TOCCOA, Ga. — Open Arms Clinic, a free clinic serving low-income residents in this North Georgia town, has doubled its patient load since enhanced Affordable Care Act subsidies expired late last year. Executive Director Sherry Beavers expects demand to rise further as people struggle to afford insurance and medical care. The clinic serves people earning less than $20,000 a year. On a recent September evening, a doctor was scheduled to see 17 patients as people arrived for appointments. Open Arms nearly closed late last year, Beavers said, but its growing caseload has kept the clinic busy. It now receives roughly 50 to 60 new patient applications a week, compared with about five a week in 2022. Some patients are arriving after putting off care, Beavers said. The clinic treats chronic conditions such as diabetes and high blood pressure, along with more urgent needs. When people cannot afford routine care, providers say, health problems can worsen and eventually require emergency treatment. The end of the enhanced federal subsidies has also added pressure to hospitals as more patients lack coverage or struggle to pay. Rural hospitals typically have fewer financial resources to absorb unpaid bills, and leaders say the losses can threaten services in communities with few alternatives. At Moultrie’s Colquitt Regional Medical Center, CEO Jim Matney said the number of patients who are self-pay or uninsured has grown since the subsidies ended. The hospital’s bad debt has risen sharply, he said. Vicki Lewis, a hospital CEO, said nearly $2 million in services went unpaid at her hospital last year. “That’s not sustainable,” she said. Georgia has lost 18 hospitals in rural areas since 2013, according to the Georgia Hospital Association. Hospital leaders warn that nearby facilities may not be able to take on all the patients displaced if another rural hospital closes. Atlanta-area hospitals are also reporting more uncompensated care, though they have more capacity than many rural providers. Insurance costs are adding to the strain. Marketplace premiums are projected to rise by about 20% in 2027, according to estimates cited by state officials. Advocates say that rising premiums could push more people to drop coverage or delay treatment. Federal funding could offer some help: Georgia is slated to receive $219 million over five years through the Rural Health Transformation Program. Hospital leaders say the money may support improvements, but it does not resolve the immediate challenges of unpaid care, staffing and the long-term financial stability of rural facilities. Open Arms is relying on donations and volunteer support to meet the growing need. Beavers said the clinic is concentrating on keeping its doors open and caring for the patients who come through them.