That amounts to around $1 billion a year, 40 percent of the state's entire annual budget. One way to pay for it? Cut public school funding by 85 percent. Given their hatred for public education, maybe that approach would suit Idaho's elected Republicans just fine.
Saying he opposes "the overreaching nature of the PPACA and its infringements on Idahoans and the authority of the States under the Tenth Amendment of the United States Constitution," the governor stated in his order that "no executive branch department, agency, institution or employee of the state shall establish or amend any program or promulgate any rule to implement any provisions of the PPACA" without his consent. The Tenth Amendment is a favorite of right-wingers eager to nullify federal initiatives and take back the state sovereignty they believe has been dwindling ever since the presidency of...uh...Abraham Lincoln.
Medicaid is essentially a voluntary program. States don't have to participate. But if they don't they lose out on the federal money that makes the program possible. As the Idaho attorney general wrote in an opinion requested by a state legislator in February:
…Idaho's refusal to comply with the expanded provisions within the PPACA could potentially result in Idaho exiting the program and losing the existent federal matching funds. This could create a situation where individuals presently covered would no longer be covered, yet still require medical treatment, which likely would be required to be provided for and paid for through some non-federal means.
The Legislature went ahead with its own proposal to refuse implementation of PPACA, but Otter vetoed it at the same time as he issued his executive order. His reasoning for doing so was that the wording of the proposed law might block Idaho from coming up with its own health insurance exchange and allow the feds to do it by default.
It's hard to see how Idaho's refusal can withstand a legal challenge based on the supremacy clause, under which the federal Constitution and statutes supersede any they conflict with at the state level. But the governor's stance makes a fine platform from which to regale his fans on the radical right who increasing dominate Idaho's Republican Party.