MONROE CITY, MO. — The closest emergency room is 20 miles east on the highway. That’s why it isn’t unusual for people experiencing heart attacks, blood clots and strokes to show up at Dr. Rodney Yager’s clinic on Main Street in Monroe City.

Yager, who grew up in the area, can handle the fast pace of a small-town clinic. What worries him more is how federal health care policies being shaped in Washington, D.C., could affect his patients.

The most recent proposal by Senate Republicans would cut taxes for the wealthy and leave 22 million more U.S. residents uninsured by 2026, compared to current law.

But voter frustrations with the Affordable Care Act’s rollout in communities like Monroe City helped fuel the elections of candidates who promised to dismantle it.

“Honestly, I can see the Republican side of wanting to make budget cuts and try to eliminate waste," Yager said."But at the same time, they’re hurting a lot of people."

This town of almost 2,500 people sprang up about 130 miles northwest of St. Louis, along the railroad in the 1850s. Monroe City, which is just west of Hannibal, was once a Democratic stronghold in northeast Missouri. In the last decades, voters have shifted to favor conservative Republican candidates and their policies. In the most recent presidential election, Monroe, Marion, and Ralls counties voted for Republican Donald Trump over Hillary Clinton, his Democratic rival, by a 3 to 1 margin.

Nevertheless, Democratic U.S. Sen. Claire McCaskill received a warm welcome at the Monroe City Senior Nutrition Center last week, where she held her eighth of 10 town halls during the Senate’s July 4 recess. Her Republican counterpart, Sen. Roy Blunt, held none, a decision that drew protests in the St. Louis area. Members of Blunt's staff said he met with constituents one-on-one throughout the week.

McCaskill is in a tough spot. Her six-year term will be up at the end of 2018, and she’s running for re-election in an increasingly red state. But in Monroe City, about 60 people listened as she vowed to vote against the latest Republican plan to gut the Affordable Care Act, and reiterated a call for Republican senators to accept amendments proposed by Democrats.

"It's really a big tax break for wealthy folks, paid for by cutting the Medicaid program," McCaskill said. "So I’m hoping it doesn’t pass. And then we can sit down together and try and fix what we have, repair what we have."

It took just three questions before someone asked whether health insurance should be the basis of a health care system at all. Nearly everyone in the room raised their hands when McCaskill asked who would favor extending Medicare coverage to everyone, of any age. The idea of a single-payer system for American health care is a non-starter for conservative lawmakers and think tanks, but has grown in popularity among the general public. A recent Politico poll found that 44 percent of respondents would support a federal health care program for everyone.

“Even though more of you are for ‘Medicare for all,’ I’m worried that we can’t afford it right now," McCaskill told the crowd. "It’s very expensive.”

Like many small towns in the United States, Monroe City’s population is aging. While voters are more likely to cast their ballot for Republican candidates, they are disproportionately affected by cuts in public spending for health care programs.

Durrie Bouscaren | St. Louis Public Radio

About half of the 60 or so residents at Monroe City’s nursing home, for example, are covered by Medicaid — a federal- and state-funded health insurance program for people who are low-income, disabled or elderly. (Medicare, which covers people over 65, does not cover long-term care.)

The residents at the Monroe City Manor get together in the mornings and watch the news — CNN in one room, Fox in another. Some follow the health care debate, but others find it too depressing, said Lacy Seward, the nursing home's social services coordinator.

The Senate’s latest proposal caps Medicaid funding on a per-capita basis, leading to 35 percent less spending over 20 years, the Congressional Budget Office estimated. The changes would be tough to absorb, Seward said. To stay afloat, the facility may be forced to no longer accept Medicaid coverage.

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“It would take down our census, and it would just ultimately be sad for our rural community,” Seward said. “They won’t have a place to go, because the cost would be too high or they can’t afford the nursing home.”

On the south side of town, in a small neighborhood of double-wide trailers and ranch-style homes, 49-year-old Dawn Fortner said she relies on her Medicaid coverage, too.

Fortner lives with a rare autoimmune disorder called myasthenia gravis. She estimates that just one of her prescriptions costs $2,000 a month, but Medicaid covers it.

“In the past, my treatments have been denied, and I’ve had to fight it, and that’s hard,” Fortner said. “It scares me.”

Still, when Republican candidates promised to repeal and replace the Affordable Care Act, Fortner said she felt forced to decide between two bad choices for president and decided not to vote at all.

“I don’t follow politics because it does not seem to benefit the underdog anymore," Fortner said. "People on disability, the elderly, the disabled, our vets, we all are the ones that get cut first."

Today, Fortner is healthy enough to work part time at a call center. She and her wife take care of three miniature horses, which they let neighborhood kids ride for free.

Durrie Bouscaren | St. Louis Public Radio

If faced with cost restrictions, state Medicaid programs could face some tough choices about who they cover, and how. States that expanded the program through the Affordable Care Act, such as Illinois, would be hit by a rapid phase-out of Medicaid eligibility for people who newly gained coverage.

Missouri’s legislature voted repeatedly not to expand Medicaid to low-income workers under the Affordable Care Act. The eligibility limit remains low, particularly for adults without disabilities. That means about 96,000 Missouri residents who fall below the poverty line — earning $20,160 dollars a year for a family of three — could find health insurance unaffordable. They make too much to qualify for Medicaid, but too little to receive subsidies to buy health insurance on the marketplace set up by the Affordable Care Act.

The uninsured rate in Missouri’s rural counties is higher for another reason: a small-business economy. Though the Affordable Care Act requires firms to offer health insurance to full-time employees, businesses that employ fewer than 50 people are exempted from the rule.

Durrie Bouscaren | St. Louis Public Radio

Phillip Potterfield, owner of the Ren Potterfield Trucking company, offers health insurance anyway, but is finding it harder to do. He insures 35 employees with a plan through Blue Cross Blue Shield, but premiums keep going up.

“Before the ACA, ours was taking leaps and bounds. And it got just as bad if not worse after the Affordable Care Act. So we’ve seen no improvement, none,” he said. “It’s atrocious.”

Supporters of the ACA argue that employer-based premiums have risen more slowly than they did before the law was passed. But Potterfield worries that if costs continue to rise he may no longer be able to offer health benefits to his employees.

“But then you can’t find people to work,” he said.

Republican proposals to make health insurance cheaper by stripping out the types of coverage that insurers must include — such as maternity coverage, hospital stays and mental health services — seems promising to him.

Potterfield said he doesn’t know how Congress should fix these issues, but his frustration with the health care system is one of the reasons he voted for Donald Trump.

"Everyone put Trump in to shake things up," Potterfield said. "I want health care, I want a cure for cancer, I want clean air ... but you've got to be able to afford to do it."

Durrie Bouscaren | St. Louis Public Radio

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This post has been corrected to reflect the year that McCaskill's current Senate term ends.