Until she noticed the tiny blood spots on her sheets, Peg Fagan thought the itchy, raised area on her shoulder was a spider bite.
So when her doctor asked during a routine checkup in April whether Fagan had any health concerns, she mentioned the bite. The doctor took a sample to biopsy. A few days later, Fagan got a call saying she had to come in to the office.
"I said, 'No, I don't,' " remembered Fagan, 56, a breast cancer survivor. "If you are going to tell me that I have cancer, just tell me."
Fagan had melanoma, the most serious kind of skin cancer.
The diagnosis was emotionally crushing. But if she had received it a month earlier, before the Independence Blue Cross silver tier Proactive plan she bought through healthcare.gov kicked in, it also would have been financially devastating.
"I don't know what I would have done if I couldn't afford to pay for the operation I had last year," she said. "I would have lost my home."
Now that she finally has health insurance, Fagan, a personal chef and owner of the Flying Avocado Wholefoods catering business in Ottsville, worries that a Supreme Court ruling could take it away.
"It gets me mad," she said. "I'm not a slacker. I'm not sitting at home doing nothing all day. I'm paying my taxes and doing the best that I possibly can, but I can't afford $600 or $700 a month for health insurance."
If the court rules for the plaintiffs in King vs. Burwell, it will narrow who can receive a subsidy to buy insurance through state-run exchanges. The Rand Corp. and the Urban Institute estimate that will mean up to 8 million low- and middle-class people in 34 states - including Pennsylvania and New Jersey - will lose their federal subsidies.
Since the ACA became law five years ago, more than 16.4 million previously uninsured people are now covered, according to the government. But if almost half lose their government subsidy, the marketplace, and the law, will likely collapse.
While the court debates the case, the U.S. Department of Health and Human Services announced last week that new insurance coverage through marketplace plans or Medicaid expansions had reduced uncompensated hospital care costs by an estimated $7.4 billion.
Most of that saving - $5 billion - is from states that expanded Medicaid.
The marketplace open-enrollment period this year is generally closed, but people filing income taxes and paying a fine because they did not have health insurance last year have until April 30 to get covered for the remainder of 2015. For the 2015 tax year, the penalty for being uninsured is $325 per adult or 2 percent of household income, whichever is greater.
The only other way consumers can buy insurance through the marketplace is due to an event such as marriage, having a baby, or losing job-provided coverage.
"I don't know what would keep people from signing up," Fagan said. "It's not worth not being covered and it's not hard to sign up."
Before the ACA, Fagan had been uninsured for five years. Money was tight after she lost her job as a chef. And when preexisting conditions still were a bar to insurance, being a breast cancer survivor put coverage financially out of her reach.
"I was paying out of pocket for everything," said Fagan, who also has other medical issues. "My medications were costing me almost as much as my unemployment was bringing in."
Like an overwhelming majority of consumers (81 percent in Pennsylvania and 83 percent in New Jersey), she qualified for a tax credit subsidy ($400) that reduced her monthly premium to $39 last year and $112 this year.
"It was so inexpensive that I couldn't believe it," she said.
After getting her melanoma diagnosis last year, Fagan saw a dermatologic oncologist and was quickly scheduled for surgery. While in surgery, she went into anaphylactic shock and was intubated, put on a respirator for several hours, and whisked off to surgical intensive care.
"The thing I think about is what would have happened if I didn't have insurance," she said. "This was like $100,000. How could I have ever afforded that?"
With her business growing, Fagan is looking forward to not needing a subsidy. But for now, she needs the help.
"I'm doing the best I can," she said. "I don't understand the mean-spiritedness of the people who resent those of us that need some help."
This article was written in partnership with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.