The country’s four largest states fall into two camps when it comes to health care reform. California and New York expanded Medicaid eligibility under the Affordable Care Act (ACA) and operate their own health insurance marketplaces. Florida and Texas, on the other hand, opted out of the expansion and use the federal marketplace.

In a new report, Commonwealth Fund researchers show how those choices have led to starkly different experiences for each state. Adults in California and New York are significantly more likely than those in Florida and Texas to be insured, less likely to have problems paying medical bills, and better able to afford the health care they need.

“The striking differences among our biggest states demonstrates how much state health policy decisions affect residents,” said study coauthor Sara Collins, Vice President for Coverage and Access at The Commonwealth Fund.

Read the report here.