Hundreds of cars are lined up in a high school parking lot in Hickman County, Tennessee. Crystal Tipton is driving one of them, waiting for a box of groceries from a local food pantry, and reaching for a tissue.

“I know you probably need to talk to somebody else, because I’m afraid I’m going to get you sick,” she said, adding that she hopes it’s not the flu.

But if Tipton needs to see a doctor, at least she has insurance coverage — for now. She just received the dreaded letter from BlueCross BlueShield of Tennessee. It told her that her plan on the Affordable Care Act marketplace is going from $50 a month to $350.

Tipton said she can’t come close to affording the increase, but she still needs medications to manage diabetes and an autoimmune disease. Tipton said she had to use the county health department before and expects that’s where she’ll be again. Otherwise, she doesn’t know what else to do.

“I don’t know yet,” Tipton said. “Pray. That’s about all you can do is pray.”

Tipton is one of 4 million Americans projected to lose coverage in the new year. It’s not just because health insurance is getting more expensive — which it is. It’s because generous subsidies implemented in 2021 are expiring.

But the pain isn’t evenly distributed. For Republican-led states that didn’t expand Medicaid under Obamacare, far more people took advantage of the subsidies that are now going away. They were a kind of backdoor to getting people covered. The subsidies “leveled the playing field,” according to Nicole Rapfogel, senior policy analyst with the Center on Budget and Policy Priorities.

“You have someone who has the same income in Tennessee as someone just across the border in Kentucky, North Carolina, Arkansas, Missouri, who — just because they live on the other side of the border and have a very low income — are able to access Medicaid,” she said.

Someone who could qualify for Medicaid in an expansion state has been able to get a plan with no monthly premium.  

The no-cost premiums quietly led to a surge in signups that ballooned more than 200% in Texas, Georgia, and Tennessee. The biggest jump, according to a Sycamore Institute analysis, was among those who would qualify for Medicaid in many states.

“So, these are folks that don’t necessarily have a ton of money, so they’re going to be a lot more price-sensitive,” said Mandy Spears, executive vice president of Sycamore Institute.

Many are expected to just dump their coverage in 2026.

In Tennessee, the uninsured rate is projected to jump by 40%. South Carolina and Mississippi could spike 50% or more, according to the Urban Institute. Unless someone is using their insurance all the time, it may not seem worth it, said health care economist Kara Smith of Belmont University.

“That means people that on the margin [and] are more healthy are going to drop out, leaving that community at a higher per-person cost to provide coverage for them,” Smith said. “So, it’s just kind of a spiral that’s really concerning for us.”    

Smith called it “a double whammy,” because the people left behind will be more expensive to insure.

Those who can’t afford to go without coverage have stories like Kimberly Daft in Old Hickory, Tennessee.

“I am at the doctor so, so much. I just got out of a six-day hospital stay,” she said.

Being able to get insurance through the ACA marketplace allowed Daft to leave corporate America to start her own business selling specialty house plants.

Her subsidy is also going away, making her monthly premiums rise seven-fold. But she sees no option but to pay whatever it costs. Skimping on coverage is the last place she’d cut. So, it’s the rest of her budget that will get a trim.   

“I’m never not going to be a sick person,” Daft said. “I have to have access to good health care to stay alive.”

This story originally appeared on Nashville Public Radio.