Part 1 of an occasional series on how people are being affected by the expiration of Affordable Care Act subsidies.
EDWARDS, Miss. — Every now and then a freight train rumbles through, creaking and groaning on the rusted tracks that run along the edge of the largely deserted downtown. On some days, that train is just about the only thing moving.
Grandma’s Ice Cream Shoppe, an ice cream parlor owned by a retired preacher and his wife, gets only one or two customers per day. There is a small barber shop, and the empty ruins of a former thrift store. The sugary, smoky red meat at Lee’s Heavenly Barbecue and the fried shrimp and catfish at the M & L Fish Hut draw some folks. But the ellipticals and treadmills are silent, as usual, at the 4-year-old Kut-N-Fit Wellness Club on Vicksburg Street.
Derrick Clark, 51, has lived in Edwards his whole life.
Clark has always struggled with his weight and he readily describes himself as obese. About two decades ago, he was diagnosed with Type 2 diabetes.
“My grandmother, my uncle, my dad are all diabetics, and I’ve had some relatives that have gotten some of their limbs cut off because of their diabetes,” Clark said. “When it’s a hereditary disease that runs in the family, it’s kind of hard.”
Last year, Clark was reelected as the at-large member of the Edwards Board of Aldermen. But the part-time job only pays about $500 a month. His family owns a small sports bar in town, but it’s only open for a few hours a day and doesn’t generate much additional income.
He has no health insurance.
As is the case with many chronic diseases, the worst consequences of diabetes — such as blindness and amputations — can be prevented with routine care. Clark and many other diabetes patients in Mississippi were getting that care over the past few years through subsidized Affordable Care Act insurance plans.
But Congress allowed the so-called enhanced subsidies to expire at the end of last year. Now the number of diabetic Mississippians without insurance, and thus regular care, is once again on the rise: According to state data, enrollment in ACA plans has fallen by nearly two-thirds in just eight months. The medical and financial consequences could be dire — for individual patients like Clark and for the state.
Mississippi maladies
Designed as a temporary pandemic-era measure, the enhanced subsidies were made available by the American Rescue Plan Act in 2021 and later extended through the end of 2025 by the Inflation Reduction Act.
In 49 states (all but New Mexico), the number of people enrolled in ACA plans, also known as Obamacare, has declined since the subsidies expired and coverage became more expensive. Nationwide, participation has declined this year by nearly 3 million people, to about 19.2 million from 21.8 million in 2025, according to the Trump administration. The 2025 figure was the highest ever recorded, after six years of steady increases.
But few if any states are feeling the absence of the subsidies as acutely as Mississippi.
By many measures, Mississippi is the poorest state, with more than 14% of its families living below the federal poverty line. Its traditional Medicaid program has strict income limits, and excludes nearly all non-disabled adults, including Clark. And it is among the 10 states that have not expanded Medicaid to single adults and higher-income parents under the Affordable Care Act.
Mississippi is also one of the unhealthiest states. The federal Centers for Disease Control and Prevention has identified a “diabetes belt,” where people are most likely to have the chronic disease. It includes 644 counties across 15 states, primarily in the South; Mississippi is the only state where every county made the list.
In addition to its high diabetes rate, Mississippi has the nation’s second-highest heart disease mortality rate, and it is one of only two states, along with West Virginia, with an obesity rate above 40%.
Black people make up more than 36% of Mississippi’s population — the highest percentage of any state — and Black Americans are more likely than other racial groups to have chronic diseases, including diabetes. That’s largely because Black people are more likely to live in poverty, to have trouble accessing healthcare, and to be exposed to pollution and chronic stress.
When the subsidies significantly lowered the cost of Obamacare coverage — making it free or nearly free for some people with low incomes — Mississippi state health officials made a concerted effort to get residents to enroll. Dr. Daniel Edney, Mississippi’s state health officer, said the state launched a public information campaign to encourage people to sign up at their local health departments.
It worked. The number of Mississippians enrolled in Obamacare plans more than tripled, from fewer than 99,000 people in 2020, the year before the subsidies went into effect, to more than 338,000 at the end of 2025, according to state data.
“Our uninsured rate went down significantly, and I’m convinced it’s one of the reasons why our overall population health scoring has improved,” Edney said in an interview in his office in downtown Jackson.
In its 2025 public health report card, the Mississippi State Department of Health reported lower rates of opioid-related deaths, HIV, syphilis, congenital syphilis, teen births and accidental deaths. Health officials acknowledged that the state had made less progress on chronic conditions such as hypertension and obesity, but also noted that it went from dead last in overall national health rankings three years ago to 48th last year.
But when the subsidies expired at the end of last year, Mississippi’s Obamacare enrollment numbers plunged: Roughly 134,000 residents were still enrolled as of Aug. 21, about 40% of last year’s total. And the state projects that the number will fall to around 127,000 next year.
Many of the Mississippians who dropped their coverage have diabetes or other chronic conditions. Without insurance, they are likely to put off routine care, Edney said.
“What’s gonna happen to them? Probably present to the emergency room, eventually showing up once their vision is blurry, or they start having chest pain, or they have a sore on their foot that won’t heal,” he said. “At that point, you’re scrambling to get them placed into care.”
The Obamacare subsidies made a huge difference for Clark, who is unmarried and does not have any children. With coverage, his insulin and medications to control his blood pressure and blood sugar cost him about $15 per month, he said. But he could no longer afford his insurance plan when the subsidies expired and his premiums went up by “hundreds of dollars.”
Without insurance, he says his medications now cost him about $200 per month — and that’s with discounts he gets from medical clinics. Sometimes, he said, family members give him insulin they don’t plan to use.
At some point, he said, he might have to choose between paying for medications and paying his other bills.
“I still have utilities and water and gas and food and still have to buy my medicine monthly out of pocket,” Clark said. “I’m just praying for a better day and trying to lose some weight so I can try to get my diabetes in control.”
Opening a gym
Like Clark, 49-year-old hair stylist and salon owner Angie Myles-Griffin grew up in Edwards, and she never really wanted to leave. But the limitations of living in a small town hit home after she gave birth to her third child and she set out to lose some of the weight she had gained: She had to drive more than an hour round trip to Jackson to find a gym and a grocery store selling healthy food.
Frustrated by the back and forth, Myles-Griffin decided to do something about it: She became a certified personal trainer and opened her own gym in Edwards, the Kut-N-Fit Wellness Club, right down the street from Lee’s Heavenly Barbecue.
“I became very passionate about health and just fitness overall,” Myles-Griffin said. “So I wanted to bring that back to my community, so people wouldn’t have that excuse of having to drive.”
Myles-Griffin said that in 2024 she partnered with the University of Mississippi Medical Center in Jackson to lead a yearlong diabetes prevention program for 20 Edwards-area women. Myles-Griffin gave participants fitness and nutrition coaching at her new gym and even brought in dieticians to show them how to prepare healthy meals. A dozen people stuck with it.
But since the medical center concluded its sponsorship, most of Myles-Griffin’s clients have melted away. Even though Kut-N-Fit is conveniently located, she said most Edwards residents just don’t have the “mindset” to work out regularly. And Edwards residents still have to drive about a half hour to get to a grocery store with a wide selection of healthy offerings, she said.
Unfortunately, a lack of transportation is one of the many challenges that Edwards residents face.
“If you don’t have transportation, you can’t get to a job, and if you can’t get to a job, there’s no income,” Myles-Griffin said. “And so when there’s nothing going on, it’s like a lack of motivation.”
Poverty, a lack of exercise, obesity, diets high in sugar, unhealthy fats and processed ingredients — that confluence of factors exists in many Mississippi communities. It’s a recipe for diabetes, and it’s costing Mississippi billions of dollars.
Diagnosed cases of diabetes cost the state an estimated $5.1 billion annually — $3.4 billion from direct medical expenses and another $1.7 billion from lost productivity in 2022, according to the American Diabetes Association.
And when diabetics don’t get regular care, because they don’t have insurance or don’t have easy access to a doctor, the most extreme — and expensive — health outcomes become more likely. Mississippi’s lower extremity amputation rate is about twice the national rate, according to the American Heart Association.
Irena McClain, the executive director of the nonprofit Diabetes Foundation of Mississippi, said that since the subsidies expired, her organization has been receiving more calls from people asking for help. Without insurance, medical care for diabetes can cost people upward of $1,000 per month, according to a 2022 study.
“I had someone call me up last week, whose doctor wants her on an insulin pump to control her Type 1 diabetes, and she doesn’t have any insurance. She can’t get a pump unless someone donates a pump to us,” McClain said. “And there’s certainly a lot of people who need help much more than the amount that these charities have to give. I don’t know what’s going to happen.”
In Jackson, McClain said, charities, free clinics and community health centers are struggling to provide care to all the diabetes patients who have lost their Obamacare coverage.
Mississippi hospitals also are feeling the pinch, according to Richard Roberson, president and CEO of the Mississippi Hospital Association. In 2023, the most recent year for which numbers are available, Mississippi hospitals provided more than $600 million in “uncompensated care,” or care for which they received no payment from either the patient or an insurer.
“That trajectory of costs combined with the trajectory of uninsureds is just going to really exacerbate the challenges for hospitals,” Roberson said. He added that changes to hospital funding included the broad tax and spending law President Donald Trump signed last summer, the One Big Beautiful Bill Act, will increase the financial strain.
“We’re just going to start seeing that decrease in revenue, increase in cost, and at some point on the axis, they’re going to cross, and it’s going to be bad,” he said.
No help coming
Meanwhile, the cost of Obamacare coverage keeps going up. Next year, the median proposed premium increase is expected to be close to 15%, the second consecutive year of a double-digit premium hike.
In addition to the expiration of the federal subsidies, prices have increased because of other factors, including labor shortages and the rising cost of prescription drugs, driven in part by the growing demand for GLP-1 drugs such as Ozempic and Wegovy.
At least 10 states are using their own money to help people buy Obamacare health plans, partially replacing the expired subsidies. But Mississippi isn’t one of them.
“It’s not that there’s a big money room in the basement where we can go get the money that we’re keeping from everyone,” Mississippi Republican state Rep. Lee Yancey, who serves on the House’s public health and human services committee, told Stateline. “It’s just there’s a limited amount, and there’s only so much you can do.”
Yancey expressed sympathy for Mississippians who can’t afford Obamacare plans without the subsidies. However, he added, he doesn’t believe that “just because a problem exists the government is the one that has to fix it.”
Without the Obamacare plan he used to have, Clark said he has little choice but to drive to Jackson every month to get discounted medications at the Jackson-Hinds Comprehensive Health Center.
“Sometimes you got to do what you got to do, and with this high price of gas and food … it’s just rough,” Clark said as he stood outside the clinic.
“If you go in there, you see it’s not about a race thing,” he said. “It’s just poor people — the working poor.”
Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.
This story is part of “Uninsured in America,” a project led by Public Health Watch, a nonprofit newsroom based in Texas. The project focuses on life in America’s health-coverage gaps and the impact of potential Medicaid cuts and other changes.
