WASHINGTON – Health insurance is the last thing Linda Inness wants to worry about.

The chemotherapy pills her husband, Gabe, takes for the colon cancer that spread to his liver costs more than $1,000-a-month.

Yet the couple, who reside outside Knoxville, Tennessee, live daily with distress over the real possibility they could lose their subsidized insurance next year and won’t be able to make up the difference.

It is the same anguish millions of other low to middle-income Americans face if President Donald Trump follows through on his threat to not fund $7 billion in subsidies to insurance companies that participate in the national Affordable Care Act.

Humana, the only insurer offering subsidized coverage to Linda and Gabe Inness and 40,000 others in rural Roane County, announced in February it plans to leave the federal insurance marketplace.

Inness said her husband will qualify for Medicare next year, but she doesn’t know how much it will cost to buy supplemental insurance to cover chemotherapy. Or even if she’ll be able to find insurance given her husband’s condition.

“It’s not the turn you expect your life to take,” she lamented.

According to the Kaiser Family Foundation, about a third of the nation’s counties have only one insurer selling subsidized coverage and are at risk of having none if federal payments to insurers end.

Insurers have until June to decide whether to continue offering insurance through the federal marketplace in 2018. Few are expected to do so absent subsidies.

The federal subsidies, which currently benefit seven million people, compensate insurers for offering reduced premiums to individuals who cannot afford to pay full boat. The premiums can range from $7,150 to $2,350 per year, depending on income.

Without the subsidies, insurers will either raise premiums or require individuals to make up the difference from the lost federal payments, said Kristine Grow, spokeswoman for America’s Health Insurance Plans, an industry group.

Larry Levitt, vice president of the Kaiser Family Foundation, predicts many people will drop their insurance policies, creating a national health care crisis for millions of individuals without the financial means to buy private insurance.

“It’s likely we’ll see more insurers leaving,” Levitt said in a call with reporters last week.

Linda Inness, who owns a trucking business with her husband, said she’d have to sell some of the company’s trucks to pay for supplemental insurance if subsidized coverage ends. That, in turn, would cut into the company’s income.

Cynthia Cox, a Kaiser health policy expert, said many individuals don’t have a similar option. She said they simply could not afford non-subsidized insurance premiums.

The fate of subsidized insurance lies with the president and a divided Republican majority in the House. If they can’t agree by April 28 to include subsidy payments in the short-term spending bill to keep the government running through September, the outlook is bleak for sustaining the program.

Democratic leaders insist on including the $7 billion for insurance subsidies in the spending bill. If it isn’t, they are prepared to drag their heels on the legislation and create the prospect of the government shutting down.

“The window is quickly closing” on funding the subsidies,  America’s Health Insurance Plans and the Blue Cross Blue Shield Association wrote to congressional leaders and Trump last week.

Insurers lost money under the Affordable Care Act, largely because not enough healthy people signed up for insurance to offset the expense of covering individuals with pre-existing conditions and essential health benefits such as maternity, mental health and prescription drugs.  

A House Republican plan would have offered insurers some relief by allowing them to cover fewer conditions and benefits, and also charge older people higher premiums. But the legislation died last month when conservatives said it didn’t go far enough and moderate Republicans said it went too far.

Earlier this month, Aetna and Wellmark Blue Cross & Blue Shield announced they will stop selling subsidized insurance in Iowa, citing costs and the uncertainty over national health care. That left Medica Insurance as the only insurer in the marketplace in all but five of the state’s counties, according to the Iowa Insurance Division.

Medica spokesman Greg Bury said Wednesday the company is “exploring our options.” He said a guarantee to continuing cost-sharing federal subisdies “is necessary for insurers to feel confident offering products in the individual market.”

The company is the only provider in Mahaska County, around Oskaloosa, and Wapello County, around Ottumwa.

Blue Cross and Blue Shield of Oklahoma, the only insurer offering the subsidized coverage in that state, declined comment of what it might do if the federal subsidies stop.

That’s a large if given Republican control of Congress and the presidency.

House Republicans in 2014 sued to overturn the subsidies, arguing they were created by the Obama administration without congressional approval. The litigation is still pending.

Trump could effectively end the subsidies by withdrawing the government’s defense of them in the suit and giving weight to his prediction that the Affordable Care Act is unsustainable.

Linda Inness said residents of rural Tennessee would see that as an unfriendly outcome.

“People in Washington live inside a bubble,” she said. “They have no idea how people in the hinterlands feel. Without some future that looks better, people get bitter.”

Contact CNHI Washington reporter Kery Murakami at kmurakami@cnhi.com.