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It's now crunch time for one of the nation's insurance giants, and that could have a big effect on people around Colorado, especially in 14 rural, western counties.

Anthem Blue Cross Blue Shield will decide this June whether to stay in Colorado's individual insurance market, created under the Affordable Care Act. Depending on the decision, 37,240 customers, like 64-year-old retiree Darla Volgamore, could be left in the lurch.

Volgamore got an education about the value of health insurance last year. During that time, her health situation has been a rollercoaster ride — a scary one.

"I was very thankful I was able to get insurance that I could afford," she said of her Anthem plan purchased through Connect for Health Colorado.

Volgamore is diabetic. But thanks to changes brought on by Obamacare she could not be denied health coverage. Her medical history in the last year includes a urinary tract infection that later turned into sepsis, a life-threatening complication. She was hospitalized for a month, and in a coma for 10 days.

"My toes turned black because of the drugs and no oxygen to my feet during that 10-day time in the ICU," Volgamore said. "Ouch! My hospital bill hit a million dollars before I got out of there."

Most of that astronomical bill was covered by her previous insurer, Rocky Mountain Health Plans. She lost four toes on each foot, but she didn't go bankrupt. "I could have lost everything," Volgamore said.

Delta County retiree Darla Volgamore.

courtesy of Darla Volgamore

Her insurer later pulled out of the Western Slope individual market. Now covered by Anthem Blue Cross Blue Shield, Volgamore finds herself experiencing a bit of déjà vu as the carrier weighs pulling out of the state's insurance exchange like Rocky Mountain did.

Anthem declined comment, but Colorado's insurance commissioner, Marguerite Salazar, said she's talked to them "and they're saying that they have not made a decision to leave Colorado."

Should Anthem pull out, 14 Western Slope counties — Archuleta, Delta, Dolores, Gunnison, Hinsdale, Jackson, Lake, Moffat, Montrose, Ouray, Pitkin, Rio Blanco, San Juan and San Miguel — would be left without a carrier.

Marguerite Salazar works in the state's Department of Regulatory Agencies as the insurance commissioner.

John Daley/CPR News

Salazar worries that the uncertainty over ACA repeal efforts in Washington complicates the business decisions for health insurers, like Anthem, which is the third most popular carrier on the state's exchange.

"We're just going to keep our fingers crossed that we're going to have as many carriers as possible stay with us, stay in Colorado," Salazar said.

As Congress looks for ways to reform health care, the fate of $7 billion in subsidies remains in limbo. Initial plans look to cut billions of dollars in funding for what are called cost-sharing reductions. Those subsidies help shrink out-of-pocket costs for millions of low-income people covered by Obamacare.

The situation is so fluid, Salazar said she extended the deadline by a month for carriers to submit their 2018 plans.

"Three plans told me they would get out of the individual market if the cost sharing reductions were taken away," she said. "If the individual mandate was done away with, they said, 'we can't stay in the market, we will get out.'"

If that happened, consumers would need to buy insurance that's both not available on the state's exchange and likely to cost them more. All of this will change things for consumers, and the places they go to for care like hospitals and clinics. Delta County Memorial Hospital CEO Jason Cleckler said Anthem's possible departure gives him heartburn.

"If there's nothing available on the exchange again we're looking at an increase in uncompensated care, uninsured," Cleckler said. "It's pretty concerning."

The Anthem building at 7th and Broadway in Denver, Colo.

John Daley/CPR News

In Delta County, if Anthem pulls out of the exchange, people without insurance will likely go to the emergency room when they get sick. Cleckler says that's less effective care for patients, and more expensive care for hospitals. "I think that it creates barriers to care and we're trying to break down those barriers and we're trying to make it more affordable," he said.

Plans from Anthem Blue Cross Blue Shield are about 21 percent of the nearly 175,000 plans customers bought on the exchange, according to Connect for Health Colorado. Anthem ranks third among insurers selling plans there, behind Cigna and Kaiser Permanente Colorado.

According to published reports, Anthem Blue Cross Blue Shield lost $374 million nationally on individual health plans in 2016. The company expects a "modest profit" in 2017, according to Bloomberg Intelligence. The news outlet also reported that among major U.S. carriers, Anthem has the biggest financial risk involving the Affordable Care Act. Nearly 9 percent of its 2017 revenue comes from the individual market.

Colorado's insurance premiums are expected to go up in 2018. Insurance commissioner Marguerite Salazar thinks they could rise as much as 25 percent.

In the meantime, Delta County resident Darla Volgamore is set to qualify for Medicare when she turns 65. The catch will be the first three months of the year, Volgamore pointed out. "January, February, March, who knows where we're going to be, you know?"

She's hoping Anthem Blue Cross Blue Shield will still be doing business here. It's a scary time for the county of about 30,000 — "I know, I try not to think about it, actually," Volgamore said — but residents won't have to wait too long for an answer. The deadline for insurers to submit their 2018 plans to Colorado is June 19, 2017.

Update: Hickenlooper Considers Hardball Response If Anthem Pulls Out Of Health Exchange