Mary is single, in her late 50s, widowed and earning about $2,000 a month cleaning bathrooms downtown. She's had no health insurance for the last decade, but she's received medical care when she needed it at free clinics and emergency rooms.

But now it's the era of Obamacare, and Mary hears that she has to buy health insurance. We check her options on Maryland Health Connection, the state's online health insurance exchange:

The cheapest "bronze plan" is only $2.20 per month, which will avoid a year-end fine for being uninsured, but it pays for little up until the $6,000 deductible. The "silver plans" cost $130 to $360 per month with a $900 annual deductible, but for those she'd have to choose between a health savings account, a limited HMO provider network, a 40 percent or a $40 co-pay, and many other confusing options.

None of it sounds like straightforward "affordable care" to her.

This isn't a story about error messages or frozen screens. Website crashes make news; they don't make history. This is about the real implications of Obamacare, about which ideas work in real life and which just sound good on paper.

Mary was just one of dozens of low-income Baltimoreans I met as a health insurance enrollment volunteer in a Baltimore free clinic over the past six months, but she shares the experience of thousands of Marylanders this season. Once the website glitches subsided, the reality set in that the government was telling uninsured people to spend a significant portion of their incomes on health insurance. I have seen how many low-income Marylanders will remain uninsured because of the cost and complexity of buying insurance.

If we really want universal health care, we need a public system that actually includes all people, such as extending Medicare to all Americans. Obamacare's individual mandate to buy health insurance does not reach everyone because many uninsured individuals will not "buy-in" to an expensive and overly complex insurance system.

Unlike some critics, I do not think the Affordable Care Act (a.k.a. Obamacare) got everything wrong: It has made health insurance for individuals cheaper and better. Obamacare expands Medicaid to cover more low-income people, creates tax credits to make insurance cheaper for individuals, makes it illegal for insurance companies to deny coverage based on preexisting conditions and stops insurers from rescinding coverage when beneficiaries get sick.

But while Obamacare patches some of the gaping holes in the health insurance market, it also fails to create access for many of the people who never budgeted for insurance before. The bottom line is that Obamacare will insure millions, but it will also leave tens of millions of Americans still uninsured.

The only way to reach "universal coverage" would be for all Americans to be enrolled in basic public health insurance. This sort of "single-payer system" already exists for Americans over 65 (i.e. Medicare). While many politicians criticize single-payer systems, the millions of seniors who staunchly defend their Medicare are living proof that universal public coverage is worthwhile.

True universal coverage would protect our nation's most vulnerable from medical bankruptcy, it would save tremendously on administrative costs currently siphoned off by the insurance industry, and it would vastly simplify insurance in this country.

Plans are in motion to create a universal public health insurance system for Vermonters of all ages, but the hodgepodge of government programs and private insurers in Maryland continues to leave some of our neediest without a reliable source of care.

In Washington, my very own U.S. Rep. Elijah Cummings co-sponsored the Expanded & Improved Medicare for All Act in 2013, which tried to create this kind of comprehensive system to insure every American, but he needs more allies in Congress to turn this bill into law. On a local level, "Healthcare is a Human Right — Maryland" is a grass roots alliance of physicians, labor groups, and other Marylanders working to promote true universal health care in our state, and they have several local organizing chapters that need your support.

After months of trying to help low-income Marylanders like Mary sign up, I'm more convinced than ever that Obamacare will not reach many of the people who need health insurance the most and that universal public coverage is the only way we can provide real health care for all in Maryland.

Max Romano is a medical student and public health student at Johns Hopkins University and a volunteer at the Shepherd's Clinic, a free clinic for the uninsured in northeast Baltimore. The opinions expressed herein are the author's alone and do not represent the views of Johns Hopkins University or the Shepherd's Clinic. His email is mromano4@jhmi.edu.


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