Probably no state in the union than Idaho has been more officially aligned against the Affordable Care Act. Now it is going to have to decide what it will do about its terms.

The court challenge, turned aside (in general) by the U.S. Supreme Court on Thursday, likely means the law’s provisions mostly will stand. The one major unpopular part of the law, the insurance mandate, will be defended to the death by the insurance lobby. And most of the the other pieces, such as such as the ban on pre-existing condition denials, payments in the donut hole and extensions of parental policies to twenty-something children, among others, separately will be be politically hard to reverse.

Thursday’s decision, widely unexpected (the online inTrade site ran at 73% predicting a mandate overturn minutes before the decision was announced), is a real head-snapper in Idaho, where officials like Governor C.L. “Butch” Otter, the congressional delegation and legislative leaders have routinely described it and the whole law as unconstitutional. Otter’s official website even has a whole page with numerous links headlined “Fighting Obamacare,” wherein labeled “unconstitutional.” (Will that be edited?) Idaho is in a category distinct from many other states, including Washington and Oregon, where officials have moved to establish health insurance exchanges and take other actions.

Idaho may even lead its pack. In 2010 the Idaho Legislature was first in the nation to vote for a lawsuit to overturn the Affordable Care Act. Soon after, legislators gave serious consideration to what amounted to nullification (Idaho was among about a dozen states where that idea was pursued seriously) – an effort blocked by a narrow vote of a Senate committee (one of whose opposition Republicans, John McGee, won’t be back). Legislators held off partly on the theory that the law would be thrown out by the Supreme Court. In April 2010 Otter issued an executive order which, his news release said, “directs State agencies not to establish new programs, promulgate rules or accept federal funding to implement Obamacare. It also bars State agencies from assisting federal agencies in implementing the law.”

And now?

Get ready for battle. The two top state Senate Republican leaders, President pro tem Brent Hill and Majority Leader Bart Davis, were among the critics of the nullification legislation; don’t be surprised if both are challenged. Nullification legislation will be back, whoever is in the White House next January.

While the Supreme Court said that states can opt out of the law’s Medicaid expansion without costing them all Medicaid payments, it still allowed substantial penalty in new funds. Will the Idaho Legislature write it off?

There is an aspect to the law Otter did support (in a different fashion) putting in place: The exchange of private health insurance plans. That was derailed by the legislature; now, budget committee Co-Chair Dean Cameron said after the decision, “Unfortunately, if (Republicans) do not win the presidential election or are able to take over Congress – both the House and Senate – it leaves Idaho completely behind the eight-ball.”
One of the biggest questions remaining: Will the 19 percent of Idahoans, about 294,000 of the state’s citizens, along with the many hundreds of thousands of others left behind in the health care system America has had, be forgotten in the battle over ideology?