As a physician for over 20 years, including the last 14 as owner of a small rural clinic, I have witnessed our healthcare system change for the better and for the worse depending on the policies our elected officials in Washington, D.C. and Jefferson City decide to pass, repeal or ignore altogether.

When the Affordable Care Act (ACA) passed, many of my patients gained insurance, and gained protection from discrimination by insurance companies. The ACA prevents insurance companies from charging women more than men for the same policy, provides protections for individuals with pre-existing conditions, including the nearly 2.5 million Missourians living with pre-existing conditions, and requires insurers to cover essential services like preventive care, mental health, maternity and hospitalization.

But my patients are still struggling to afford or access the care they need. That’s why Missouri should pass Medicaid expansion. Missouri politicians are leaving behind many low-income families and workers by refusing to expand Medicaid in our state, costing them not only their hard-earned money but their health, and even in some cases their lives.

A new working paper published by the National Bureau of Economic Research compared mortality between the Medicaid expansion states and those that rejected Medicaid expansion under the ACA. The study estimates that between 2008 and 2013, an additional 15,600 people died in the fourteen states who rejected Medicaid expansion, because of the difference in access to care between the Medicaid-expansion states and those, like Missouri, who refused the expansion. Medicaid is also one of the best ways to treat people struggling with opioid dependence, particularly in states like Missouri that already have high levels of opioid overdoses and deaths.

For rural areas like mid-Missouri, Medicaid would help address the dwindling number of doctors and hospitals patients can access. That’s because it’s also far easier for providers like my clinic to work with Medicaid than with commercial insurers. Medicaid has clear, published guidelines for its coverage — which is rarely the case with commercial insurance companies.

A few years ago, I had a patient who had been able to bring her HGA1C (“blood sugars”) down from an alarming range to almost-in-control by using an insulin pump. An insulin pump monitors blood sugar continuously and provides a dose when the patient needs it, and some diabetics have such fragile and fluctuating systems that an insulin pump is the only solution. Her insurance paid for the pump when she had traditional Medicare plus Medicaid. Then she was talked into switching to a private “Managed Medicare” or “Medicare Advantage” plan sold by a commercial insurer. In spite of their glib assurance that her insulin pump supplies would be covered under her new plan, they weren’t. The only suppliers for her insulin pump materials available in Missouri were “out of network” so the insurer would not pay.

My staff spent hours of non-reimbursable time trying unsuccessfully to find a new supplier or negotiate with the insurance company, the pharmacy benefit manager, and the supply company. She had to give up using the pump until she could switch away from that plan, and her health suffered.

Incidents like this, which happen regularly, don’t only put patients’ health at risk, they stress my clinic’s financial well-being and make it increasingly difficult for providers like me to keep the doors open.

It’s why more and more physicians in our area are transitioning to a financial model where the patient pays the doctor directly (and then tries to get reimbursed by insurance), cutting out the doctor's contact to insurers. This also cuts out medical coverage for low-income patients who can't afford to pay the doctor directly. This trend increases the burden on hospitals and clinics like mine that serve everyone regardless of coverage. In fact, the economic difficulties have resulted in hospitals in two neighboring counties almost closing: Callaway County’s hospital has been sold a number of times with reduced services at each sale, and another hospital in Cooper County has been on the verge of closing for the last year. It has had to cut services when it no longer could pay suppliers.

Our Federally Qualified Health Centers (FQHCs) are trying to fill the gap but are also over-burdened and have “productivity” requirements based on numbers, not quality of visits.

Medicaid can help relieve this kind of pressure on centers and private clinics by increasing the number of insured patients, while also providing better care and outcomes for patients. Rural hospitals in states that have expanded Medicaid face fewer challenges to their financial stability, like unrecoverable debt and charity care.

If we had the political will, we could make sure that every man, woman and child in our state and country had access to affordable, high-quality healthcare — and that starts by expanding Medicaid. Elected officials in Jefferson City need to put aside partisanship and expand Medicaid in Missouri now. Their refusal is putting my patients’ health and lives at risk.