Randy Tiffany was working as a carpenter in 2013 when he was diagnosed with throat cancer. Though he was forced to quit his job, his boss kept him on the company's insurance for several months.

In early 2014, Tiffany and his wife obtained a policy through the health insurance marketplace, part of the 2010 Affordable Care Act, also known as Obamacare. It was around that time Tiffany's doctors informed him the cancer had spread to his lungs.

The Valparaiso couple say the only reason they can afford coverage is because the government subsidizes it to the tune of nearly $1,000 a month. But a case that was argued Wednesday in front of the U.S. Supreme Court could change all that.

King v. Burwell, which was brought by conservative lawyers opposed to Obamacare, argues the Affordable Care Act, as written, only allows subsidies in states that set up their own insurance exchanges. Indiana and Illinois, like 32 other states, did not, and instead use ones operated by the federal government. That means the Tiffanys, like millions of other Americans, are at risk of losing the tax credits that allow them to afford coverage.

"He has to keep on taking treatments," Cindy Tiffany said of her husband in a tearful phone interview Wednesday. "He can die. So I hope they don't take this away from us."

The federal government argued Wednesday the law was intended to provide subsidies to all Americans, whether or not they live in states that have their own exchanges. The justices' decision is expected in June.

"I think they'll uphold the subsidy provision, but if they strike it down, about 200,000 people in Indiana will lose their insurance," said David Orentlicher, a professor of law and co-director of the William S. and Christine S. Hall Center for Law and Health at Indiana University.

"The reason they will lose their insurance is because they will lose about a billion dollars in subsidies."

Roughly 225,000 Hoosiers use an average of $4,110 in tax credits annually to buy coverage through the marketplace, according to a report by the Robert Wood Johnson Foundation and Urban Institute. Of those, the report estimates that 195,000 would become uninsured if the court rules for King.

Indiana was among seven states that filed an amicus brief in favor of the plaintiffs (Illinois joined 22 states and the District of Columbia in filing briefs supporting the federal government).

In the event of a decision for the challengers, states without their own exchanges could establish them  to keep receiving subsidies. A spokeswoman for Gov. Mike Pence, however, said he is opposed to starting a state-based exchange in Indiana. (Illinois Gov. Bruce Rauner has not indicated how his administration would react.)

Many stand to lose insurance

Anthony LoSasso, a professor of health policy and administration at the University of Illinois at Chicago, has studied several states that in the 1990s instituted Obamacare-like regulations, such as not allowing discrimination based on factors like pre-existing conditions, age and sex. He said in many cases their insurance markets broke down, after rates exploded and only the very sick bought coverage.

What makes the Affordable Care Act different, he noted, is that it requires nearly every American to buy insurance and provides tax credits to those who can't afford it. Take either of those provisions away, and it likely won't work.

"If the subsidies go away, you would definitely expect to see people dropping plans, and they will likely be the relatively healthy," LoSasso said.

"For the less healthy and older people, more of them will likely stay with their plans, and you have the makings of an adverse-selection death spiral."

A ruling for the plaintiffs would likely not take away tax credits that have already been spent, as the Obama administration has said it has the authority, under federal tax law, to decide whether to apply the court's decision retroactively.

Either way, such a ruling would have a big impact in Northwest Indiana. An estimated 12,093 people in Lake County and another 3,777 in Porter County bought subsidized insurance on the marketplace through Jan. 16, according to zip-code-level data from the U.S. Department of Health and Human Services. And since enrollment is ongoing, those numbers are likely higher now.

Beth Wrobel, CEO of Valparaiso-based community health center HealthLinc, said her agency serves about 500 patients who get tax credits to purchase coverage through the Affordable Care Act.

"In some cases, this is the first time in these people's lives they have had insurance," Wrobel said.

"Now all of a sudden it's taken away? If they qualify for subsidies, they're not going to be able to pay $500 a month. People who have gotten used to having insurance will become uninsured again."

The Tiffanys don't want to think about the possibility. They currently pay $245 a month for a Blue Cross Blue Shield policy that comes with a $2,300 deductible; after that amount is met, the insurer covers everything at 100 percent: Randy's medications, his doctors' visits, his chemotherapy.

Without the subsidies, the plan would cost about $1,000 more on a monthly basis. And even with Randy, 52, not working and Cindy's part-time salary, the two earn too much to qualify for Medicaid.

"There's no way we can pay $1,200 a month," she said.

"We'd have to make a choice: Are we going to pay the mortgage this month, or are we going to pay for health insurance? That's a not good choice for families to have to make."

"We're putting our lives in (the Supreme Court justices') hands. How would they like it if their family members had cancer, and they had to make that decision?"


Health Reporter

Giles is the health reporter for The Times, covering the business of health care as well as consumer and public health. He previously wrote about health for the Lawrence (Kansas) Journal-World. He is a graduate of Northern Illinois University.