Last time I saw Sara Gagliardi, she was bent double. Sweat poured off her brow. She was in pain. She limped to the back of the health food store where she was working and sat down on a bench.

"I think we should call the ambulance," I said.

"No," she said. "Not that. I can't afford the hospital. This will pass."

Instead she drank some herbal tea and waited. She waited for two years, until the pain got so bad she went to see her sister, who works in a clinic, who referred her to a doctor. "I had a bile duct that was blocked by gallstones," she says. "I needed gall bladder surgery. By then it was a matter of life or death."

Sara was lucky. Because the pain made it impossible to work, she became unemployed and managed to get funding from CMS -- County Medical Services. But she was back at work three weeks after her operation.

That was important, because Sara, who's 33, is helping to raise three nephews in an Otay Mesa household of four adults. She also works seven days a week at three jobs to bring in around $900 a month.

Sara's one of the country's 31 million uninsured who don't qualify for state-funded medicine because she works.

"Medical expenses? We have plenty without my problems. One nephew broke a finger. That cost us $700 to fix. Last night one of them shot the other in the leg with a BB gun. We took him to the ER: $300. I haven't even bothered looking at health insurance for myself. I have these prior health problems. I know it wouldn't be in my budget."

Until two weeks ago, Jim Lammert hadn't been to the doctor in 25 years. Then he caved in to pressure from his kids -- and his heart. "I went, a one-time shot. Doctor said, 'You've got really high blood pressure.' He gave me a prescription, and of course he wanted to do a bunch of tests. He called the hospital, and it was $800 to have all these tests done, and I can't afford that. I can hardly afford the $75 for the visit. So I thanked him very much and told him I appreciated his looking me over and stuff, and I can get the high blood pressure medicine down in Mexico three times cheaper than it costs on this side, and I don't even have to have a prescription."

Jim is 53, blind in one eye, has been a cook for most of his life but currently makes a living running a maintenance and lawn-mowing business in Chula Vista as well as "cleaning out garages and selling the contents at swap meets."

Jim hasn't had health insurance since the last company he worked for changed hands and he was let go. "So the insurance company wrote me a letter saying, 'Do you want to continue getting it?' But it was close to $300 a month -- $292. I can't afford $292 a month. So, I don't get fixed."

Diane Plank refuses a coffee. She doesn't drink the stuff anymore. She's just come through a serious bout of hepatitis, so she's watching her liver. "I don't have a good feeling about doctors," she says. "Bottom line is I think a lot of doctors make us sicker."

Diane is a hairdresser who lives in Point Loma. We're talking in the morning sun at an outside cafe. "I had had a problem with alcohol and drugs, but I haven't had either one in eight years, and I was able to get Blue Shield for my son and me. It cost me around $400 every three months, with a $2000 deductible."

The trouble was the insurance didn't cover a lot. "Like, I went in to get a physical, and that [insurance] covered about a chest x-ray and an EKG. Everything else they did I got billed for. I made payments for years. That's on top of the $200 a month -- cash -- for the prescription I was getting from my psychiatrist for an attention-deficit drug my son and I needed. I thought, 'That's it. I can't afford this. I could take the $400 every three months and go get my own physical with that.' "

So she dropped it -- just before she was felled by hepatitis. "And it was that attention-deficit medication that gave me hepatitis. It interfered with my liver. The doctor said if I'd stayed on it a week longer, I'd have died. I became yellow. My eyes were orange. But I didn't have my insurance. I couldn't stop working. I kept thinking, 'Maybe it'll go away tomorrow.' "

If Diane hadn't had a friend who lent her $3000; if she hadn't been able to qualify, after two weeks' waiting, for MediCal (she finally had to stop working); if her landlady hadn't let her off a month's rent she might not have made it through, received the treatment, and got her job back after two months. "It was scary because I couldn't afford to be sick. I had to take care of the family," she says. "There are a lot of people like me, just hoping nothing happens."

"I was a pariah! After I had breast cancer and moved to California, no insurance company here would touch me," says Bette Wooden, a 72-year-old volunteer who staffs the American Cancer Society phones, offering suggestions to those who fear they may have cancer. "When I had breast cancer, I was living in Maryland, and I had Blue Cross/Blue Shield. I carried that with me and moved out here after I had surgery, thinking I would transfer to California Blue Cross. But I couldn't. They wouldn't even talk to me, because I had had cancer. They said, 'You can get a supplementary policy -- when you reach 65.' And the only reason for that is the government kicks in with Medicare. And I was never so happy in my life to become 65 years old. I chose one of the HMOs. But it's just very frightening. I don't know what I would do if I didn't have my HMO now."

Knowing what to do for a cancer sufferer without insurance is "one of the most difficult parts of my job," says Bette's colleague Lynda Barbour, a regional cancer control manager. "There are so many people without adequate insurance. It can be a devastating thing. I wish I had a solution to it, but there's not a whole lot I can do. I can't get them insurance. And if they've been diagnosed with cancer, they're not in any position to battle bureaucracies."

"I really think access to health care should be part of the Bill of Rights, which it isn't in this country," says Dr. Paul Phillips, director of interventional cardiology at Mercy Hospital. Phillips is just back from a year's sabbatical in Spain, a country that touts a national health care system. "My Spanish colleagues always hear the horror stories about patients in the U.S. who don't get care because of lack of insurance," Phillips says.

But even though average life-expectancy in Spain -- "where everybody smokes and nobody exercises" -- is 76 years versus only 71 years in the U.S., Phillips says he still thinks the U.S. system is best. "[Uninsured people] are not going to get their flu shots," he concedes. "They're not going to get annual rectal examinations. They're not going to get some of the things that we think are good things to have for routine health maintenance. But the first time that they're having a life-threatening medical problem and end up in a medical emergency room, do you think they're going to be turned away? They never get turned away. They just don't get cared for as efficiently as they might if they had a G.P. And believe me, in the vast nationalized systems like Britain, they don't do as good a job as we do."

Jim Lammert doesn't agree. "I think we should have socialized medicine like some of these other countries. I've been paying Social Security for 40-some years, and it's probably not going to be around when the time comes for me to collect it. I'd rather be paying x amount of money on payday for socialized medicine. At least then I'd know I'd have that. Everybody would go to the doctor -- and the dentist -- more often if they didn't have to pay so much. I can't believe that being the country we supposedly are, good old U. S. of A., freedom of speech, blah blah blah, that we haven't done this long ago."

Does he think about his own future medical problems? "I try not to dwell on it. I'm watching my diet, I'm starting to work out a little more than I used to, I'm doing breathing exercises. I buy antibiotics down in Mexico if I start feeling an infection coming on, and hopefully that clears it up. So far I've been real lucky. I think the Guy Upstairs helps me along."