Idaho leaders were stunned by Thursday's ruling upholding the federal health care reform law, and face big questions on how to respond. State lawmakers this year refused to set up a state insurance exchange under the law, betting instead that courts would overturn it. They turned away $20 million in federal grants for the exchange. Idaho House Minority Leader John Rusche, D-Lewistion, a retired physician and health insurance executive, said the ruling “means we have a lot of work to do.”

State Insurance Director Bill Deal still is studying the decision and weighing how to proceed. In addition to the exchange issue, Idaho officials were taken by surprise that the court said states could opt not to go along with the reform law's Medicaid expansion; it would raise Idaho's Medicaid caseload by as much as 70 percent, largely at federal expense, at least at first. But if Idaho opts out, its citizens still would be subject to the individual mandating, requiring that they buy insurance or pay a penalty.

North Idaho Rep. Vito Barbieri, R-Dalton Gardens, who's been among the Idaho Legislature's most outspoken opponents of the health care reform law, said, "I know if the states do not comply, that they at least can't strip the regular Medicaid help that the federal government is doing. But what does that mean for our constituents, and what is the added burden to the taxpayers in Idaho? How will the law affect their burden?" For now, Idaho doesn't have those answers. You can read my full story here at spokesman.com.