Georgia is among 18 states that did not decide to expand Medicaid under the Affordable Care Act. A new study says that decision may have had a cost to communities.

Hospitals, often strapped for cash in rural areas, were substantially less likely to shut down in places where Medicaid had been expanded to cover more of a community’s poor adults, the study found.

In Georgia, at least seven rural hospitals have closed since 2010. They typically cite a range of causes, including an unsustainable number of patients who do not have insurance and can't pay.

The researchers, from the University of Colorado, looked at the period 2008 through 2015. The Affordable Care Act passed in 2010 and led to Medicaid expansions starting in 2014.

Hospitals in rural areas are usually an economic anchor, providing skilled jobs as well as nearby health care.

Georgia GOP leaders have acknowledged that the state is passing up large amounts of federal money by not expanding Medicaid. They note, however, that the state would still have to pay its part and say it can’t afford it.

House Speaker David Ralston, R-Blue Ridge, and a committee led by Lt. Gov. Casey Cagle, R-Gainesville, have both discouraged the notion that the state would make sweeping changes to Medicaid eligibility this year, though they did not rule out next year.

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