Volusia County is a Prenatal Care Desert

Pamela Carbiener, M.D.

Over 50% of women in Volusia County use Medicaid insurance to obtain prenatal care. Over half of these women can’t find any. First trimester access to prenatal care has declined. Maternal death rates have increased. In 1929, Dr. Howard Haggart wrote:

“The position of woman in any civilization is an index of the advancement of the civilization; the position of woman is gauged best by the care given her at the birth of her child. Accordingly, the advances and regressions of civilization are nowhere seen more clearly than in the story of childbirth.” A century later, we are observing the regression of our county’s health and future prosperity in the egregious lack of care we tolerate for our mothers and babies.

In 2011, Florida privatized the state’s Medicaid system. Florida, like other states, hoped to transfer to a third party, the responsibility of assuring that Medicaid dollars reached Medicaid covered citizens for their healthcare. As stated in 2015 by D. Douglas Stephenson in the Gainesville Sun, “The companies are paid by state government and their profit depends on spending as little as possible on Medicaid patients It’s hard to imagine any greater disconnect between public good and private profit.” Presented to Floridians as a cost savings measure, privatization rolled out and by 2015, the insurance companies stated they were over $500 million in the red, and requested increases in rates that eliminated the anticipated cost savings. It is now 2023 and Medicaid ingests 48% of the state budget. Again, half of our mothers cannot get prenatal care. In what world can this be considered a success? This privatization is a failed venture and those in the position to rectify this situation need to admit that the emperor is not wearing any clothes.

In a state that already is spending 32% of its budget on Medicaid, the legislators consider Medicaid expansion off the table. And one should ask why isn’t 32% of the State budget enough? Shouldn’t one half of Florida’s budget be able to create accessible health care? And shouldn’t we at least be prioritizing pregnant women?

Nowhere is the emperor’s nakedness more apparent than in care for childbirth. And we cannot ignore the birth of babies because babies must be born. They need to be if we are to survive as a species. A civilization that acknowledges this should protect childbirth as if its existence depended on it, because it does.

Prior to 2011, the Volusia County Health Department ran a perinatal care clinic, with Halifax Health Family Practice Residents and community physicians. Women came to one of three sites and their pregnancy was confirmed, their applications for “Pregnancy Medicaid” were completed on site, coverage assured in 72 hours and a visit scheduled. Women were also networked to needed services. The private Medicaids lowered reimbursements to these clinics and large health departments closed them. Smaller counties that could prove they have no other prenatal care providers maintained “carve outs.”

Halifax Health and Advent Daytona Beach opened prenatal clinics intended to make up for the loss of the VCHD clinic, but they fall far short. “Secret shoppers” have called both these clinics and told eight weeks until the first visit. Not one private office would schedule any pregnant patient with Medicaid and referred them to the two hospital-based clinics. It is estimated that Volusia needs 18 additional obgyn physicians to cover our pregnant population.

When the state privatized the Medicaids, The Department of Children and Families, tasked with overseeing enrollment, discontinued access to onsite Medicaid enrollment navigators. All applications are to be completed online. This assumes that women have access to the internet and can navigate the tortuous application. Any blanks, inaccuracies, or current enrollment in non-pregnancy Medicaid delays the process and it now can take over two months.

So, too many women do not have Medicaid coverage before their fifth month, and then cannot find a provider who will take them. We are seeing more women arrive at our hospitals in preterm labor with complications that could have been avoided or minimized. This means longer hospital stays for moms and babies, with long term consequences and costs.

Other parts of Florida have developed relationships between the maternity hospitals, taxing authorities, Healthy Starts, Federally Qualified Health Care Centers, doctors, and health departments. They have created collaborative clinics that provide early and consistent perinatal care. It is reflected in the outcomes of their mothers. The counties in Florida that do not have these collaborations are experiencing similar access issues and higher morbidity for mothers and babies. Volusia County has all the players—two taxing authorities, three hospitals, a health department, a Healthy Start Coalition, three FQHC ‘s and obstetricians. Yet, Volusia County fails to provide access to prenatal care for most of its pregnant population.

This is not an insignificant concern. This is a dumpster fire on which we are spraying gasoline, as the few remaining local physicians stop seeing Medicaid covered moms. Issues of diabetes, hypertension, obesity, domestic violence, and substance abuse are now belatedly treated in our hospital triage units, as women arrive with emergencies that could have been avoided, addressed earlier, less expensively and more effectively. The cost for “the system” pales in comparison to the poor outcomes for mothers in our community.

AHCA, DOH and our legislators must hold the private Medicaids accountable for providing the health care they promise. The Medicaids need to assure early access to care and realistic rates for providers. DCF needs to create access to Medicaid enrollment and assure that women don’t have to wait months to start their search for a prenatal care provider. And Volusia County needs to hold all the stakeholders accountable and demand a collaborative system that uses all funds effectively, filling in gaps and avoiding duplications in administrative services and oversight.

Perhaps, if enough of us acknowledge this crisis and work to restore care for our women, we can reach 2029, one hundred years after Dr. Haggard’s wrote his book and show that our civilization is again advancing.

Way out yonder in the rural part of Volusia County lies the small town of DeLeon Springs population 2,481 (2023 census). Passing many horses and cattle ranches for thirty minutes after leaving Ormond Beach farms, we pulled into Karling’s Inn. This quaint restaurant that has been a local fixture for over 30 years is still worth the trip. Not too long agotheowners,ChefJimmyBuzzaandhiswifeLilyopenedtheTwinBrothersKafenextdoor.Namedaftertheirtwin boys,BurleyandElliot,theymakehomemadebakedgoodsandservebreakfastandlunchfrom9-2Wednesday through Sunday.DinnerisinKarling’sfrom5-9WednesdaythroughSaturday.

Entering the German farmhouse style eatery, the hostess led us to our table. The menu was then presented to us along with a sample of their Kafe bread served warm and wonderful. Karling’s is noted for their German fare and seafood. Appetizers ranged from Escargots (French snails, Muenster cheese, tomatoes, concasse and garlic butter) toAngels on Horseback (lightly breaded oysters wrapped in bacon, fried, and served with Bérnaise sauce).The classic French onion soupbakedtoorderwithhousemadebuttercheese,andofcourseBavariansausagewithsauerkraut.

We went straight to the entrées. Lisa and I decided to share two entrées. The first was the Roast Crispy Duck Montmorency which was half a deboned duck and served with apple dressing and cherry bing sauce. It came with a side of a scrumptious potato pancake and an incredibly delightful German cucumber salad. We enjoyed it but we felt the duck was somewhat overcooked. We also chose the absolutely mouthwatering, satisfying Karling’s black grouper which was a 10 oz. thick cut, sautéed with a creamy Scotch sauce with 2 jumbo shrimp, roasted peppers, olives, and pine nuts.This came with the potato pancake and a great cheese covered spätzle with which my glass of Ruffino Pinot Grigio from Italy paired well. One of our friends that joined us for this great meal ordered an end cut of prime rib that hethoroughlyenjoyedandwascookedperfectly.

Yes of course we saved room for dessert. Lisa and I thoroughly enjoyed the Key Lime BakedAlaska, and our friends shared their apple strudel with vanilla ice cream which was amazing as well. Our total bill for Lisa and myself without tip was just over $100. Karling’s is located at 4640 US Highway 17. Be prepared that they only take Visa and Mastercard. They serve beer and wine as well as after dinner cordials. They have a Kids menu as well. Reservations may be made by calling (386) 985-5535. I give Karling’s Inn: Ambience 5 stethoscopes Quality of food 4 1/2 stethoscopesValue4stethoscopesService4stethoscopesIknowwe’llbebacktodineagainrealsoon!