U of I hospital won't ask Branstad for Medicaid abortion reimbursement

Iowa House Republicans failed in 2011 and again last summer to curtail Medicaid coverage of abortions in this state. A compromise passed near the end of this year’s legislative session gave the governor power to determine whether the state should reimburse abortion providers for certain Medicaid cases. However, administrators at the University of Iowa Hospitals in Iowa City have apparently let Governor Terry Branstad off the hook: the hospital no longer bills Medicaid for the handful of abortions that might be eligible for coverage.

Follow me after the jump for background and more details on the current policy.

First, it’s important to note that Iowa was already a relatively restrictive state on Medicaid coverage of abortions. For example, Iowa requires “a police report of a rape within 45 days of it occurring” in order to get Medicaid coverage for terminating a pregnancy caused by rape. Iowa also covers abortions under Medicaid in cases of incest or a threat to the mother’s life (consistent with federal law) and in some cases of severe fetal abnormalities. But only a very small number of abortions are covered under Medicaid each year in Iowa; 22 during fiscal year 2012 and only seven during the first nine months of fiscal year 2013, for which final figures are not available.

For decades, Medicaid coverage of abortion in cases of rape, incest or fetal deformity was a settled issue in Iowa, no matter which party controlled the state legislature. After winning back the Iowa House majority in the 2010 elections, Republicans tried to eliminate Medicaid coverage of abortion except in cases of incomplete miscarriage or where the mother’s life was threatened. However, Democrats in control of the Iowa Senate refused to budge on the issue. A compromise reached on the last day of the 2011 fiscal year offered Republicans a fig leaf without changing the reality of abortion coverage.

Under the terms of the agreement, the state will comply with the minimum federal Medicaid guidelines, which include rape and incest.

Fetal deformity is also an option. It will be up to the state Department of Human Services and the governor to determine whether the state will comply with those terms.

The bill does not spell out in what instances Medicaid-funded abortions will be provided. It only refers to complying with federal guidelines, said Rep. Beth Wessel-Kroeschell, D-Ames, one of the conference committee negotiators.

The practical effect is that the scope of services available to low-income women will not change, she added. The compromise language included a statement that “Iowans support reducing the number of abortions performed in our state.”

During fiscal year 2012, Medicaid reimbursed providers for 22 abortions in Iowa, less than one-half of 1 percent of all abortions performed in the state. Most of the Medicaid-covered procedures happened at the University of Iowa Hospitals. Fetal deformity was cited in 15 cases. Last summer, most of the Iowa House Republican caucus filed a petition for emergency rulemaking with the Iowa Department of Human Services, seeking to halt Medicaid payments for abortion in cases of fetal anomalies. But DHS Director Chuck Palmer denied the request for emergency rulemaking. Soon after, Branstad made clear that state legislators would need to change Iowa law to alter policy on Medicaid coverage of abortion.

During the 2013 legislative session, this issue became one of the last sticking points during negotiations over the DHS budget for fiscal year 2014 and an alternative to Medicaid expansion in Iowa. You can read the final language in Section 12 (page 26) of Senate File 446, signed by Branstad in June. It includes the statement, “Iowans support reducing the number of abortions performed in our state.” It does not grant the governor power to decide whether a woman on Medicaid can get an abortion. Instead, the office of the governor must approve reimbursement for each abortion under Medicaid before money can be allocated for that purpose.

Some pro-choice activists worried that providers would hesitate to perform abortions on low-income women without guarantees the procedure would be covered. Sharing those concerns, I made some inquiries about this over the summer. Planned Parenthood of the Heartland, the largest abortion provider in Iowa, does not bill Medicaid. Most of the abortions billed to Medicaid happen at the University of Iowa.

I had heard but not confirmed that the university might resolve the problem by not billing Medicaid for abortions. Fewer than two dozen abortions a year at a cost of less than $1,000 each represents a minuscule portion of the U of I hospital budget. The hospital doesn’t need public arguments over which circumstance warrants taxpayer coverage of an abortion.

Indeed, Tony Leys reported for the Des Moines Register today,

Dr. Jean Robillard, the university’s vice president for medical affairs, said Wednesday that since the new rules took effect July 1, U of I staff members have performed two abortions that could have qualified for Medicaid reimbursement. Both cases involved fetal anomalies, he said, and neither was billed to Medicaid.

When asked whether the decision was related to the new requirement that the governor review Medicaid bills for abortion, Robillard said: “I don’t want to get involved in the politics of this.” […]

Robillard said the billing issue will not affect U of I staff members’ treatment of patients. He said the situation is similar to what the university faced when the state launched IowaCare, a limited insurance program for poor adults. The University of Iowa didn’t get much reimbursement from that program at first, he said, but the hospital provided care for program participants anyway. “What we are focusing on is really to take care of the patients.”

Branstad must be relieved not to have these judgment calls arriving on his desk. Allowing reimbursement in almost any case would enrage social conservative activists. Then again, denying Medicaid coverage to a rape victim or a woman whose baby had no chance at life outside the womb would look bad to a mainstream audience. The governor’s not tipping his hand on whether his office requested the policy change at the U of I hospitals:

Branstad spokesman Tim Albrecht declined to say whether the governor believes the university made the right decision in declining to bill Medicaid. “The Iowa Legislature made clear, with bipartisan support, their intent to reduce the number of taxpayer-funded abortions,” he wrote in an email to the Register. “Medicaid providers have a great amount of discretion in the claims they submit to the state for reimbursement, and UIHC is no different. Certainly, the Legislature is free to determine if other changes are necessary when they convene in January.”

In a roundabout way, anti-choicers got the outcome they were seeking. Medicaid will pay for few, if any, abortions in Iowa. Leys noted near the end of his report,

The only other hospital system that has billed Medicaid for abortion services in recent years was UnityPoint Health, formerly known as Iowa Health System. A spokeswoman noted that such cases are very rare for the system, but she said the company has not changed its policies for billing Medicaid for them.

Any relevant comments are welcome in this thread.

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