A new study finds that conservative states that rejected Medicaid have hospitals that are feeling financial pain for that decision.

It’s been a year and a half since the Affordable Care Act — also known as “Obamacare” — brought sweeping reforms to the U.S. healthcare system, but the results aren’t all uniformly positive, and can differ greatly depending on which hospital you go to.

In fact, there has been a growing divide nationwide between hospitals that are suddenly making nice profits and those that are desperately turning to public donations to stay open, according to a Reuters report.

As it turns out, some hospitals that are accepting federal money to expand Medicaid are getting paid, allowing patients that were uninsured to get regular care, but in states that didn’t expand Medicaid — most notable, those in conservative areas that opposed Obamacare like Georgia — the Affordable Care Act hasn’t been helping public hospitals at all. So while Obamacare may not be actively preventing access to healthcare in those states, rejecting some of the key aspects of it is indirectly.

The public exchanges the government has established along with 14 other states have allowed previously uninsured people in all parts of the country to start getting health coverage for the first time in a long while, but poor people in many states aren’t seeing any difference.

In fact, nearly four million uninsured Americans with low incomes who live in states that didn’t expand Medicaid would have qualified for coverage had the states not avoid expanding Medicaid, and hospitals in these states often have to rely on bond markets to fund themselves. And they are probably going to feel the financial pain as time goes on, which will limit available health care for people.

The Affordable Care Act has caused the number of Americans with health coverage under Medicaid to increase by 21 percent to 71.1 million, and nonprofit hospitals in states that expanded Medicaid had 13 percent less bad debt on average.

So it appears that ACA appears to be working on a large-scale level. In conservative states that voted against Medicaid, however, not so much.