How the divide between pro- and anti-ACA states may impact the US health care system.

Bradford Regional Medical Center and Olean General Hospital sit just 20 miles apart on opposite sides of the Pennsylvania/New York border. They serve a similar patient population in the rural, forested region. They are both owned by the not-for-profit Upper Allegheny Health System.

But there is one striking difference between the two facilities. Olean General is in Democratic-led New York, which chose to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level and has a functioning, state-run health

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insurance exchange that is signing up a significant number of previously uninsured people. Bradford Regional, on the other hand, is in Republican-led Pennsylvania, which has not expanded Medicaid and, because it refused to set up its own exchange, has been served by the troubled federal exchange that has signed up few uninsured people so far.

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Experts say those different healthcare reform choices could make a big financial and patient-care difference for the two hospitals. The same is true for hospitals throughout the country that are in pro-ACA and anti-ACA states. It could lead to a big divide in hospital financial health and healthcare access, producing two different U.S. healthcare systems.

Well-functioning state exchanges such as New York’s, which has enrolled 41,000 people in private plans and 35,000 in Medicaid, are signing up a better mix of healthier and sicker people and larger numbers of new Medicaid beneficiaries, whom hospitals previously served on an uncompensated-care basis. Pennsylvania and 35 other states relying on the federal HealthCare.gov website—which Obama administration officials promise will be working better this week—have seen much smaller numbers of new, privately insured residents. They’ve also seen few new Medicaid enrollees because many have kept their old, restrictive income eligibility criteria, which exclude most childless low-income adults.

Upper Allegheny Health System is not expecting an immediate difference in financial performance between its two hospitals on opposite sides of the state border, said spokesman Dennis McCarthy. But, he said, “it’s the long-range impact that no one has the answers for.”

While hospitals already have negotiated reimbursement rates with insurers for 2014, the experience healthcare providers and insurers have next year will nevertheless set the tone for the 2015 negotiations. “They’re negotiating risk based on the expectation that they’ll have higher volume and fewer uninsured,” said Daniel Steingart, an analyst at Moody’s Investors Service. “If the exchange doesn’t work or too many sick people sign up, insurers will need to raise rates and decrease payments to hospitals.”