President Obama and Senate Democrats sought on Sunday to generate momentum from the House's passage of health-care legislation, even as a new hurdle emerged: profound dismay among abortion-rights supporters over antiabortion provisions inserted into the House bill. 
 
 The House passed its version of health-care legislation Saturday night by a vote of 220 to 215 after the approval of an amendment that would sharply restrict the availability of coverage for abortions, which many insurance plans now offer. The amendment goes beyond long-standing prohibitions against public funding for abortions, limiting abortion coverage even for women paying for it without government subsidies. 
 
 The abortion issue had been rumbling within the House Democratic caucus for weeks, but Saturday's votes revealed the depths of the fault lines. The amendment passed with the support of 64 Democrats, roughly a quarter of the party caucus. 
 
 But abortion-rights supporters are vowing to strip the amendment out, as the focus turns to the Senate and the conference committee that would resolve differences between the two bills. 
 
 Although House liberals voted for the bill with the amendment to keep the process moving forward, Rep. Diana DeGette (Colo.) said she has collected more than 40 signatures from House Democrats vowing to oppose any final bill that includes the amendment -- enough to block passage. 
 
 "There's going to be a firestorm here," DeGette said. "Women are going to realize that a Democratic-controlled House has passed legislation that would prohibit women paying for abortions with their own funds. . . . We're not going to let this into law." 
 
 Senate Majority Leader Harry M. Reid (D-Nev.) is waiting for cost estimates of provisions of the bill he is cobbling together, and he hopes to bring it to the Senate floor before Thanksgiving. The battle over abortion has been more muted in the Senate, but Jim Manley, Reid's spokesman, predicted that would change. 
 
 "The debate in the House highlighted some of these issues that we're going to have to face here in the Senate, and on this issue in particular, it's something [Reid] is going to have to talk with his caucus about," Manley said. 
 
 Obama left the abortion issue unmentioned Sunday when he appeared in the White House Rose Garden to give brief remarks congratulating the House on its "courageous" passage of the bill. "Now it falls on the United States Senate to take the baton and bring this effort to the finish line on behalf of the American people," he said. "And I'm absolutely confident that they will." 
 
 Other issues remain unresolved. The House bill's primary new revenue source to pay for the bill is an income tax surcharge on families earning more than $1 million; the Senate bill will probably rely on a proposed new excise tax on costly insurance plans. The House and Senate also differ on a government-run insurance plan to be offered on the new marketplace where small businesses and people without employer-provided coverage -- about 30 million in all -- would buy coverage. 
 
 The Senate version would limit this "public option" by allowing states to opt out of it, but even in that form, the bill's prospects are unclear. Sen. Joseph I. Lieberman (I-Conn.), whose vote Democrats will probably need to break a filibuster, warned again Sunday on Fox News that he will withhold his support if the bill includes a public option. 
 
 The bills also differ in their requirements for employers to provide coverage -- the House's language is tougher -- and in the subsidies for those who cannot afford coverage, which are larger in the House version. Both bills deny subsidies to illegal immigrants, but the Senate version goes further by also barring them from buying coverage on the new marketplace with their own money. ||||| Photo Advertisement Continue reading the main story 
 
 WASHINGTON — A restriction on abortion coverage, added late Saturday to the health care bill passed by the House, has energized abortion opponents with their biggest victory in years — emboldening them for a pitched battle in the Senate. 
 
 
 
 
 
 
 
 
 
 The provision would block the use of federal subsidies for insurance that covers elective abortions. Advocates on both sides are calling Saturday’s vote the biggest turning point in the battle over the procedure since the ban on so-called partial birth abortions six years ago. 
 
 Both sides credited a forceful lobbying effort by Roman Catholic bishops with the success of the provision, inserted in the bill under pressure from conservative Democrats. 
 
 The provision would apply only to insurance policies purchased with the federal subsidies that the health legislation would create to help low- and middle-income people, and to policies sold by a government-run insurance plan that would be created by the legislation. 
 
 Abortion rights advocates charged Sunday that the provision threatened to deprive women of abortion coverage because insurers would drop the procedure from their plans in order to sell them in the newly expanded market of people receiving subsidies. The subsidized market would be large because anyone earning less than $88,000 for a family of four — four times the poverty level — would be eligible for a subsidy under the House bill. Women who received subsidies or public insurance could still pay out of pocket for the procedure. Or they could buy separate insurance riders to cover abortion, though some evidence suggests few would, in part because unwanted pregnancies are by their nature unexpected. 
 
 Not many women who undergo abortions file private insurance claims, perhaps to avoid leaving a record. A 2003 study by the Alan Guttmacher Institute found that 13 percent of abortions were billed directly to insurance companies. Only about half of those who receive insurance coverage from their employers have coverage of abortion in any event, according to a study by the Kaiser Family Foundation. 
 
 Abortion rights advocates, however, are grappling with a series of incremental defeats in the courts and in Congress, and are now bracing for another struggle as the health care legislation goes to the Senate. 
 
 “This is going to make it that much more challenging on the Senate side,” said Nancy Keenan, president of Naral Pro-Choice America. 
 
 The president and Democratic leaders alike have long promised that their proposed health care overhaul would not direct taxpayer money to pay for elective abortions. But the president has never spelled out his answer to the contentious question of how to apply that standard to the novel program of offering insurance subsidies or a government-run plan to millions of poor and middle-class Americans. 
 
 House Democratic leaders had sought to resolve the issue by requiring insurers to segregate their federal subsidies into separate accounts. 
 
 Insurance plans would have been permitted to use only consumer premiums or co-payments to pay for abortions, even if individuals who received federal subsidies used them to buy health plans that covered abortion. But the House speaker, Nancy Pelosi, was unable to hold on to enough moderate and conservative Democratic votes to pass the health bill using that approach, forcing her to allow a vote Saturday night on the amendment containing the broader ban. 
 
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 Five states go further than the amendment to the health care overhaul. The five — Idaho, Kentucky, Missouri, North Dakota and Oklahoma — already bar private insurance plans from covering elective abortions. 
 
 The federal employees’ health insurance plan and most state Medicaid programs also ban coverage of abortion, complying with a three-decade old ban on federal abortion financing. Seventeen state Medicaid programs, however, do cover the procedure, by using only state money. 
 
 The bishops objected to the segregated funds proposal previously embraced by the House and Senate Democratic leaders in part because they argued that it amounted to nothing more than an accounting gimmick. 
 
 Advocates on both sides of the question weighed in, but the bishops’ role was especially pivotal in part because many Democrats had expected them to be an ally. They had pushed for decades for universal health insurance. 
 
 “We think that providing health care is itself a pro-life thing, and we think that, by and large, providing better health coverage to women could reduce abortions,” said Richard M. Doerflinger, a spokesman for the anti-abortion division of the United States Conference of Catholic Bishops. 
 
 “But we don’t make these decisions statistically, and to get to that good we cannot do something seriously evil.” 
 
 Beginning in late July, the bishops began issuing a series of increasingly stern letters to lawmakers making clear that they saw the abortion-financing issue as pre-eminent, a deal-breaker. 
 
 At the funeral of Senator Edward M. Kennedy in August, Cardinal Seán O’Malley, the archbishop of Boston, stole a private moment with Mr. Obama to deliver the same warning: The bishops very much wanted to support his health care overhaul but not if it provided for abortions. The president “listened intently,” the cardinal reported on his blog. 
 
 Bishops implored their priests and parishioners to call lawmakers. Conservative Democrats negotiating over the issue with party leaders often expressed their desire to meet the bishops’ criteria, according to many people involved in the talks. On Oct. 8 three members of the bishops conference wrote on its behalf to lawmakers, “If the final legislation does not meet our principles, we will have no choice but to oppose the bill.” 
 
 On Sunday, some abortion rights advocates lashed out at the bishops. “It was an unconscionable power play,” said Cecile Richards, president of Planned Parenthood Federation of America, accusing the bishops of “interceding to put their own ideology in the national health care plan.” 
 
 Now some Senate Democrats, including Bob Casey of Pennsylvania and Ben Nelson of Nebraska, are pushing to incorporate the same restrictions in their own bill. Senior Senate Democratic aides said the outcome was too close to call. ||||| CLOSE The law, which goes into effect on July 1, will require physicians to conduct an abdominal ultrasound to test for a fetal heartbeat on any woman seeking an abortion. If a heartbeat is detected, a physician cannot perform an abortion. Des Moines Register 
 
 Buy Photo Representative Shannon Lundgren of Dubuque speaks on the floor of the Iowa House Tuesday, May 1, 2018. (Photo: Zach Boyden-Holmes/The Register)Buy Photo 
 
 With a middle-of-the-night vote that followed hours of heated debate, Iowa Republicans have approved a measure that would ban most abortions in the state and give the state the strictest abortion law in the nation. 
 
 The move came in the final days of the legislative session, after mounting pressure from the Legislature’s most ardently anti-abortion corners to pass the so-called heartbeat bill before adjournment. It was accompanied by legislative threats and predictions — even hopes — the resulting law will be challenged in court. 
 
 Senate File 359, if signed into law, would ban nearly all abortions after a fetal heartbeat is detected. That can occur about six weeks into a pregnancy and often before a woman realizes she’s pregnant. 
 
 The House narrowly approved the bill 51-46 late Tuesday night. It immediately advanced to the Senate, where Republicans approved it with a vote of 29-17 at about 2:30 a.m. Wednesday. 
 
 The legislation now goes to Gov. Kim Reynolds, a Republican. She has not said whether she will sign it into law. 
 
 "When we get the bill, we have our team sit down and we review it," she told reporters. "Sometimes, there’s things in there we weren’t anticipating or didn’t know about. And so we take the time, whoever the policy person is in that area, and the team goes through it," the governor said. "Then we make the decision.” 
 
 Senate threatened to hold up budget 
 
 The Iowa Senate approved a similar fetal heartbeat ban earlier this year, but action stalled in the House, where Republicans struggled to muster the 51 votes necessary to pass the bill. 
 
 In an effort to force the House into action, Sen. Rick Bertrand, R-Sioux City, said a group of Republican senators had threatened to withhold their votes on critical budget bills needed to end the 2018 legislative session. 
 
 “There is a group of us that were more than willing to sit here until July 1,” he said, noting the date by which a new budget must be enacted in order to fund state government. 
 
 House leaders, attempting to get more of their members on board, brokered a deal on an amendment that created exceptions to the ban for some cases of rape and incest. 
 
 The amendment garnered them enough votes — but no more — to pass the bill at about 11 p.m. Tuesday. Six Republican representatives voted against the bill. 
 
 Democrats throughout the process called the legislation "frightening," "extreme" and "unconstitutional." 
 
 “Tonight, Republicans, you have once again made a choice: a choice to debate legislation that devalues the bodies and decision-making skills of Iowa women and girls,” said Sen. Janet Petersen, D-Des Moines. “None of you went to medical school, yet you Republican politicians are making dangerous medical decisions. This bill tells Iowa women and girls that forced pregnancy is more important than their health and well-being.” 
 
 Iowa law currently bars most abortions after 20 weeks, which already is among the strictest abortion bans in the country. 
 
 Hope to overturn abortion legalization 
 
 But many Republicans said they felt the time is right to pass legislation that could advance to the U.S. Supreme Court and pose a challenge to Roe v. Wade, the 1973 landmark case that found women have a constitutionally protected right to abortion. 
 
 The Supreme Court has declined to hear similar cases in recent years. But as states continue to pass legislation restricting abortions and President Donald Trump appoints more conservative federal judges, abortion opponents are increasingly optimistic. 
 
 “This law, if signed, I believe could very well be the very bill that overturns Roe v. Wade,” said Sen. Jake Chapman, R-Adel. 
 
 More: Republicans hope a challenge to Iowa's fetal heartbeat bill will overturn Roe v. Wade. How would that work? 
 
 More: If it gets challenged, who would pay for Iowa to defend its 'fetal heartbeat' abortion ban? 
 
 Sen. Matt McCoy, D-Des Moines, criticized Republican efforts to pass legislation that would inevitably face court challenges. 
 
 “Here we are, at 1:05 in the morning, pushing a bill that has absolutely no constitutional chance of ever passing muster,” McCoy said. “Where it’s been tried, it’s been quickly struck down by the courts — but (only) after extensive and expensive lawsuits.” 
 
 What the bill does 
 
 The bill requires physicians to conduct an abdominal ultrasound to test for a fetal heartbeat on any woman seeking an abortion. If that heartbeat is detected, a physician cannot perform an abortion. 
 
 Previously, the legislation allowed exceptions to that ban only in cases of "medical emergency," which was defined as a situation in which the life of the woman was in danger. 
 
 Republicans on Tuesday amended the bill to also allow exceptions if: 
 
 the woman was raped and reports the rape to a law enforcement agency, a public or private health agency or a family physician within 45 days; 
 
 the woman was the victim of incest and reports the issue to a law enforcement agency, a public or private health agency or a family physician within 140 days; 
 
 "not all the products of conception are expelled" following a spontaneous miscarriage; 
 
 a physician certifies that the fetus has an abnormality that, in the physician’s "reasonable medical judgment," is incompatible with life. 
 
 Rep. Mary Wolfe, D-Clinton, noted that physicians would not be tasked with confirming reports of incest or rape that are made by women seeking abortions. She also questioned whether the state should be requiring victims of violence to report crimes within a certain time frame. 
 
 “That is a good message to be sending to the children of Iowa that, 'You know what? If you’re scared and you don’t know what to do and you finally get the guts to go to your mom or your dad and tell them what happened but it’s 50 days after you were raped instead of 45, you’re stuck with that baby because the Iowa Legislature decided you needed to accept responsibility for coming forward,' " she said. 
 
 Rep. Shannon Lundgren, a Republican from Dubuque and the bill's floor manager in the House, said those requirements would allow justice to be served. 
 
 “We need to do everything in our power to encourage young women ... to come forward and tell people that they’ve been raped so that we can bring that perpetrator to justice," she said. 
 
 Rep. Steven Holt, R-Denison, said he disagreed with the exemptions because they water down the intent of the legislation. 
 
 "I do not agree with the exceptions in the amendment, for I believe that all unborn lives matter and that all unborn lives should be protected," he said. "However, I will vote to protect most of the unborn and we will continue to work to protect all unborn children." 
 
 Criminal penalties for doctors? 
 
 The bill no longer includes civil or criminal penalties for the physician, as some previous versions had. 
 
 And although it includes specific language granting women legal immunity, it does not do the same for physicians. 
 
 That led some Democrats to question whether a physician could be charged with murder if somebody later questioned whether the abortion he or she performed met the definition of a medical emergency. 
 
 "The courts, I can tell you, will likely interpret this as an intentional omission," said Rep. Todd Prichard, D-Charles City. "They will review that and say that the Legislature had a choice, and they chose not to provide immunity for doctors. This is extremely dangerous." 
 
 He called it a "glaring and perhaps purposeful" omission from the bill that could frighten doctors who want to provide legal abortions. 
 
 Rep. Chip Baltimore, R-Boone, disagreed, saying the bill does not make an unborn child a "person" and an abortion would not meet the statutory definition of murder. 
 
 Training could be threatened at OB-GYN residency program 
 
 Democrats said the legislation could negatively affect the University of Iowa Carver College of Medicine and Iowa Obstetrics and Gynecology Department. 
 
 Josh Lehman, senior communications director for the Iowa Board of Regents, said in a statement the program is required to provide family planning training "including all forms of contraception and training in the provision of abortion, if the student so chooses." 
 
 "If this law was passed, limitations on abortions in Iowa would eliminate the ability to meet training requirements," he said. 
 
 School leaders have said they would likely have to arrange out-of-state training options for students if the university could no longer do so on its own. 
 
 Rep. Mary Mascher, D-Iowa City, warned the changes would reduce the numbers of qualified OB-GYNs across the state. 
 
 "This change would result in a weakened program affecting all Iowans who seek all types of obstetric and gynecological care, not just those seeking to end a pregnancy," she said. "Fewer well-qualified obstetricians and gynecologists, as well as physicians from other specialties, will choose to train and live in a state that appears to devalue the practice of medicine. Patients will lose access to critical life-sustaining services. 
 
 Rep. Jon Jacobsen, R-Treynor, said the implication the program would lose its accreditation amounts to "scare tactics," arguing there are other ways for the school to meet its accreditation standards. 
 
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– The abortion funding ban included in the health-care bill passed by the House Saturday could doom it down the road, as abortion supporters in the Senate threaten revolt, and those who voted for it in the House vow they won't back the final bill if it's still included, the Washington Post reports. The 11th-hour provision, which was pushed through with the help of the Roman Catholic bishops, "is going to make it that much more challenging on the Senate side," the president of NARAL-Pro Choice America tells the New York Times. And even if the bill somehow manages to squeak by in the Senate, a group of House liberals who voted for the amendment just to keep the bill moving has vowed to block its final passage. "We're not going to let this into law," said Rep. Diana DeGette. For those on both sides of the abortion debate, the stakes are high. "This would be the greatest restriction on a woman's right to get an abortion with her own money in our lifetime," the pro-choice activist said.