Here is the simple secret of health insurance and health care provision policy: You can create efficiencies and savings by constructing functioning markets. But at the end of the day, more money equals more care. Or in the proxy we judge these things by, more money means more people are insured. If you see a plan that costs a lot less money than Obamacare, it means many fewer people will be covered. It’s as simple as that. You may have to look closely at the details to see just where the care reductions are made. But it’s there, just as certain as night follows day.

The hardcore conservatives in the so-called “Freedom Caucus” are right. The real way to do this is simply to repeal the Affordable Care Act root and branch – no pretending about making it better and “access” and other nostrums. Just set the clock back to 2009 and pretend the whole thing never happened. There are certain disruptions this will cause that go well beyond just setting back the clock. But there is at least an honesty and clarity to the exercise: the government, public policy has no interest in making sure people are insured.

The problem is that over the course of seven years Republicans have essentially accepted the premise of the ACA: which is to say, the people who got coverage under the ACA should have coverage. That’s what’s made ‘replace’ all but impossible. That’s why we’ve heard years of claims that the replacement would be even better. Even more people would be covered. The coverage would be better. The deductibles would be lower – even though a key element of GOP health insurance policy is that deductibles should be higher.

That’s coming apart now, now that we’re in the crunch. And we’re hearing talk of coverage replaced by ‘access’. ‘Access’ is the eatability of famine policy studies. There’s plenty of food to eat, as long as you have money to buy it. Access rather than food.

So long as we don’t have a universal system such as exists in various permutations in virtually every other wealthy industrialized country, the only real measure of policy success or failure is the number of people who have health care coverage – not theoretical access to coverage, coverage. Health savings accounts may have some marginal utility as they exist today. They don’t count as health care coverage. Democrats and everyone else who cares for the millions who are about to be tossed onto the chopping block need to force an honest setting of the terms of the debate now. The number of uninsured people has dropped dramatically over the last five years. It’s about to start going up again. It will go up even higher once the mid-term elections are past since the GOP plan is designed to push much of the bloodletting past the mid-term election. The current plan also starts the phaseout of Medicaid and preps for the phaseout of Medicare – a key policy goal for Paul Ryan.

The number of people with usable insurance is the only measure that counts. “Access” is bullshit. I’m sorry to put it in such a raw fashion but that is the fact. The number of people who lose their insurance is the only legitimate measure. And it doesn’t really matter whether they lose their care in 2017 or 2020. That’s just political gamesmanship.

This is the reality. The real issue is access to quality medical care. In our system, you only have true access to medical care when you have a health insurance policy. Access to health insurance is a meaningless concept. Coverage is all that matters.

I hope everyone is up to this political challenge. There are millions of people who are about to lose their health insurance coverage for a mix of ideology, political need and tax cuts.