Political theater often bears striking similarities to the staged world of professional wrestling any characters, outlandish claims and over-the-top bickering. And in the weeks following the Supreme Court's ruling to make Medicaid expansion optional, a full-fledged political battle is brewing between states and the federal government.

On its surface, the court decision means states must decide whether to expand their Medicaid programs with 100 percent federal funding in the first years  to virtually all uninsured legal residents with incomes below 133 percent of the poverty level. An estimated 16 million to 20 million people are in this category. However, it is not just a simple matter of will they or won't they in terms of expansion. A host of factors are at play, including state budget concerns, the desires of conservative governors to one-up the Obama administration, and states seeing the potential to push for more flexibility in how they run their programs.

In one corner of this high-stakes battle are a handful of conservative states whose governors have already rejected Medicaid expansion, led by the -Rick and Rick tag-team of Texas and Florida. In Texas alone there are an estimated 1.2 million people eligible for Medicaid if the expansion occurred. And while budget concerns are at play, with Texas facing a $5 billion Medicaid funding gap in its current biennial budget, there is no doubt political ideology is a driving force. Texas Gov. Rick Perry and Florida Gov. Rick Scott are not big fans of the Obama administration, as you may have heard.

In another corner stands a mixture of states whose Republican governors are sensing an opportunity to pursue state-based waivers from the Obama administration to restructure their Medicaid programs. Governors in Virginia, Nebraska, Utah, Tennessee and Wyoming have floated the idea of expanding their programs but only in exchange for unprecedented flexibility including possible block grants. Under this scenario, states would be given one lump sum for Medicaid, without federal requirements on how to spend it. Medicaid advocates worry this would mean more cuts, and the Obama administration has come out against the idea of block grants. Still, expect some states to mount a push for special waivers in return for going along with the expansion.

In yet another corner stands Maine, with outspoken Republican Gov. Paul LePage interpreting the court ruling as he sees fit. Facing an $80 million budget shortfall in the state's Department of Health and Human Services, LePage wants to eliminate Medicaid coverage for 14,500 working parents with incomes from 100 percent to 133 percent of the federal poverty level. Under healthcare reform, LePage's plan requires a special waiver the federal government, but LePage says the Supreme Court ruling means states no longer have to maintain eligiblity levels under previous requirements. Under that school of thought, LePage says there is no need for Maine to seek a waiver. Needless to say, the Obama aministration disagrees. Other states could mount this approach as well, seeking further cuts or pushing as far as they can.

Unlike the world of pro wrestling, there are serious stakes on the line in these scenarios. Healthcare coverage for millions is hanging the balance. So while, in essence, one can say the Supreme Court upheld healthcare reform, it put a cloud of uncertainty over Medicaid.

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