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Katie Martin, Vice President

From the desk of ... Katie Martin

Delays are Destructive: Puerto Rico and the U.S. Virgin Islands Need Health Care Funding Now

February 7, 2018 | Health Care

Alongside more than 100 million people, I spent Sunday night watching the Super Bowl. As I voiced my approval that one of the companies touting hurricane relief efforts included Puerto Rico, my young son asked, “Why do you care so much about Puerto Rico?” I paused and said, “Because not enough people do, and there are families like ours without power or water. People there are hurting.”

I have spent my career working in health policy, with a focus on improving care for underserved communities, so I know how urgent it is that Congress act to alleviate the health care crisis in Puerto Rico.

Even before Hurricane Maria ravaged the island, systemic differences contributed to a lower quality health care system and worse health outcomes in Puerto Rico than in the rest of the United States. Women had to navigate a health care system with emergency department wait times of almost 13 hours and only 90 obstetricians/gynecologists on the entire island to assist in childbirth. Prior to Maria, one doctor was leaving the island every day.

Infant mortality and premature birth rates in Puerto Rico were, and remain, higher than the U.S. mainland. Additionally, people in Puerto Rico were less likely to receive certain preventive services. For example, less than 75 percent of women between the ages of 21 and 65 in the Commonwealth received a Pap test, compared to nearly 83 percent on the mainland.

And that was before Hurricane Maria, which substantially worsened conditions. Forty percent of Puerto Ricans were without power 4.5 months after the hurricane made landfall. Two in five hospitals on the island were running on generators rather than electric power seven weeks after the hurricane, threatening health services like dialysis and forcing patients to travel to the mainland for care. Health care providers say the destruction of basic resources like food, water, electricity and housing is exacerbating the health problems the island’s population is experiencing. Tragically, news outlets have reported recently that the suicide rate has increased to nearly one suicide per day, underscoring the acute need for mental health services.

Today, Puerto Rico is about to run out of funding for Medicaid — a major crisis since nearly half of the population relies on Medicaid (compared to 20 percent of people living on the mainland). This will hit women especially hard: More than half of Puerto Rico’s Medicaid enrollees are women and girls.

Medicaid has always functioned differently for the Americans living in U.S. territories, including Puerto Rico, than for people living on the mainland. For example, federal funding for Medicaid in all territories is capped in law — no money above that statutory limit can go to Medicaid in the territories. Moreover, reimbursement for Medicaid expenses in the territories is set in law at 55 percent, rather than calculated by the formula used for state Medicaid programs. If calculated by the same statutory formula used for the 50 states and D.C., Puerto Rico’s reimbursement rate would be 83 percent (the maximum allowable). If unconstrained, it would be 93.34 percent.

There also are dramatic differences in who is eligible for Medicaid coverage. A family of four in Puerto Rico with an annual income higher than approximately $6,600 would not qualify for Medicaid. On the mainland, this limit is $15,800 — a substantial difference.

Right now, Congress has the opportunity — and responsibility — to begin to right decades of wrongs and address the immediate health needs of our fellow citizens in Puerto Rico. In the budget deal under discussion now, Senate Democrats rightly pushed for funds to help Puerto Rico and the U.S. Virgin Islands (USVI) rebuild and improve their electric grids and infrastructure, money to support the Medicaid program, and a temporary increase of the federal Medicaid matching rate to 100 percent. This is progress, but Congress should also fully reimburse states hosting evacuees for their Medicaid costs and allow people from the U.S. territories affected by the hurricanes to self-attest that they are eligible for Medicaid.

In the longer-term, Congress must address the historical, systemic inequities that harm Americans in Puerto Rico and the USVI. Congress should make structural changes to the Medicaid programs in Puerto Rico, the USVI and the other U.S. territories to eliminate restrictive block grants. Congress should lift the limit on federal reimbursement and establish a matching rate that is consistent with how federal reimbursement is calculated for states.

It is my hope that by Super Bowl 2019, I will be able to tell my son that Puerto Rican families have the resources they need to enjoy a Sunday football game, rather than worry about basic necessities and access to affordable health care. On behalf of the 1.75 million women living in the Commonwealth and their families, and the thousands more living in the USVI, we urge Congress to act without further delay.


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