Idaho will be the fifth Republican-led state to participate in a key element of President Barack Obama's health care reform law, Gov. C.L. "Butch" Otter announced Tuesday.

Otter, like his GOP counterparts in New Mexico, Nevada, Iowa and Mississippi, isn't a supporter of the health care law, but said he wanted Idaho to exert some influence over the law's effect on state residents.

"This decision does not signal support for the law or how it is being implemented," Otter said in a press release. "However, it does reflect my continued determination for Idaho to be actively engaged in making the best possible choices -- to the degree we are allowed -- in the interest of more accessible and affordable health care for our citizens."

Otter cited the failure of the opposition to the health care reform law as a factor in his decision. "Despite our best efforts, the law remains in place, and almost certainly will for the foreseeable future. There will be a health insurance exchange in Idaho. The only question is who will build it," he said. A working group appointed by Otter recommended the state run its own exchange, he said.

Including Idaho, 18 states and the District of Columbia are now committed to creating health insurance exchanges under Obamacare. The exchanges will be online marketplaces that will serve as gateways for as many as 30 million uninsured people to obtain health coverage and financial assistance starting in 2014.

Gov. Susana Martinez of New Mexico, Gov. Brian Sandoval of Nevada and Gov. Terry Branstad of Iowa are the only Republican state chief executives so far who agreed to go along with Obamacare and run health insurance exchanges in their states. Mike Chaney, Mississippi's Republican insurance commissioner, intends to set up an exchange over the objections of Gov. Phil Bryant (R).

The health care reform law allows federal authorities to run health insurance exchanges in states that don't make their own, but Congress intended states to share oversight. If federally managed exchanges and state regulators aren't in sync, it may make it harder for uninsured people to find coverage and financial assistance. States that don't operate exchanges also give up some of their authority, such as determining what health insurance companies are permitted to sell plans on the exchanges.

Nevertheless, 21 states so far -- nearly all led by Republican governors -- have said they won't run exchanges and will let the federal government do the work in their states, according to the Henry J. Kaiser Family Foundation. Six states plan to manage exchanges in partnership with the federal government.

Tennessee Gov. Bill Haslam (R) rejected a state-run health insurance exchange on Monday. On Tuesday, Utah Gov. Gary Herbert (R) asked Obama to approve his state's existing health insurance exchange despite refusing to consider incorporating it into the rest of Obamacare.

States face a Friday deadline to inform the Obama administration whether they will run the exchanges on their own, leave the task to federal authorities, or partner with the U.S. Department of Health and Human Services. Five remain undecided: Florida, Indiana, Pennsylvania, Utah and Virginia. Of those, Virginia and Indiana already have indicated they won't build state-run exchanges.

In addition, nine Republican governors say they won't expand Medicaid to their poorest residents under Obamacare. The Supreme Court made the Medicaid expansion optional when it upheld the rest of the health care reform law in June.

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  • Kansas

    Federal minimum in Kansas: 26 percent of Federal Poverty Line Unemployed parents in a family of three who earn more than $4,963.40 make too much to receive Medicaid coverage (26 percent of FPL). Employed parents in a family of three who earn more than $6,108.8 make too much to receive Medicaid coverage (32 percent of FPL).

  • Pennsylvania

    Federal minimum in Pennsylvania: 26 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $4,963.40 make too much to receive Medicaid coverage (26 percent of FPL). Employed parents in a family of three who earn over $8,781.40 make too much to receive Medicaid coverage (46 percent of FPL).

  • Virginia

    Federal minimum in Virginia: 23 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $4,772.50 make too much to receive Medicaid coverage (25 percent of FPL). Employed parents in a family of three who earn over $5,917.90 make too much to receive Medicaid coverage (31 percent of FPL).

  • Nevada

    Federal minimum in Nevada: 23 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $4,772.50 make too much to receive Medicaid coverage (25 percent of FPL). Employed parents in a family of three who earn over $16,608.30 make too much to receive Medicaid coverage (87 percent of FPL).

  • Mississippi

    Federal minimum in Mississippi: 24 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $4,581.60 make too much to receive Medicaid coverage (24 percent of FPL). Employed parents in a family of three who earn over $8,399.60 make too much to receive Medicaid coverage (44 percent of FPL).

  • Idaho

    Federal minimum in Idaho: 21 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $4,008.90 make too much to receive Medicaid coverage (21 percent of FPL). Employed parents in a family of three who earn over $7,445.10 make too much to receive Medicaid coverage (39 percent of FPL).

  • Florida

    Federal minimum in Florida: 20 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $3,818 make too much to receive Medicaid coverage (20 percent of FPL). Employed parents in a family of three who earn over $11,072.2 make too much to receive Medicaid coverage (58 percent of FPL).

  • Missouri

    Federal minimum in Missouri: 19 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $3,627.10 make too much to receive Medicaid coverage (19 percent of FPL). Employed parents in a family of three who earn over $6,872.40 make too much to receive Medicaid coverage (36 percent of FPL).

  • Indiana

    Federal minimum in Indiana: 19 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $3,627.10 make too much to receive Medicaid coverage (19 percent of FPL). Employed parents in a family of three who earn over $4,581.60 make too much to receive Medicaid coverage (24 percent of FPL).

  • West Virginia

    Federal minimum in West Virginia: 16 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $3,054.40 make too much to receive Medicaid coverage (16 percent of FPL). Employed parents in a family of three who earn over $6,108.8 make too much to receive Medicaid coverage (32 percent of FPL).

  • Arkansas

    Federal minimum in Arkansas: 13 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $2,481.70 make too much to receive Medicaid coverage (13 percent of FPL). Employed parents in a family of three who earn over $3,245.30 make too much to receive Medicaid coverage (17 percent of FPL).

  • Texas

    Federal minimum in Texas: 12 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $2,290 make too much to receive Medicaid coverage (12 percent of FPL). Employed parents in a family of three who earn over $4963.40 make too much to receive Medicaid coverage (26 percent of FPL).

  • Louisiana

    Federal minimum in Louisiana: 11 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $2,099.0 make too much to receive Medicaid coverage (11 percent of FPL). Employed parents in a family of three who earn over $4,772.50 make too much to receive Medicaid coverage (25 percent of FPL).

  • Alabama

    Federal minimum in Alabama: 11 percent of Federal Poverty Line Unemployed parents in a family of three who earn over $2,099.90 make too much to receive Medicaid coverage (11 percent of FPL). Employed parents in a family of three who earn over $4,581.60 make too much to receive Medicaid coverage (24 percent of FPL).