A friend of mine had physical therapy for a joint injury. During the session, even as his joint felt better, nagging stress started to tighten up the rest of him. This – his sixth session – was not covered by insurance, even though his doctor recommends three more. Yet he has what’s considered a very generous insurance policy through his employer.

His story made me think of the presidential election (because most things do)… but seriously, do you notice how often “health care” gets conflated with “health insurance” in the national debate?

The remaining viable presidential candidates seem to focus on getting insurance (well, except McCain; his “plan” is a $2500 to $5000 tax credit if you’ve spent that much on healthcare. If you don't earn enough for that to help you, then he has a great lecture for you on “personal responsibility").

Obama’s approach is the most attractive (to me) on the surface. I’m more comfortable – if only philosophically – with enhanced access than with a mandate. He even nods to the idea that insurance isn’t the end all. But it’s unclear how he’d to pay for any of it. And, most relevant to my point: it’s still primarily about access to insurance.

Clinton’s plan appears to be the most comprehensive. But it’s almost entirely about extending – requiring – coverage. Frankly, I’d rather pay a tax than be forced to buy something – but that’s a separate discussion.

Both Clinton and Obama would prohibit insurance companies from denying coverage based on age, illness, etc. But neither prohibits them from denying claims for any reason. Neither prohibits them from creating obstacles to proper care. (Obama says he’ll demand efficiency, but no details, no credibility).

Most of us who have ever had an extraordinary medical need know the draconian “pre approval” processes required by our insurers for non-routine procedures. My insurance company once told me that the approval process for a procedure I needed was outsourced to a “service coordinator” (a different company). When things were held up for days, I called to find out what happened. My doctor called. The facility where the procedure was scheduled called. We were all told by the insurance company that we had to call the “service coordinator.” That company wouldn’t talk to any of us, because we weren’t its customer: the insurance company was!

It all got ironed out eventually, but the whole ordeal, especially while I was sick, felt pretty nightmarish. Imagine going through this and worse if you’re very old or very poor, battling a life threatening illness, can’t read very well, don’t speak English (or Spanish), a victim of domestic violence… any number of stress factors that make it immensely more difficult to navigate these layers of bureaucracy.

And don’t even get me started on claims disputes.

Insurance has no intrinsic value (except to insurance companies). To consumers it is valuable only if it leads to timely and meaningful access to doctors, diagnostic procedures, treatments, therapy, medication, healthcare.

People seemed to be paying some attention to that last year: Michael Moore released “Sicko”; a number of journalists came out with their own “expose” pieces. Yet, in the end, the consensus “solution” seems to begin and end with more insurance.