I have practiced general obstetrics and gynecology with a focus on underserved populations in Volusia and Flagler Counties since 1992. Both in the county health departments and in my private practice, we have seen women with mental health concerns, substance use disorder, homelessness and other poor social determinants, as well as late entry to care. These patients are often screened out of private practices (the practice does not take Medicaid, the patient is "too far along," or "too high risk." The hospital-based clinics are scheduled out weeks to months, and do not manage issues of mental health or substance use, and referral to treatment is unavailable or simply not discussed. Access to postpartum contraception and mental health care is inconsistent; many providers are unaware the Florida has expanded Medicaid postpartum care through the first year, or they find the reimbursement for this unacceptable. Too few women know about Title X tubal ligation programs or the options of long acting reversible contraception, such as IUDs and Nexplanons. If these issues are not enough for women and their families, the access to Medicaid coverage of pregnancy has deteriorated significantly in our area. During the first twenty years of my practice, women routinely applied for presumptive eligibility Medicaid for pregnancy and received coverage within 72 hours. This coverage was guaranteed for 45 days, giving the Medicaid administration time to confirm eligibility for the remainder of the pregnancy, while allowing the mother to be to schedule and receive immediate prenatal care. Doctors were incentivized to get women into prenatal care within the first twelve weeks of pregnancy by additional reimbursement. Rarely was the woman denied continued Medicaid after the 45 day period, and care was continuous and carried on through the first 6 weeks postpartum. Women were able to apply for their "pregnancy Medicaid" by presenting to the health departments, or the Medicaid offices in the county, where designated providers walked these women through the process and assured their coverage before they left. Women typically left these appointments with scheduled prenatal visits, networking to WIC and SNAP and a sense of relief that they were receiving support during their pregnancy. The designated providers for in person application to Medicaid disappeared in the last decade. Women now must apply online. Many struggle with internet access or navigation. If any mistake in the application occurs, it postpones enrollment for weeks. If they already have Medicaid, the online system does not allow for easy transition to pregnancy Medicaid. There is no physical place for women to meet with a Medicaid navigator and be assisted with the process. On multiple occasions, my staff has sat with a woman for hours (no exaggeration) trying to assist with the online initial application, change to pregnancy Medicaid or transition to a Medicaid we can accept. On average, it is taking 4-10 weeks between the time a woman learns she is pregnant and obtains her Medicaid coverage. Add the time to get in for the initial visit and the result is that many women are not seen until their late second or early third trimesters. I learned that Medicaid enrollment is overseen by The Department of Children and Families in the 7th Circuit which oversees the Medicaid Region 4. I reached out to Chuck Puckett, the Circuit 7 Family Safety Operations Manager, asking for guidance in expediting this enrollment delay. He directed me to Kevin Jolly, also with DCF. He stated he would bring this to the attention of the call center manager and provided us with the new call center number. We have called the center with our patients together and continue to have the same delays. I tried to schedule meetings to address my concerns. These efforts were made in the winter and spring of this year. I have made my concerns known to the DOH and ACHA through networking with FBH Impact and FPQC, and I am encouraged by the interest and concern voiced during these discussions. But while the wheels of administrative move slowly, moms are attempting to schedule their first appointments in their third trimesters. They miss out on genetic screening, early treatment of diabetes and hypertension. They remain on teratogenic medications through fetal development because they have not had opportunity to change to medications safe in pregnancy. They continue to smoke and drink, without support to desist. They miss opportunity to enroll in Healthy Start and other social services. They continue their illicit drug use, unable to transition to medication assisted treatment and sometimes overdose, resulting in two deaths. They endure unstable housing, domestic violence, untreated mental conditions and unacceptable stress during pregnancy--a risk factor for preterm delivery in and of itself. With so much funding available for prenatal care, substance use disorder and mental health issues, it makes no sense that initial access to the system remains a barrier. The Medicaids all have their individual pregnancy programs, that once alerted to an enrolled women's pregnancy, should provide rent assistance, transportation, counseling, doulas, etc. But none of this is accessed if the women can't get Medicaid in the first place. We need this to be addressed NOW, with the recreation of positions for Medicaid navigators--people who can meet with these women and facilitate enrollment, and who can schedule appointments to prenatal care and other services. Mechanisms to transition women to pregnancy Medicaid, or to switch between different Medicaids exist in theory, but in practice are not navigable online or on hours-long calls. There needs to be a quick transition, so that women with mental health and substance use can come to a prenatal provider that will screen for these issues and create a care plan. Through FPQC and BH Impact, we are educating other providers in our area about SBIRT (Screening, Brief Intervention and Referral to Treatment), providing buprenorphine and mental health services either in their own obstetrical office or by networking to services. But women have to get their health care coverage first, in order to access any of this. The health of our moms and babies depends on addressing this issue. I apologize for the length of this post and hope others will comment on their experiences and ideas to address.