You can tell how far off track the discussion on health-care reform has gone when the idea of forcing everyone to buy corporate health insurance is sold as "universal health care."

That has been the crux of the debate between Senators Hillary Clinton and Barack Obama over what is called individual mandates. She's for it, he's against it.

Compelling people to pay private insurance premiums is not "universal health care." Especially when you let those insurers continue to charge as much as they want and do nothing to stop the all too routine practice of denying medical treatment or blocking access to specialists or diagnostic tests because the company doesn't want to spend the money.

Senator Obama has a point that many without insurance can't afford it, especially as the economy continues to collapse and premiums now average over $12,000 per family, not including skyrocketing deductibles, co-pays and other costs that have made medical bills the leading cause of personal bankruptcy.

To hear just one example of how the costs have become crushing for so many Americans, listen to the voice of Karen Hlynsky, of Providence.

"Because of my low income I get a discount on insurance. But the discounted costs are still more than my mortgage payments. Because I must pay for labs out of pocket, I'm reluctant to see a doctor until I'm very worried about an ailment. I'm still paying for tests done 10 months ago.

"Three years ago I had a terrific job with terrific benefits, including great health care. Who knew that on leaving that job I'd be in this awful situation?

"For three years I've been looking for work with benefits. It's amazing how few jobs actually offer health benefits, and how few jobs pay enough to enable me to pay for health-care benefits myself."

Hlynsky is one of some 700 people with similar stories responding to a California Nurses Association/National Nurses Organizing Committee ad describing the disparity of care available to Vice President Dick Cheney and members of Congress and the rest of us ( www.cheneycare.org).

Her story is a reminder of the serious shortcomings of any proposals that reinforce the existing insurance-based system.

Insurance companies' first commitment is to guaranteeing a high rate of return to their shareholders, not making sure that you get the care you need.

To insurers, health care is a commodity, like lumber or pork bellies. They make money by increasing the number of people, who they can get to pay premiums while containing their costs by restricting what they pay out in claims, or what they call "medical loss ratio," a sure sign that's not their priority. And their ever-rising charges force many to stare at financial ruin or self-ration care they need, as Karen could probably attest.

Rewarding those same insurers with millions of more customers will not change their behavior. It merely entrenches a dysfunctional system and distorts the role of government, which should be to protect people, not act as an insurance agent..

"Visiting my brother living in Toronto," Hlynsky writes, "I saw how universal health care relieves people from daily worries. His friends and acquaintances are living very creative fulfilling lives without concern for health care. They are teachers, artists, therapists who work as an expression of their talents and desire to contribute to society. They don't have to take a job simply for the health-care benefits. Our health-care system has ripped the creativity and fulfillment out of our American lives."

What Hlynsky is describing is a genuine sea change, sort of an expanded and improved Medicare for all. It guarantees everyone has good health-care coverage. It provides defined, uniform and comprehensive benefits, including dental, vision and mental-health care.

Perhaps most importantly, it takes decisions about your health out of the hands of insurance companies and provides the health security for people like Hlynsky and the rest of us. Surely that's the real reform all Americans deserve.

© 2008 The Providence Journal Co.