Hillary Clinton returns to the stage after the Democratic presidential primary debate in December resumed from a break. (Jim Cole / AP)

Obamacare is leaving millions in serious financial pain, pointing up the need for universal health care—Medicare for all. That’s Sen. Bernie Sanders’ position, and it is a crucial difference between him and Hillary Clinton, his chief rival for the Democratic nomination for the presidency.

READ: MoveOn Endorses Sanders in a Landslide: 78 percent of Its Members Back Bernie

Reiterating one of his major themes Saturday, Sanders told a Putting Families First forum in Des Moines, Iowa, “What this campaign is about is ending the disgrace of the United States being the only major country not to provide health care to all people as a right.”

Clinton, who did not join Sanders and fellow candidate Martin O’Malley at the forum, has offered a considerably more limited plan. She would fix the Affordable Care Act rather than replace it with Medicare for all. She would limit what patients pay for doctor visits and prescription drugs and repeal the law’s planned tax on high-cost, employer-sponsored insurance. And she would try to stop excessive insurance rate increases and limit drug price increases.

These would just be fixes to a system scathingly described this way by Robert Pear of The New York Times: “For many families, the Affordable Care Act has not made health care affordable.”

A recent study by The New York Times and the Kaiser Family Foundation shows how Obamacare falls short of rescuing Americans from the nagging medical insecurity the act was supposed to have ended.

On the plus side, Obamacare has made health insurance available to millions who were previously denied it, such as those with pre-existing conditions or freelancers, small-business people and those who found themselves without insurance after losing a job and being confronted by few choices and astronomical rates. Insurance is purchased through an online marketplace—an exchange—with subsidies for those with lower incomes. The poor can buy insurance through Medicaid in the 31 states that have agreed to accept federal funding through Obamacare. A total of 16.4 million people have gained coverage under Obamacare. In addition, millions more have health insurance through employers or with policies purchased individually.

But the survey of the Times and the Kaiser foundation showed great weakness in this complex system, which is pretty much run by the insurance industry.

The survey consisted of in-depth interviews of 1,204 adults ages 18 to 64 who said that they or someone in their household had problems paying or were unable to pay medical bills in the previous 12 months.

Confusing insurance company networks have thrust patients into the hands of physicians and other caregivers who are “out of network,” so patients are only partly covered or not covered at all. Policies with low premiums can impose high deductibles and payments. Despite the goals of Obamacare, people find it confusing to shop for policies or to sign up.

The survey showed that “problems related to unaffordable medical bills and medical debt are prevalent, affecting roughly 1 in 4 non-elderly adults in the United States. Certain groups are more vulnerable, including individuals and families with lower incomes and limited financial assets, people with chronic medical conditions and disabilities, the uninsured, and people insured by plans with high deductibles.” Also hurt are “people … [with] higher incomes, who are insured, or who are otherwise in good health and then experience unexpected health problems.”

“Of those who were insured when the bills were incurred, three-quarters … say that their share of the medical cost was more than they could afford,” the report said.

The survey found about seven in 10 of those interviewed reported cutting back or delaying vacations or major household purchases, as well as reducing spending on food, clothing and basic household items. About six in 10 said they used up all or most of their savings in order to pay medical bills.

These are more than dry figures for policy wonks who study health care. They help explain the anger simmering in the country, as well as numbers that show the discouraged unemployed dropping out of the workforce while income gains go mainly to the top earners.

Sanders is campaigning for an end to this. He’s doing it in a blunt, forthright way that appeals to Democrats tired of an economic system stacked against them. His message, uncluttered with Clinton-like ambiguities, seems to be resonating in the states of the first two contests: Iowa, where caucuses will be held Feb. 1, and New Hampshire, which has a Feb. 9 primary. Clinton, in the latest polling, is leading Sanders slightly in Iowa and trailing him in New Hampshire.

These numbers were pumping up the dozen or so volunteers making phone calls for Sanders in a Hollywood studio built in 1916 by Mack Sennett, the pioneer director of slapstick comedies. I watched in the big barn of a soundstage as the volunteers phoned people in Iowa, determining whether they were potential Sanders voters and then pitching those who were. Laptops connected to Sanders’ headquarters in Vermont provided the numbers and dialed them. This scene was repeated in other places in the country.

The way the volunteers stuck with it on a Sunday afternoon was impressive. Sanders is on to something, connecting with the anger in a positive way, as opposed to Donald Trump’s foul negativism.

Sanders has been every bit a match for the overly cautious Hillary Clinton—maybe enough of a match to beat her in Iowa, New Hampshire and elsewhere.

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