DES MOINES, Iowa — Any Iowa hospital or clinic seeking Medicaid payment for providing an abortion would need approval from the state’s most prominent abortion opponent: Gov. Kim Reynolds.

No one bothers to try.

Iowa’s Medicaid regulations include an unusual policy requiring signoff from the governor’s office before the public health insurance program could pay for any abortion services, even if they meet the state’s strict criteria.

Reynolds is a Republican and a vehement foe of abortion. In more than six years as governor, she has never been asked to approve a Medicaid payment for an abortion, said her spokesperson, Kollin Crompton.

The novel policy, instituted a decade ago by legislators, leaves providers who perform abortions with a choice: Swallow the procedure’s costs, or risk a showdown with the governor.

The state’s Medicaid program spends roughly $8 billion a year to cover about 800,000 Iowans with low incomes or disabilities. It allows payment for abortions if a pregnancy endangers a woman’s life, is the result of rape or incest, or involves a fetal deformity. The Iowa Department of Health and Human Services posts a form for abortion providers to fill out for Medicaid compensation, but the program hasn’t paid for any abortions in several years, spokesperson Alex Carfrae said.

The federal government, which finances more than half of Medicaid costs, helps pay for abortions only in cases of rape or incest or when a pregnancy endangers a woman’s life. But it requires state Medicaid programs to cover such cases.

Most state Medicaid programs pay for at least a few abortions, according to a 2019 report from the federal Government Accountability Office. The report found that in fiscal years 2013 through 2017, only Iowa, South Dakota, and Wyoming reported covering no abortions meeting the federal criteria.

Abortion remains legal up to 20 weeks of pregnancy in Iowa, where 4,062 abortions were reported in 2022. Reynolds signed a bill in July that would ban most abortions after six weeks, and she is fighting in court to implement the law. However, the abortion ban would allow exceptions for cases of rape, incest, fatal fetal abnormalities, and medical emergencies.

Iowa’s Medicaid program paid for 22 abortions in the fiscal year before legislators passed the governor-oversight rule in 2013. Most were performed at the University of Iowa Hospitals and Clinics in Iowa City, a state-owned facility that handles many of Iowa’s most complicated pregnancies. After the rule went into effect, hospital leaders decided to pay for such abortions out of the facility’s revenues instead of trying to bill Medicaid.

Jean Robillard, then a University of Iowa Hospitals vice president, declined at the time to explain how the state rule affected the decision to stop billing Medicaid for abortions. “I don’t want to get involved in the politics of this,” he told the Des Moines Register.

University of Iowa Hospitals spokesperson Laura Shoemaker said this fall that the hospital has not billed Medicaid for abortions in recent years. She declined further comment.

UnityPoint Health, a large nonprofit hospital system based in West Des Moines, also occasionally billed Iowa Medicaid for qualifying abortions before the governor-approval rule went into effect. UnityPoint declined comment on its current practice.

When the rule was implemented, it was called unique by the Guttmacher Institute, a national nonprofit that supports abortion rights. The group still lists Iowa as the only state requiring the governor’s permission for Medicaid payments for abortion. But a spokesperson said the institute cannot say for certain that no other state has implemented such a rule.

The policy took effect while Reynolds’ predecessor, Republican Terry Branstad, was in office. Branstad also opposed abortion but suggested the rule be rescinded. Reynolds’ spokesperson declined to say whether the current governor approves of the rule.

Maggie DeWitte, executive director of Pulse Life Advocates, an Iowa group opposing abortion, said she favors the policy as a way to limit use of taxpayer dollars for the procedure.

“I don’t think it’s anything the government should be paying for. It’s the taking of an innocent life,” she said. “We should have as many stops along the way as possible.”

Sally Frank, a law professor at Drake University in Des Moines who studies women’s rights issues, said the rule appears intended to prevent requests for Medicaid payment. “It’s kind of set up to fail,” she said.

Frank, who supports abortion rights, said a hospital or clinic would have strong legal grounds to challenge any denial by the governor of Medicaid payment for an abortion that met Iowa’s criteria. She noted that states are required to cover Medicaid services spelled out under federal law. She added that if the governor blocked payment without citing a valid reason, the provider could argue in court that they were denied due process. “It should not be up to the governor’s discretion.”

But she wasn’t surprised to hear no hospitals or clinics have challenged the policy, given the state’s increasingly conservative politics.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.