In the 19 states that have not expanded Medicaid under the Affordable Care Act, doctors, public health officials and community leaders are struggling to get care to patients who need addiction treatment, the Los Angeles Times reports.

Many poor patients in these states are on waiting lists for recovery programs, or cannot obtain medicine to treat their addiction because they can’t afford it, health officials say.

In states that expanded their Medicaid programs through the Affordable Care Act, poor adults have access to health insurance and a way to pay for addiction treatment, the article notes. The 19 states that have rejected federal aid to expand Medicaid eligibility have effectively made coverage available only to poor children, seniors and pregnant women. All of those states have Republican governors or legislatures.

“The best way to get treatment if you’re addicted to drugs in Missouri is to get pregnant,” said Dr. Joe Parks, director of the state’s Medicaid program, which has not been expanded. The state is trying to find money for addiction recovery programs from other federal grants and state tax revenues. Those funds are limited. State officials say waiting lists for many addiction programs remain long.

“Not expanding Medicaid has been a tragedy,” said Mark Stringer, the state’s mental health director.

Nebraska has also rejected expanding Medicaid. At First Step Recovery addiction clinic in Lincoln, Nebraska, many uninsured patients drop out and relapse because they cannot afford treatment, according to Jared Ray, the clinic’s substance abuse director. A year of treatment, including medications, medical appointments and drug counseling, can cost as much as $10,000, even with discounts offered to uninsured patients. Ray said, “It’s damn near impossible for many people to get the services they need.”

If Nebraska expanded Medicaid eligibility under the Affordable Care Act, many of these patients would be eligible for coverage.