Iowa Gov. Terry Branstad announced Friday that he expects to sign the state’s budget into law, including a new rule that will allow him to decide on a case-by-case basis whether Medicaid funds will be used to reimburse for abortion services when pregnancies are the result of rape or incest, when there are fetal abnormalities, or to protect the life of the woman.
The rule will give the anti-choice Republican governor complete control over federal Medicaid funding for the roughly two dozen Medicaid-eligible abortions that are performed in the state each year. It could also make many providers unwilling to offer abortions in cases that should be covered, because they won’t know if Medicaid reimbursement will occur.
As RH Reality Check reported in May, restricting access to safe abortion care for Medicaid patients has been a multi-year debate in the Iowa legislature, with anti-choice legislators repeatedly proposing bills or amendments, and even a direct query to the governor, in an attempt to deny reimbursement for almost all abortions that are eligible for Medicaid funding. This new tactic of allowing the governor to approve each case allegedly came about as a compromise between warring factions anxious to get final budget approval. However, it offers the potential for abortion opponents to get the all-out ban they wanted—Gov. Branstad’s could refuse to allow Medicaid reimbursements, or the lack of clarity regarding what he will and will not approve could make doctors afraid to offer services to begin with.
Branstad appears to have no desire to address that lack of clarity. When asked during an appearance on Iowa Public Television how he would approach the new protocol, he touted his opposition to abortion in all instances, though he admitted he would need to consider whether the funding rules apply. “As I understand it, the decision is not whether there’s an abortion or not, the decision is whether the state is going to approve funding, which is a decision that is made after the fact,” said Branstad, according to the Sioux City Journal. “So I’m not really going to have any say in whether this procedure occurs or not—I would discourage it wherever possible—but then I’ll have to make a decision whether or not it’s appropriate under the circumstances and under the guidelines that we have.”
It remains unclear what those “guidelines” are. Under the federal Hyde Amendment, all abortions performed in cases of rape, incest, or health of the pregnant person should be covered—though how those rules play out in practice leaves much to be desired. Iowa has traditionally also included cases of fetal anomaly, and for this year at least, those have been the majority of the abortions in question. As the Journal reports, there have been nine Medicaid abortion payment requests this year, of which eight were for medical issues with the fetus. Under Iowa’s traditional rules, all such procedures should be reimbursed, and under Hyde only one of them should be. Without specifically saying which “guidelines” he would consider, Branstad leaves most of this fiscal year’s cases in legal limbo.
Even more problematic than those ambiguities, and putting so much power over people’s reproductive decisions into one person’s hands, is the reinforcement of the idea that there are “worthy” and “unworthy” abortions—putting a value judgement on when it is appropriate to allow a person access to have an abortion. If and when Branstad does make his guidelines clear (which he would likely do out of fear that a denial in payment for a sexual assault case could put the state’s full Medicaid funding in jeopardy, not because of concern for reproductive rights), those value statements would get passed on to the public.
“This law seems to harken back to those days [when] outsiders get to determine if a woman’s reason for an abortion fits their prescribed list of ‘good enough’ reasons,” reproductive justice activist Steph Herold told RH Reality Check. Herold, who has focused much of her work recently on helping to reduce stigma surrounding abortion, noted that the governor’s new role isn’t unlike that of the original “hospital approved” abortion panels women often had to endure prior to legal abortion, where the pregnant patient would be required to prove herself worthy of needing the procedure.
“Medicaid should cover abortion. Period,” said Herold. “No one should have to be subject to a politician’s review to determine if their abortion warrants coverage. Iowa falls under the Hyde Amendment, meaning that Medicaid can only cover abortion in the case of rape, incest, or life threat. This is already unjust. Now the governor wants to make Hyde even more cruel by asking survivors of rape, incest, and medical emergencies to let him decide if their circumstances merit insurance coverage? What a callous law. It perpetuates the idea that some abortions are more deserving of insurance coverage than others, when really, all types of insurance—Medicaid and private health insurance—should cover abortion no matter the circumstance. No one should have to forgo rent to be able to access the health care they need.”