The 2014 budget for Iowa's Department of Human Services is sitting on Republican Governor Terry Branstad's desk right now, awaiting his signature, and buried within the bill is an amendment that would give his pen an extraordinary power: the right to deny Medicaid reimbursements to poor women who've had medically necessary abortions.
By U.S. law, Medicaid covers abortions in cases of rape, incest, and danger to the mother's life. Iowa also uses state dollars to cover cases where the fetus is too deformed to survive. But under this proposed amendment, women will only be covered by Medicaid "upon receipt of approval from the office of the governor ... for each abortion performed under the program." Simply put, when a low-income woman gets an abortion to save her own life, or because she doesn't want to give birth to the child of her rapist (whether he be a stranger or, say, her father), the governor gets to decide—case by case—whether public funds cover that abortion or whether she has to pay for it out of her own pocket (if the clinic declines to swallow the cost).
There's no precedent for this in any other state, according to Elizabeth Nash of the Guttmacher Institute. And, she pointed out, it certainly doesn’t exist for any other medical procedure. “I can’t think of another health care procedure where a governor would say, ‘I need to approve all of the gastric bypasses in my state that are paid for with public dollars,'” she said.
And yet, the unprecedented amendment has received scant attention. So far, local papers like the Des Moines Register have mostly referenced the anti-abortion provision at the bottom of longer stories about the state budget. The only outlet to give it a prominent headline has been the reproductive-justice watchdog site RH Reality Check.
"It is discriminatory against women and it is misogyny," said Jill June, president and CEO of Planned Parenthood of the Heartland, which is headquartered in Des Moines. And, if this measure is successful at limiting abortion access, the larger anti-abortion network is bound to notice it. "You can bet that you’ll see this popping up in other states," June warned.
Iowa is a classically purple state. Its House of Representatives—where the amendment began, and originally required Branstad to rule on a woman's Medicaid eligibility before the abortion took place—is Republican dominated. The Senate, which hammered out a compromise resulting in the current version, is narrowly Democratic (26-24). Obama won the state by six points in 2012. But Branstad, in office since 2011, is solidly anti-abortion—as RH Reality Check notes, he previously appointed a rabidly pro-life Catholic priest to the state health board. That said, he has also stymied his party’s plans to limit funding for abortion. In negotiations over the 2011 budget, Republicans tried to eliminate taxpayer dollars for the procedure except when necessary to save the life of the mother. When Democrats overruled the policy, Republicans filed a petition to Branstad and his Department of Human Services director—who flatly rejected it because denying coverage to rape and incest victims would have violated federal code and put all of Iowa’s Medicaid dollars at risk.
State Democrats are convinced their Republican colleagues pushed this particular measure not just to clamp down on abortion, but also to punish Branstad for being too soft on reproductive rights. “This is really an attempt by Iowa Republicans in the House to put him on the spot,” said state Senator Joe Bolkcom, a Democrat who was involved in the negotiations on this part of the budget. (Republican lawmakers did not return multiple requests for comment on this story.) This year, “this Republican caucus came into this session very unhappy with the governor,” Bolkcom said.
Iowa Democrats maintain that they won this round—strange as the law is, they say it won’t affect women. “The governor is not approving any abortions,” emphasized state Senator Lisa Heddens. “Do I like the precedent it set up? I do not,” she said, but added that it seems likely the Iowa Medicaid Enterprise will continue to approve Medicaid payouts to clinics and hospitals using the same procedures as before, and will just have to find a way to loop the governor in. (IME director Jennifer Vermeer, a governor appointee, did not return multiple phone calls.)
“The patient won’t notice it—it’ll all be on the back end,” Bolkcom said, adding, “My sense is that all these abortions are going to get paid for.
But women’s groups aren’t so sure. Nash worried the measure could precipitate a “chilling effect” among women who are afraid they’ll get stuck with giant bills if Medicaid doesn’t come through. The average cost of a first-trimester abortion was $470 in 2009, but later procedures or ones involving complications—like many abortions performed to save a mother's life—can run much more. June said she fears smaller abortion providers in the state will refuse care to poor women if they have reason to doubt they will get paid.
“I think there already is an impact,” June said. “These decisions won’t be regulated by the laws and requirements of the Medicaid program. They’ll be determined by the decision of the governor. He may be stating that, well, he’ll just follow those rules and laws. But what about the next guy?"
The compromise over abortion snuck through at the end of what the Des Moines Register called a "productive legislative session," which reached compromises on education and property tax reform, among other issues, and managed to pass Obamacare's Medicaid expansion. Democrats may not have wanted to risk tarnishing a session that scored the headline "Both sides come away winners." "This is one of the things that just sort of appeared in finished form," said Jason Noble, who covers politics for the Register: It was decided swiftly by a legislative conference committee, before there was time for public debate, and the lack of prolonged wrassling suggests a level of mutual satisfaction with the compromise.
But June thinks Democrats could have fought harder. "There is no doubt that more could have been done to derail this unprecedented transfer of authority into the hands of the Governor," she said in an email. "In the heat and haste of the moment ... some lawmakers held the misguided assumption that there would be no practical affect."
The Iowa amendment is the latest chapter in the long, fraught battle over public funding for abortions. In 1976, just years after Roe v. Wade made abortion legal, Republican U.S. Representative Henry Hyde introduced a measure that banned the use of federal money to pay for it. After years of revision, today’s version of the Hyde Amendment mandates that Medicaid pay for abortions in cases of rape, incest, and life endangerment—no less, no more. Like a few other states, Iowa goes slightly above Hyde by allowing some state dollars to go towards abortions of pregnancies with fatal impairments. According to the Guttmacher Institute, 32 states limit Medicaid funding of abortion to what Hyde requires—or, like Iowa, just above—while 17 states provide significantly more. (And then there's South Dakota, which only provides public dollars in abortions performed to save a woman’s life, but somehow has not lost its Medicaid funding for violating the Hyde Amendment).
That doesn’t mean all the abortions detailed under Hyde get covered. Planned Parenthood of the Heartland representatives say their clinics routinely perform procedures for victims of rape and incest, but they stopped seeking Medicaid reimbursement in the late 1990s because their efforts never bore fruit. Some of this can be attributed to the gross underreporting of rape, but June remembers “instances in years past when we had to find statements by a prosecuting attorney” to prove a rape and “we really had documentation, and still the claim gets denied.” Planned Parenthood handles the funding gap by asking donors to defray at least some of women’s costs. The only abortion provider in Iowa that gets reimbursed, as far as June has heard, is the University of Iowa Hospitals and Clinics, which handles virtually all complicated abortions involving fetal abnormality or risk to the mother. In fiscal year 2012, state and federal money covered 22 abortions in Iowa: fifteen for "severe fetal anomalies," five for life of the mother, and only two for rape.
Governor Branstad's office has yet to announce how it will administer the new policy. A spokesman said they are still reviewing the legislation and declined to comment further. Branstad still has the option to veto, but that would surely send his party into conniptions. If he doesn’t, the law takes effect July 1.
The upshot of the Hyde Amendment, and of bills like Iowa’s, is that the poorest women lose their rights first. A study published in the journal Women's Health Issues in May found that the majority of women who get abortions pay out of pocket despite having either public or private health insurance. Many reported that their insurance wouldn't cover them, while others said they just assumed it wouldn't—part of the "chilling effect" that Nash fears in Iowa. And come July 1, with the flick of Branstad's increasingly powerful pen, the state could become a whole lot colder.
Nora Caplan-Bricker is an editorial assistant at The New Republic. Follow her @ncaplanbricker.