Healthcare in Puerto Rico: Before and After Hurricane Maria

On September 20, 2017, Hurricane Maria hit Puerto Rico. Within the space of about two weeks it devastated Puerto Rico, Dominica, and the U.S. Virgin Islands, and became one of deadliest and costliest tropical storms on record. Puerto Rico was in debt, filing for bankruptcy, and facing stagnating public health resources. Consequently, Hurricane Maria turned what was a worrying situation into a public health emergency. Yet, despite repeated calls for help and the fact that all Puerto Ricans are U.S. citizens, aid from the U.S. federal government was sparse, slow, and hotly contested. A long relationship between Medicaid, Medicare, and Puerto Rico’s public healthcare system, threats of an economic crisis, and a declining, aging population have so far defined the extent and efficacy of the healthcare system -- but with the new and monumental challenges introduced by Hurricane Maria, this healthcare landscape is in the midst of significant change.

Puerto Rico is a U.S. territory -- which puts its healthcare system in the liminal position of being under the umbrella of U.S. federal control, but without the rights and privileges of a full state. The healthcare system in Puerto Rico broadly resembles the U.S. model of private services combined with Medicaid and Medicare-funded public services, with physicians serving both the publicly and privately insured (Perreira et al., 2017). This structure is one that has evolved over the past several decades. From the 1930s to the 1970s, Puerto Rico’s healthcare system much more closely resembled socialized systems that are common elsewhere across Latin America. Doctors and health professionals were employees of the Puerto Rican government, and each of the 78 municipalities had a publicly-funded clinic, hospital, or care center (Arbona & Ramírez de Arellano, 1978). In the 1970s, increasing pressure from U.S. agencies resulted in the steady growth of the private healthcare sector; as care was slowly shifted outwards towards private providers, the public healthcare system became increasingly fragmented, and better wages, freedom, and job security incentivized physicians to leave jobs working for the state for private practices (Pagan-Berlucchi & Muse, 1983). In 1993 Puerto Rico enacted “La Reforma,” a healthcare reform that essentially sanctioned the public-to-private shift that had already taken place. Public hospitals and clinics were sold to private organizations, and doctors were incentivized to contract part-time with Medicaid or Medicare MCOs and provide care to publicly-insured patients (Perreira et al., 2017).

Medicaid and Medicare in the U.S. functions as an income-based reimbursement system for care provided in both public and private facilities. The proportion that the federal government reimburses is calculated state-by-state based upon the per capita income for that state. Mississippi, for example -- the poorest U.S. state -- is reimbursed for 83% of its total healthcare expenses, whereas wealthier states receive approximately 50% back from Medicaid/Medicare (Portela & Sommers, 2015). Since Puerto Rico is not a full U.S. state, federal fund matching for the territory is capped at 50%, despite the regional poverty level being double that of Mississippi (Noss, 2012). However, because of funding caps from Congress on the amount of money that can be allocated to U.S. territories, that consistently fall below half of Puerto Rico’s total healthcare expenses, the Medicaid/Medicare reimbursement system in Puerto Rico in reality functions less as a fund-matching system and more as a fixed-block system where they receive reimbursement up until this funding cap (Mach et al., 2016; Portela & Sommers, 2015). The majority of Puerto Ricans rely on the public health system “Mi Salud,” which relies primarily on Medicaid and Medicare reimbursement (Mac et al., 2016). 94% of Puerto Ricans are insured -- a higher rate than in mainland U.S. Of this proportion, only 30% receive health insurance privately via an employer, and the rest are completely reliant on the underfunded Mi Salud system; this is in contrast to the rest of the U.S., where 60% of insured individuals receive that insurance from a private provider (Perreira et al., 2016).

While healthcare coverage is relatively high, the Puerto Rico healthcare system is also tasked with caring for a population that has a higher proportion of individuals in “poor health” than in the mainland US (Portela & Sommers, 2015; Colón et al., 2016). Puerto Rico’s disability rate is double that of the rest of the country’s, and the prevalence of diabetes is 50% higher, a worrying statistic that is also coupled with a much higher risk of death due to diabetes as a result of inadequate treatment, care and access to medication (Perreira et al., 2017). Puerto Rico also has one of the highest proportions of citizens currently living with HIV in the U.S; 17,000 people are currently diagnosed and managing the disease (Michaud, 2017). In addition to these intrinsic health problems, Puerto Rico also must frequently deal with epidemics common in Latin America such as dengue, chikungunya, and more recently, Zika (Michaud, 2017).

This was the public health backdrop against which the devastation of Hurricane Maria unfolded in 2017, with consequences that are as yet not fully clear. The official mortality data released by the U.S. counted 64 death resulting from the hurricane, but recent studies have asserted that upwards of 4,600 deaths are the result of the effects of the hurricane, and should be included in the official death toll (Kishore et al., 2018). It was not the high winds and flooding itself that has had the most drastic impact on the Puerto Rican population, but rather the destruction of key social and medical services. Water treatment and pumping stations were damaged or destroyed, and many existing water stores were contaminated by debris or pollution (Michaud, 2017). These facilities remained damaged or nonfunctional for more than a month in many cases, greatly restricting the population’s access to clean water. Food resources were similarly affected; grocery stores and warehouses were damaged or contaminated, and many people were wholly reliant on the Red Cross and FEMA for their meals until well into November of 2017 (Michaud, 2017; Zorrilla, 2017). Without consistent access to clean food and water, many people turned to streams and rivers for their drinking water, putting themselves at risk for parasites and other infections, that damaged hospitals often did not have the resources to treat (Rodriguez & Bluth, 2017). Damage to the power grid had a devastating impact on the functionality of hospitals and clinics in Puerto Rico; unless equipped with multiple backup generators, these facilities were more or less nonfunctional until access to electricity was restored. Repair of the power grid was prioritized in large cities, and so these hospitals were able to resume services the soonest -- but in many other areas, electricity was lost or intermittent for more than 16 months after the hurricane hit (Zorrilla, 2017). Damaged roads, collapsed bridges, nonfunctional public transport, and intermittent cell service meant that those in rural areas were disproportionately affected. Those suffering from chronic illnesses that require consistent medication or monitoring were left without access to vital services, and the long-term effects of this lack of treatment are still being felt today (Zorilla, 2017).

Support from privately-funded organizations and volunteer groups, mostly from the U.S. mainland, have been instrumental in helping to rebuild clinics, hospitals, and medical centers. In 2019, most of these services are once again functional, but some access and power issues remain (Artiga et al., 2018). Increasing healthcare needs of the population -- due to chronic diseases that went prolonged periods of time without adequate treatment as well as sharp increases in severe mental illnesses -- indicate that these already-damaged healthcare services will have to shoulder an even greater burden of care than they have in the past. A bill passed by the Federal government in February 2018 provided much-needed immediate support to Puerto Rico, increasing funds for relief processes and providing -- for one year -- a 100% match of Medicaid spending (Artiga et al., 2018).

While this aid is both welcome and necessary, it does not address the long-term needs of the healthcare system as it continues to recover from the hurricane. Once this year of financial support is over, the healthcare system will be funded with the same fixed-block system as before, and will have to support a population with increasing health needs using the same arguably inadequate sum of money. The Puerto Rican healthcare system was facing financial crisis before the hurricane, and in order to truly address the systemic issues that were exacerbated by this natural disaster, fiscal plans that extend further than just one year will be necessary to support it. This treatment of Puerto Rico’s healthcare -- guiding the system structure while restricting access to the funding that is necessary to support it -- is setting Puerto Rico up for failure. Ownership of a territory without allowing it full rights and voting privileges echoes unpleasantly of our colonial past -- and as the financial crisis worsens, it becomes more apparent that this colonialism seems to extend into the present.

Additional Resources

Understanding Puerto Rico’s Health Care Crisis

Further reading the declaration of bankruptcy in Puerto Rico in 2016

Comparative Statistics on the Financial Costs of Hurricanes

Countdown clock and activism information on the restoration of power in Puerto Rico

References

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Colón, H.M., Sánchez-Cesareo, M. (2016). Disparities in Health Care in Puerto Rico Compared With the United States. JAMA Intern Med.176(6):794–795.

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