When my father was a boy, hunger and disease were rampant in Puerto Rico. Decades later, he would still remember the pallor of the anemic countryside jibaros — poor and uneducated but revered for their close ties to the land — who traveled to San Juan in their Sunday best. In 1949, my father boarded the Spanish ship Conde de Argelejo in San Juan. He would arrive in Spain that fall to enroll at the University of Salamanca Faculty of Medicine. At the time there were only 537 doctors in Puerto Rico to take care of 2.2 million people.
My father would return to Puerto Rico in 1955 with a diploma, a pretty wife and a baby boy. By the time my brother joined my father’s rheumatology practice in the mid-1980s, there were 8,562 doctors for 3.3 million Puerto Ricans. The number of patients served per doctor had dropped from 4,116 to 383 in 35 years.
The quality of health in Puerto Rico had greatly improved as a result of federal economic development programs launched in the 1950s and increases in federal health funding. A medical school was opened, and the number of hospitals and medical personnel increased.
Thanks to these changes over the course of the 20th century, Puerto Rico’s population quadrupled between 1899 and 2000, and the mortality rate decreased by 80%. Life expectancy rose from 30 to 77 years of age.
Puerto Rico’s medical class was created in roughly one generation, transforming the lives and health of many people on the island as a result. Unfortunately, chronic health care underfunding — aggravated by Puerto Rico’s fiscal crisis and exacerbated by the Zika outbreak — threatens to undo in just a few years the gains made over the course of my father’s lifetime.
The financial turmoil in Puerto Rico has received widespread news coverage — even prompting a freestyle performance from Lin-Manuel Miranda on John Oliver’s “Last Week Tonight ” in which the composer-actor asked Congress to tackle the fiscal crisis. Treasury Secretary Jack Lew visited Puerto Rico on Monday to help galvanize Congress to authorize debt restructuring and provide aid.
What’s been less discussed is the degree to which Puerto Rico’s looming health crisis is deeply connected to its disastrous financial situation. One can even argue that disparities in federal health care programs, particularly in Medicaid and Obamacare, contributed to the fiscal crisis.
Medicaid, the federal health care program for low-income individuals, is capped for the territories, and federal matching funds are set at 50%. By contrast, the 50 states do not have a cap, and matching funds range from 50% to 83%.
To put this in perspective, Mississippi, the poorest state, received $3.6 billion in federal funds in 2014 for about 700,000 beneficiaries, while Puerto Rico receives $260 million annually and must spend more than $1.4 billion of its funds to cover about 1.2 million low-income beneficiaries.
Puerto Rico received a one-time boost of $6.4 billion under the 2010 Affordable Care Act. This amounted to $1.2 billion to $1.3 billion annually, significantly less than Mississippi and grossly inadequate. Obamacare funds could be depleted as early as 2017, at which point Puerto Rico will revert to receiving less than $300 million in Medicaid funds. A bankrupt Puerto Rican government is in no position to make up the difference.
Medicare, the federal health insurance program for the elderly, is another program that shortchanges Puerto Ricans, even though they pay the same Medicare tax as mainland residents. More than three-quarters of Medicare-eligible residents in Puerto Rico enroll in Medicare Advantage Plans, making them the primary source of health care coverage for the island’s senior citizens. For a variety of reasons, Medicare Advantage pays 40% less per capita in Puerto Rico than in the states.
Medicare reimbursements for Puerto Rico’s 71 hospitals are also lower than those of their mainland counterparts. To make ends meet during the local funding cuts prompted by the recent economic crisis, hospitals have closed floors, reduced staff benefits and encouraged early retirement. Jaime Plá, chief executive of Puerto Rico’s Association of Hospitals, told a newspaper an estimated 3,000 hospital workers have been laid off in the last 12 months.
Puerto Rico’s grim economic outlook has caused physicians to re-evaluate their working conditions. Frustrated and lured by higher salaries, many are opting to leave. Between 2014 and 2015, Puerto Rico lost 864 doctors, according to the Puerto Rican Surgeons and Physicians Association. As result, Puerto Rico is experiencing a shortage in many specialties. For example, only 90 obstetricians are left to handle an average of 34,000 births annually.
Meanwhile, the Zika outbreak has compounded the health crisis exponentially. The Centers for Disease Control and Prevention estimates that one quarter of Puerto Rico’s population will be infected with the virus. The island’s public health system is ill-equipped to manage and contain the disease. To avoid a catastrophe, it is imperative that the federal government step in to bridge the gap.
Last week, the Pittsburgh Pirates and Miami Marlins scrapped a two-game series in Puerto Rico due to concern about the Zika virus. The series will be played in Miami, in the county with the largest concentration of Florida’s 105 confirmed Zika cases. Cancellation of the series has stirred an uproar among Puerto Ricans, who feel their island is being unjustly penalized and who fear tourism will suffer.
Saddled with a $72 billion debt load, Puerto Rico’s bankrupt government can no longer cover the health care gap between what the U.S. government is willing to provide and what its citizens desperately need. The American citizens of this U.S. territory deserve to be treated fairly, particularly in the face of a potential Zika epidemic. Should the United States fail to intervene, the damage done to Puerto Rico’s health care system could be irreversible and its consequences deadly.