Spending that money "would have left me nothing at home," said Walker, who pays for doctor visits and medications out of his paycheck and hopes no one in the family falls seriously ill.

An estimated 43 million Americans, members of a working class left vulnerable by skyrocketing health care, share Walker's plight.

"He's in a tragic middle ground people find themselves in," Gov. Mark Sanford said this week after hearing Walker's story. "It's not an infrequent story."

In response, Sanford plans to back a pair of proposals he says could make health coverage more affordable to more people.

One of these plans would help small businesses pool their resources to buy health insurance. Another would lead to pared-down health insurance policies.

The attention to the issue is welcomed by small-business interests, though neither idea has left these groups confident about their potential to ease the health insurance burden.

Sanford also plans to back a set of recommendations from a state Department of Insurance committee that has been studying the issue for the past year. The Health Insurance Policy Advisory Committee is expected to report its findings to the General Assembly in January.

This is hardly a South Carolina problem alone. Rising health care costs and insurance affordability have become huge issues nationwide.

Premiums for health insurance rose 13.9 percent this year, according to the Kaiser Family Foundation. It was the third-straight year of double-digit increases and the highest increase since 1990. The figure was nearly seven times the rate of inflation.

Insurance is becoming a big topic in labor disputes across the country, such as in Southern California, where 70,000 grocery store workers have been on strike for weeks over plans to cut their health benefits.

As costs rise, more people are finding themselves without coverage. Between 2001 and 2002, the rate of uninsured South Carolinians grew from 12.2 percent to 12.4 percent, according to the U.S. Census Bureau. That's lower than the rate nationwide, 15.2 percent, but some advocates for the poor say the South Carolina figures are conservative.

Many of the uninsured are employed, and they often work at small businesses, which have struggled more than others to afford the rising cost of premiums.

This is particularly true in South Carolina. Only 31.9 percent of the state's businesses with fewer than 50 workers provided insurance in 2001, according to Kaiser. That's a third lower than the national average.

"We're a relatively poor state," said Frank Knapp, the president of the S.C. Small Business Cham-ber of Commerce. He said many employers may offer health insurance plans but that the low wages prevailing in the state mean their workers might not be able to afford the coverage.

The poor health of the state's residents also could be driving up the cost of coverage and forcing small businesses out of the market, said Todd Stephenson, owner of Employer Benefit Strategies, a benefits broker in Summerville.

In a recent ranking of states' health status by the UnitedHealth Foundation, South Carolina was listed 48th.

Another factor driving premiums higher: insurers that have quit selling coverage to small businesses, weakening competition that would have helped keep rates down.

Small employers in general have more difficulty than larger ones in buying insurance because they have fewer workers and thus less bargaining power.

In a company with only a handful of workers, a couple of sick employees could drive up premiums and force the company to scale back on coverage or stop providing insurance at all.

Health insurance premiums are "a major component in the cost structure of most businesses, and it's in an inflationary spiral," Sanford said. "It's an acute problem."

The legislation that Sanford is promoting would encourage small employers to form purchasing pools to increase their bargaining position. With more employees in the same coverage group, backers say, these plans would be able to better weather occasions when employees undergo expensive medical procedures.

Knapp, however, said such pools are already available in the state and haven't worked. That's because companies with healthier workers are lured out of the pools, leaving those groups with the companies that have the least healthy workers. Their costs increase as a result and, Knapp said, the plan collapses.

"Historically, it hasn't worked," he said. "There's nothing to stop any groups of small businesses to come together and buy health insurance now. The issue is how you get enough small businesses together so it works."

Knapp says the only way such a plan could work would be if the state itself formed the pool from which any small business could buy insurance.

Another idea that Sanford hopes will make a difference would reduce mandates that would allow insurers to provide stripped-down coverage plans at a lower cost.

South Carolina has 27 mandates it places on insurers. These include requiring insurers to pay for a mother's two-day stay in the hospital after her baby is born. Another mandate allows women to see their obstetrician without first getting a referral from a primary-care doctor. Two years ago, the General Assembly established a moratorium on the establishment of additional health coverage mandates. Sanford says that ban should be extended.

A Department of Insurance task force has been studying the mandate issue and is getting ready to come out with a list of recommendations, said Larry Marchant, a member of the task force and the director of the S.C. Managed Care Alliance.

The mandates add to the cost of insurance premiums by requiring more coverage.

"The more you allow a person to purchase, the more utilization will occur, therefore costs will be more," Marchant said.

The level of coverage, he said, should be decided by those who buy the insurance, namely the employer and the employee, rather than be mandated by the government.

"It's a double-edged sword," countered Jim Head, senior vice president of the South Carolina Hospital Association. "It could reduce coverage people already have. On the other hand, some businesses or individuals who don't have any insurance now may find a bare-bones policy that's more affordable, which would be a plus. There's good and bad to it."

Knapp doesn't hold out much hope for this plan, either.

South Carolina already has fewer mandates than many other states, he said, and reducing those requirements probably wouldn't save employers a lot of money on premiums. The most expensive mandates, he said, come from the federal government.

Marchant said some mandates are simply "good public policy" that keep insurers honest.

Sue Berkowitz, the director of the South Carolina Appleseed Legal Justice Center in Columbia, questioned whether people would be interested in buying bare-bone coverage at all.

Marchant agreed.

"People like prescription drug cards," he said. "People like to pay a co-pay when they go see their family doctor."

For the moment, Odell Walker has neither, not for himself nor his family.

So when his two children recently got sick, the cost of taking them to the doctor came out of his own pocket, as did the cost of the prescription drugs they needed afterward. His wife, who is anemic, also needs to see the doctor.

"Money only gets you so far," Walker said. "You got medical bills, dental bills, and you don't expect none of it."

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