From her seat behind the reception desk at Raven Industries, Becky Lyon picks up all the company gossip. The scuttlebutt about next year's health insurance premiums -- which are not due out for several weeks -- has been terrifying.

Twenty percent, she's heard. Twenty-five. Maybe even a 30 percent increase.

"With a 2 percent pay raise, that's a really big hit," said Lyon, a wiry 35-year-old with more debt than her age would suggest. "It really makes me nervous."

After surgery in January to remove a benign lump from her breast, Lyon was deluged with bills for her portion of the cost -- from the surgeon, the anesthesiologist, the hospital -- each more ominous than the last. "You owe this much now," the bold print screamed.

After paying $250 in cash, she put the remaining $750 on her credit card, where the interest keeps piling up. "And," she adds in a tone wavering between irony and fatalism, "my car is dying a slow death."

Raven chief executive Ronald M. Moquist parks his Mercedes in the company garage and has no big hospital debt to pay off, but he, too, is worried, over the rising medical bills his firm pays. The anxiety he and Lyon share is making the cost crunch in health care one of the most potent domestic issues of the election year.

Rising medical bills touch every U.S. family and firm, affecting wages and profits, not to mention health. Since 2000, health insurance premiums have risen 59 percent while pay grew 12.3 percent, according to the nonprofit Kaiser Family Foundation.

In each election season, it is a given that candidates and voters will put health care on the agenda. But not since the recession of 1991 has the subject of cost sparked so much unrest in the electorate.

This year, health care ranks fourth on the list of voter concerns, behind the economy, Iraq and terrorism, according to an analysis of 22 national surveys conducted by Kaiser and the Harvard School of Public Health. "The health care issues of greatest concern are the affordability of health care and health care insurance," the analysis said.

Though President Bush and his Democratic challenger, John F. Kerry, acknowledge the high cost of care, neither has devoted an entire speech or advertisement to the issue, and their platforms offer only minor attempts to deal with it.

To control skyrocketing costs, Bush supports creating an electronic medical record for everyone within a decade to reduce administrative costs and enacting legislation that would limit noneconomic malpractice awards at $250,000. Analysis by the Congressional Budget Office has found the caps would reduce malpractice premiums for physicians but would have a negligible impact on insurance premiums for patients.

Kerry has a proposal to reimburse companies up to 75 percent of the cost over $50,000 for "catastrophic" cases if the employer offers insurance to all workers and implements wellness programs. Because the "reinsurance" plan would reduce the guesswork in risk adjusting, analysts say it could lower all premiums by 10 percent, or about $1,000. Like Bush, Kerry is enthusiastic about modernizing the health care system; he has promised to create electronic medical records by 2008.

For the most part, those proposals have not reached the 800 workers at Raven. They hear a great deal of talk about Iraq and a fair amount of personal mudslinging, but few believe the candidates have focused enough attention on what they see as a threat to their livelihood.

At this vibrant manufacturing company on the Big Sioux River, there is no escaping the cost crisis in U.S. health care. Stress over escalating medical bills permeates conversations from Moquist's corner office to the plant floor.

Nationwide, the proportion of companies offering health insurance fell from 68 percent in 2001 to 63 percent this year, the Kaiser Family Foundation said. That pattern will continue, Moquist predicts. Next year, Raven's share of health insurance premiums is expected to jump from $3 million to $3.6 million. "At that rate of increase, we will see it double in five years and double again in 10," he said. "With those kind of increases, all of us will bail out."

Although the trend in the corporate world is to drop coverage, Raven Industries has moved in the opposite direction, immersing itself in efforts to provide more affordable care. The result has been upheaval and uncertainty.

Some workers, such as Illa Biteler, 65, have put off retirement. She cannot afford health care without Raven's insurance and paycheck. Others, such as Cheryl Scholl, were forced to change doctors when Raven switched plans within the past few years. And when Darnel Cuperus delivers her third child next month, it will not be in the familiar surroundings of Avera McKennen Hospital, said her husband, Don Cuperus. Raven's insurer, Sioux Valley, provides newborn care only at Sioux Valley Hospital.

Yet the disruptions are minor compared with the frustration Don Cuperus feels when the talk turns to cost. Workers here paid a total of $903,000 in premiums over the past year and expect to pay $975,000 next year. "On the one hand, the company says [premiums] only went up 8 percent," said Cuperus, an engineering manager. "Yeah, right, if you don't use it. But then add in the deductible and copayments. It's probably fair to charge people who use it more, but it's definitely misleading."

Like his workers, Moquist is frustrated -- by government, by providers and even employees, who seem to expect stellar care at no cost. He gets irritated when hospitals and physicians claim to be efficient.

"They haven't even scratched the surface," said Moquist, who took over Raven in 2000. "They have no electronic files, no standard protocols, no evidence-based medicine. There are huge costs that can be rung out of providers."

It is ridiculous, he said, that "I know more about the rollover characteristics of a Korean SUV than the outcomes of heart surgery at the local hospital."

But what most infuriates Moquist -- and virtually everyone else here -- are drug prices. Without prompting, employees rail against drug companies that often charge Americans double the Canadian price.

"I'm very mad at the pharmaceutical industry," Moquist said, acknowledging that he is at odds with friends in the Republican Party and the National Association of Manufacturers.

Moquist understands the industry's need to invest in research and development. All he wants is for U.S. consumers to be given the same low prices the drug companies have negotiated with other countries. "Let's not play the fool here," he said.

Del Jerke could not agree more. At age 60, two years after suffering a stroke, Jerke spends about $120 on medications every three months. "All that money for a little aspirin or something? It's outrageous," said Jerke, a large man in shorts and sneakers who delivers parts to several Raven plants in the area. "The drug companies don't need it."

Like many companies, Raven has begun shifting more costs to employees, raising copayments and imposing, for the first time, deductibles of $500 for individual and $1,000 for family coverage. The decision was in part about money -- but also, more significantly, it was aimed at what Moquist describes as a long-term change in employee behavior.

"We want healthy employees because they are productive employees," he said. At the same time, "we need to get employees to take ownership of these issues. When people are in control of their dollars, they spend wisely."

But the concept is not so simple when a nervous parent is dealing with a sick child.

Three months ago, when one of Shane Swedlund's children was hit with a "relentless fever and headache," he recalled, "the doctor had mentioned meningitis, and that was enough to scare me."

When the symptoms continued, the doctor said to take the girl to the emergency room. Although Raven's insurer covered much of the cost, Swedlund saw the bill: $1,200. "That's a big cost that makes premiums go up," he said.

The new focus on behavior has sparked some tensions. Tom Stoebner, a fit 51-year-old who diligently gets his annual physical, becomes irritated when he sees co-workers who smoke, overeat and do not exercise. "Those are the people who drive up the costs," he said.

What the workers at Raven do not know is that Moquist has more changes planned. If the company provided the same coverage next year that it offers now, premiums would have risen 26 percent -- just about what Becky Lyon had heard. Moquist held the premium increase to 8 percent, but drug copays will rise and deductibles will double to $1,000 for a single person and $2,000 per family.

"Not everybody uses the health plan to the same degree, so it doesn't make sense to charge everyone 26 percent more," said Teresa DeBoer, employee benefits manager.

That idea worries Stoebner, who said higher out-of-pocket costs affect recruiting and retention. "I'd like them to consider something between $500 and $1,000," he said.

Flush with cash, Raven will put $250 into every worker's flexible spending account next year in an effort to ease the pinch and take one more step down Moquist's behavior modification path. At the same time, Moquist is leaning on the government and health care providers to do their part, pushing for better data collection, electronic records and regular nurse visits to Raven's plants.

The next step is more dramatic: In 2006, Moquist hopes to switch to health savings accounts, in which workers manage a medical fund with a combination of employer and employee contributions. Employees would also have high-deductible "catastrophic" coverage and could roll over money in the savings account from year to year.

Cognizant of criticism that health savings accounts represent a "sink-or-swim" approach, Moquist intends to combine the accounts with free or discounted checkups, screenings and workplace wellness programs. He sees a bright future in which workers keep one eye on their health and one eye on the wallet.

But at Raven, employees are just finding out about next year. Word of the 2006 plan has not reached Becky Lyon yet.

Ronald M. Moquist heads Raven Industries in Sioux Falls, S.D., which is immersing itself in efforts to provide more affordable care. The result has been upheaval and uncertainty.Receptionist Becky Lyon, who owes money for breast surgery she had in January, worries about how much health insurance premiums will increase next year at Raven Industries.