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The Supreme Court's Obamacare decision will determine if this cancer patient gets chemotherapy

Chip Somodevilla/Getty Images

Marilyn Schramm is thinking about moving.

She is a 63-year-old retiree who lives in Texas, and since November 2013 she's purchased health insurance through HealthCare.gov. She has a policy that costs about $800 per month. Schramm, who earns $28,000 from her pension, pays about half the cost, and the federal government covers the rest with a subsidy.

Schramm has colon cancer. Doctors diagnosed it this fall, after she started feeling stomach pains during an RV trip through Tennessee. Doctors there removed the tumor, and she's now in Austin receiving chemotherapy, which should continue through this summer.

Schramm isn't sure if she will still be able to afford her health insurance come June. She's among the 6.4 million Americans receiving subsidized coverage through Healthcare.gov. A pending Supreme Court case, King v. Burwell, argues that these subsidies are illegal — that the White House does not have the legal authority to give people like Schramm financial help.

The Supreme Court will likely issue its decision later this month. And if it goes against Obamacare, the White House doesn't have a backup plan.

"We know of no administrative action that could, and therefore we have no plans that would, undo the massive damage to our health care system that would be caused by an adverse decision," Health and Human Services Secretary Sylvia Matthews Burwell wrote in a February 24 letter to Congress.

House Republicans don't have an exit strategy, either. There are lots of things they could do in the event of a ruling against Obamacare — strike a deal with the Obama administration or pass new legislation that would restore subsidies — but none of them look especially likely.

But Schramm needs a backup plan. Her treatment, her chemotherapy, her life — they all depend on it.

Millions with subsidies at risk

The federal government estimates that as of January, 6.4 million people had used subsidies to purchase health insurance policies through Healthcare.gov.

These are people who earn between 100 and 400 percent of the federal poverty line ($11,770 to $47,080 for an individual; $24,250 to $97,000 for a family of four).

These are the people who would be directly affected by a negative ruling in the Affordable Care Act.

(Anand Katakam/Vox)

This map shows what is arguably a worst-case scenario for Obamacare enrollees, where the states that use Healthcare.gov take absolutely no steps to build state health insurance exchanges. If Congress also does nothing, later this summer, the funding dries up.

The worst-case scenario is probably not the most likely scenario. In the wake of a ruling against the Affordable Care Act, states do have an option to keep the subsidies flowing: namely, build a state-based exchange. And some will probably do exactly that.

There are lots of Republican governors who oppose the Affordable Care Act and are unlikely to take steps to fix the law in the wake of a negative Supreme Court ruling. But there are others who, motivated by politics or policy or something else entirely, might want to keep their residents' policies intact. There are likely governors who wouldn't want someone like Schramm to lose coverage in the middle of chemotherapy treatment.

One good proxy for understanding a state government's openness to expanding an Obamacare program is whether the state has opted into the health law's Medicaid expansion. This map might be the most plausible post-King landscape.

It shows the states that have been open to participating in Obamacare by building an exchange or expanding Medicaid (or having a plan to expand Medicaid) — and the states that have outright refused.

(Anand Katakam/Vox)

There are about 5 million Healthcare.gov enrollees who live in states that have refused to participate in the law's Medicaid expansion or build their own exchange. The vast majority of them get financial help from the government.

If the Supreme Court rules against Obamacare, these people will still pay taxes that help finance the insurance subsidies that people in other states continue to receive. And their tax dollars are already going to pay for Medicaid expansions in other states, even though their own government has decided against participating in that program.

Schramm is one of these people.

"I haven't wrapped my head around it"

Neither Democrats nor Republicans have come up with a plan for what to do if the Supreme Court rules against Obamacare. They're all just hoping for the best. But Schramm doesn't really have the luxury of living without a backup plan. She knows she needs chemotherapy and knows she can't afford it without health insurance coverage.

She can't pay an $800 monthly premium on her $28,000 annual income (mostly from a state pension) if her subsidies disappear. She's thought about dipping into her retirement savings, but hopes to hold on to those for her actual retirement.

"I guess I could do that in the very short term, since I have to finish my chemo treatment," she says.

Her best backup plan right now, she says, is moving to a place with a state-run exchange. She'll live there for the next two years, until she turns 65 and qualifies for Medicare.

Schramm says she hasn't researched yet which states have exchanges and, beyond that, which one she might move to. She's been more focused on her medical issues.

"I haven't wrapped my head around it," she says. "I have so much going on. I've had a colostomy. I'm trying to figure out how to stop the colostomy bag from leaking. I have to wake up every two hours to adjust it. I'm starting to have side effects from chemo. So it's on the list to think about, but not at the top."

But she plans to start looking soon, so that she's ready for whatever ruling the Supreme Court makes in June.

"Right now I'm renting a furnished apartment near where I get chemo," she says. "I have the apartment through July, so maybe it would be a perfect time to move, if that's around when the decision comes out."

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