The health law’s expansion of Medicaid in many states hasn’t benefited nonprofit hospitals in those states as expected, according to a new report by Moody’s Investors Service.

Hospitals in the mostly blue states that expanded Medicaid were largely expected to benefit from fewer unpaid bills and more paying customers, but that hasn’t generally translated into better operating margins or cash flow, Moody’s found.

Performance improved across the board—including in the mostly Republican-led states that opted out of the law’s Medicaid expansion—as the economy gained steam last year and unemployment declined.