DES MOINES, Iowa — Catholic, anti-abortion Iowa Gov. Terry Branstad could soon find himself in an uncomfortable position: He may have to sign off on payments for every Medicaid-funded abortion in his state.


A bill requiring that authorization is sitting on the Republican's desk after moving through the statehouse. If Branstad signs it, Iowa is likely to be the only state that would have the unique requirement.


Iowa's Medicaid program covers a small number of abortions each year due to rape, incest, fetal deformity or to protect a mother's life. Currently handled by the state Department of Human Services, the Medicaid reimbursements cost the state less than $20,000 last fiscal year.


The change in who approves the payment is a result of Iowa's unusual political landscape. It is one of only three states with a divided legislature, with Republicans controlling the state House and Democrats the Senate. Blocking funds for Medicaid abortions has been a priority for some conservative Iowa Republicans in recent years, but past efforts to change the rules – as well as make some of the more sweeping abortion restrictions seen in other GOP-majority states _have failed to advance in the Senate.


But a split legislature can lead to unusual deal-making. In this case, the abortion plan was negotiated as part of a complex health care bill that included accepting additional federal dollars to expand low-income health care in the state – a key priority for Democrats. Republicans hope by putting the decision into the hands of an anti-abortion governor, fewer public dollars will be spent on abortions. Democrats say they expect no changes, but abortion rights advocates fear it could restrict access to abortions for poor women.


Branstad said he is likely to approve the legislation, which impacts reimbursements after the abortions, not authorizing the procedures ahead of time.


"The number of abortions that have been funded in Iowa has been very small. I'm hopeful that can continue and even be reduced, but I take the responsibility that I've been given very seriously," Branstad said.


The policy move is a head-scratcher for Elizabeth Nash, who serves as state issues manager for the New York-based Guttmacher Institute, a reproductive rights think-tank that tracks state policies on Medicaid abortions. Nash said no state had made such an effort in the past 14 years. Jill June, president of Planned Parenthood of the Heartland, also said she had never heard of anything like this before.


"This is completely out of the norm of how Medicaid would work in any state. This idea that the governor or someone in the governor's office would be reviewing medical documents to determine reimbursement is just – I don't even know how to describe it. It's really odd," Nash said.



Republican Rep. Matt Windschitl, who came up with the idea during budget negotiations, and said he hoped it would reduce abortion reimbursements.


"We're talking about the taking of an innocent human life here," said Windschitl, of Missouri Valley. "Why shouldn't it go to his office?"


But Democratic Senate Majority Leader Mike Gronstal said he did not expect the status quo to change. He noted that coverage rules have not changed and Branstad's administration had resisted previous efforts to halt this funding.


"From my perspective the authorization coming from the governor, coming from the Iowa Department of Human Services is in essence the same," said Gronstal, of Council Bluffs.


If Branstad were to stop authorizing Medicaid funding for all abortions that could put the state in violation of Medicaid rules and risk losing other funding. Branstad has said he wants to stay in compliance with federal guidelines, which require the state to pay for abortions involving Medicaid recipients in cases of rape, incest and to save the mother's life.


Iowa also offers state funding in cases of severe fetal deformities. Asked if he would apply a tougher standard to approving that funding, Branstad said he was going to approach those cases in a "thoughtful way." The governor, who has said he would like to further reduce abortions but doesn't see a path to that with a divided legislature, said he respected how this has been handled by DHS, which has approved funding in severe cases, like when the fetus has no brain stem or cranium.


The Iowa Department of Human Services reported 22 abortions paid for by state and federal Medicaid dollars during the last fiscal year, which ended June 30, 2012, and another nine during the current fiscal year. The total cost last year was $19,633 and this year it was $11,479, said Iowa DHS spokesman Roger Munns.


Under the current system, Medicaid reimburses medical providers for abortions after an extensive review that includes checking doctors' reports and ultrasound results. Munns said some claims are denied due to insufficient documentation or if it is determined that the fetal deformity is not severe enough. He could not provide an exact number of denials in this year or last.


Critics said the policy change could restrict abortion access for low-income women if the governor starts providing fewer reimbursements.


"It moves out of a regulated democratic process to a unilateral decision by the governor," June said. "You won't know what to rely on determining whether or not you're going to have the kind of financial support you thought you would have if you looked at the rules and regulation. It creates a great unknown."


June said that Planned Parenthood in Iowa has paid for abortions for poor patients using private fundraising dollars rather than seek Medicaid reimbursement because their claims were denied in the past. The Medicaid- funded abortions performed in Iowa in the current fiscal year were at the University of Iowa Hospitals, Iowa Lutheran Hospital and Iowa Methodist Medical Center, Munns said.


If he signs this into law, Branstad, who is expected to seek re-election in 2014, said he wasn't worried about the political fallout.


"People know where I come down on this. I've been consistently pro-life my whole life," Branstad said.



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