For many self-employed individuals in Dallas, Houston and elsewhere in Texas, health insurance is the last thing they can afford. Those who work for themselves often say, "I can't afford to get sick. Period." The term "sick days" isn't even something that crosses their minds, let alone enters their vocabularies.

In more recent years, many of these self-employed or "perma-lancers" or "perma-temps" as they call themselves, work for a growing number of small companies that don't provide work benefits. Perma-lancers have become known as people who work as if they were full-time employees, but don't receive benefits from their employers, like health insurance, paid vacation days, and paid sick days.

Such individuals work for a single employer on a long-term basis and do much the same work as their co-workers who are on the permanent payroll. Employers save on payroll taxes and employee benefits by refusing to switch perma-lancers to employee status. More and more businesses are using perma-lancers as a means of reducing personnel costs, particularly the cost of benefits.

But perma-lancers also offer businesses the flexibility to bring in resources only when they are needed, making this concept a "just-in-time" inventory of human resource talent, a practice that originated in product assembly operations such as Austin's Dell Computer Company. Opponents of this approach argue that it's merely a way for businesses to avoid paying benefits to some employees. Proponents contend that it's a necessary tool in today's globally competitive world. Along with the absence of benefits, perma-lancers are employed at the whim of market fluctuations where it's not usual for an assignment to stop if, for example, the advertising revenue falls off for a quarter.

One of the reasons for so many perma-lancers currently on the market is the recent collapse of the dot-com bubble, when thousands of freelancers poured into the workforce. Many perma-lancers love what they do, but their enthusiasm is dimmed by their concerns over whether they can maintain a full-time career, as well as maintaining their health.

"Every time I get sick, I worry," says one perma-lancer. "I have to take off work, without pay. I have to pay the doctor full price. When getting prescriptions, I ask for generics. I'm careful about crossing streets, because if I get hit by a car, that's five grand."

Many of the 20-something perma-lancers also think twice about risky sports, like water skiing or snow boarding, worried about the expense of even a minor injury, such as a sprained wrist or ankle.

A number of perma-lancers seriously consider buying individual health insurance, but many estimate they could spend up to 50 percent of their post-tax income just on housing and health insurance. With that in mind, many self-employed individuals think it makes more sense to play it safe, save the money and go without health insurance.

But perma-lancing individuals are not the only working-class Americans without health insurance. Unfortunately, there are currently more than 10 million Americans who are solidly middle income but uninsured, with many more individuals working at lower wages with the same problem.

Most of these individuals think that pricing out comprehensive health care insurance isn't even an option, though public opinion polls show that millions of American rank healthcare about third among their greatest concerns, after taxes and national security.

With the upcoming presidential elections, many perma-lancers are probably considering casting their votes based, in large part, on what the presidential candidates have to say about healthcare.