× Expand AP Photo/Charlie Neibergall Suzanna de Baca, the former president and CEO of Planned Parenthood of the Heartland, speaks during a news conference in Des Moines, Iowa, where Planned Parenthood and the American Civil Liberties Union filed a lawsuit challenging the nation's most restrictive abortion law.

Among the states competing for the most restrictive abortion laws in the nation, Iowa is a top contender. It is the only state where the governor must approve Medicaid assistance to terminate a pregnancy due to sexual assault.

It's illegal, however, to deny an abortion to survivors of rape simply because they cannot afford one. In 2013, in an effort to weaken these federally protected abortion rights, former Iowa Governor Terry Branstad signed a bill into law that gave him complete control over Medicaid fund allocation. This stipulation was in response to the 1976 Hyde Amendment, which only allows the use of federal money for abortions in the case of rape, incest, or to save the life of the mother. But that wasn’t the original purpose of the bill. The Iowa state legislature thought this bill was a compromise: Republicans hoped that this added step for Medicaid funds would lessen the number of abortions, and Democrats believed that it only applied to reimbursements and not approval beforehand. Instead, Iowa state legislators gave the governor even more power to regulate family planning.

Other state institutions stepped up to provide abortion access to survivors. In the first year the legislation went into effect, over $41,000 of the budget for the University of Iowa Hospitals was used to cover the expenses of terminating at least 20 pregnancies of low-income people who needed abortions due to either a rape or incestuous relationship. As Tom Moore, the spokesperson for the University of Iowa Hospitals and Clinics, said in an interview with the Quad-City Times in Davenport, Iowa, the hospitals chose to forgo seeking Medicaid funds in order to keep out of the “politics of this issue.”

Since 2017, Governor Kim Reynolds has made it more difficult for all women to obtain an abortion, not just rape survivors. In May 2018, Reynolds signed a law that made the termination of a pregnancy illegal once an embryonic heartbeat could be heard, which usually happens at six weeks, before many women even know they’re pregnant. A state judge ruled the heartbeat legislation unconstitutional later that year (while several states are currently advancing similar laws). In February, the state legislature introduced a bill that marked the moment of conception as the beginning of a human life, which would make any abortion illegal. As of now, there has been no vote for the proposal, but a subcommittee did recommend its passage.

“It was particularly disturbing, seeing a woman with that kind of power and using that power to put the lives of all women at risk,” Jennifer Leatherby, chair of the Iowa Access Abortion Fund, said of Governor Reynolds.

In response to Iowa's anti-abortion state legislature, advocates and activists are finding ways to support survivors. The Iowa Access Abortion Fund has set aside $100 to $200 per abortion, which covers less than one-third of the cost of a pregnancy termination. And they often go over this monthly budget. The Iowa Coalition Against Sexual Assault has also designated part of their budget for abortions. Elizabeth Barnhill, the executive director of the coalition, told The American Prospect in an email that the inability to acquire Medicaid funds “does not particularly impact survivors as there are hospitals available to provide low or no cost abortions.”

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However, it's already incredibly difficult for a rape survivor to access an abortion, and Iowa's refusal to use federal Medicaid funds to pay for these abortions only compounds the problem. “Most Americans don't have [at least] $500 laying around,” Leatherby says. And that amount is just the average cost of an abortion. By the second trimester, terminating a pregnancy can cost around $3,000. And the price for a later abortion can be up to $15,000. Almost half of women seeking abortions, however, live below the poverty line.

If the financial aspect isn't enough to dissuade survivors from terminating their pregnancies, states also make these women endure legal challenges. Utah, Wisconsin, and D.C. won’t give access to Medicaid funds without a police report. Since fewer than one-third of rapes are reported, this is a particularly high bar. Moreover, for eight other states—Arkansas, Oklahoma, Indiana, Michigan, Wyoming, Missouri, North Carolina, and Louisiana—it seems even a police report isn’t sufficient evidence to secure Medicaid funds. In 2017, they didn’t pay for any abortions.

The problem isn't the Iowa state legislature: The Hyde Amendment is what fails to protect survivors of sexual assault from anti-abortion state legislatures. There is no enforcement stipulation in the Hyde Amendment that would make states stop denying access to pregnancy terminations, and it won't take long for other states to pass legislation that restricts even rape survivors' access to abortions, just like Iowa. Georgia recently passed a heartbeat law. Alabama is trying to sentence women who terminate a pregnancy to prison for life. And these right-wing states won’t stop until abortion is completely eradicated, no matter what the government says.