and have better outcomes.

Medicare and Medicaid and private insurance plans for employees cover 80 to 90 percent of Americans, but cost controls are weak. Every year premiums rise as do the prices charged for services. It is argued that that’s because we are so innovative in creating new drugs and devices. Maybe, but we are also innovators in designing a system that fails to control costs.

In few other societies are the average doctors paid ten times what schoolteachers earn, nor are taxes on such high earners so low. In few systems are healthcare providers compensated on a piecework basis, so that the more procedures performed or meds prescribed the more the providers profit. This distorts the practice of medicine in ways that hurt patients rather than helping them, and blows a huge hole in the budget.

In other societies, taxpayers have cradle to grave healthcare but pay higher taxes to pay for the security this provides. But they do not have to see their healthcare dollars being used to subsidize price gouging by hospitals, pharmaceutical companies and insurance companies. Foes of Obamacare promise to get the government out from between the patient and his doctor. But, as we all know, Aetna and United Healthcare and the rest of the insurers are actually between us and our doctors now. At least the government isn’t trying to earn a profit by being a middleman.

It is also well known that an absurd fraction of health dollars — between 60 and 70 percent — are spent in the last year of patients’ lives. Some of this is necessary and justifiable but much is wasted on procedures or life support that should not be undertaken. Why? Because the patient or his relatives don’t want to face reality, and the medical establishment profits gigantically by extending lives that are over. Once again, financial incentives overwhelm compassion and common sense.

Clark Havighurst, a Duke law professor emeritus, in a recent Wall Street Journal op-ed argues for a truly populist reform of healthcare which he suggest now “functions under regulatory rules that benefit hospitals and insurance companies more than average patients.” He also notes that we are no longer in the era of the small town doctor who was also our friend and neighbor.

Big health now represents a monopoly power unseen since the days of the robber barons. It is engaged in a process of “redistributing wealth from ordinary people to an already privileged class of doctors and hospital administrators.”

And the tax system is a co-conspirator. It gives breaks to employers for providing a medical benefit, but the employees bear the cost burden “in premiums deducted from their checks, or…in the form of reduced pay, vacation time or retirement benefits.”

In short, the market for health care isn’t behaving as markets (beloved in Republican mythology) are supposed to — allocating resources rationally and controlling costs through competition. Nor is “socialized medicine” working to benefit the many patients, but rather to enrich the few providers.

Surely in a sane world, with so much that is flawed in our overpriced, monopolistic, market distorting, greedy, uncaring health care system that incentivizes the wrong actions and produces the wrong outcomes, there would be plenty of common ground for Republicans and Democrats to cooperate in a reform effort.

But the system got this way by legislating to please special interests. And as long as the patient’s well-being isn’t seen as the primary interest, the game will be continue to be rigged in favor of the health-industrial complex, and the patients will be viewed as either haves to exploit or unprofitable have-nots to ignore.