John O'Connor, editorial director, McKnight's Long-Term Care News

The Supreme Court has served up yet another tortured, enigmatic decision. Now comes the fun part: figuring out what they really intended — and what those intentions will likely mean for long-term care operators.

The new conventional wisdom is that Chief Justice John Roberts switched his swing vote, thereby giving the Affordable Care Act a reprieve. Whether he did this to uphold the court’s integrity, to save his powder for other issues or for another purpose is uncertain. Regardless, what’s done is done.

Going forward, it’s evident that two players may control the extent to which Obamacare will be implemented. One is Mitt Romney. The other? The nation’s 50 states.

Romney first: The presumptive GOP presidential candidate has made his intentions clear. If elected in November, overturning the law will be one of his first official acts. No real mystery there.

As for the states, well, things are a bit fuzzy. Essentially, the court ruled that states could not lose all their federal Medicaid support if they did not go along with the new, larger program. But it failed to address what the Plan B options might be.

Already, governors of 15 Republican-leaning states have indicated they may take a pass. My guess is that there are probably more from where that came from. Apparently, these state executives know a bait-and-switch maneuver when they see one. Yes, the federal government has said it will pay the full cost of Medicaid expansion from 2014 to 2017, and then 90% of the costs afterward. While that would presumably leave states picking up a lower percent of all Medicaid costs, the pot could become much larger.

Last time I checked, most states were not looking for ways to take on additional spending obligations. In fact, it’s fairly safe to say that most are looking to do just the opposite these days.

Moreover, it appears that states can begin cutting Medicaid-eligibles from their rolls, beginning in 2014. Does that include long-term care residents? At this point, nobody is saying. But I haven’t heard anyone rule out that option.

So where does all this leave providers? In a familiar place. Once again, operators are trying to figure out how Washington and their own states plan to trim Medicaid payments.

Haven’t we read this book before?