Buried in the Supreme Court’s 193-page decision on the health reform law was one big surprise: States can opt out of the law’s sweeping expansion of Medicaid, significantly reducing the number of Americans who gain insurance.

That ruling, experts say, could leave some of the poorest Americans in a “no-man’s land:” Not covered by the federal entitlement program but not eligible for the subsidized health insurance.

“Governors and state legislatures have a fundamental decision to make,” said Sue Sherry, deputy director of Community Catalyst, a Boston-based think tank. “They have to decide whether they’ll provide basic health care to their poorest residents.”

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