World Report
Puerto Rico's health system after Hurricane Maria
Published: 07 October 2017
Article Info
Hurricane
Maria has put pressure on Puerto Rico's health-care system, but a
looming budgetary shortfall could be even more devastating. Ted Alcorn
reports.
A fortnight after Hurricane Maria made landfall
on Puerto Rico, the island's shattered health system struggled to meet
even basic needs, and girded itself for a lengthy recovery
Because
municipal electricity had been returned to only a fraction of the
island, hospitals were operating with power from backup generators but
struggling to maintain supplies of diesel fuel. Phone service was
patchy, particularly in the mountainous region in the island's centre,
which hindered assessments of the needs of remote facilities. “We are
using social media and Facebook to try to communicate with the hospital
administrators around the island“, said Gilberto Gonzalez, chief
executive officer of the College of Healthcare Administrators of Puerto
Rico. He added that relief workers who have been working around the
clock need to be relieved.
Interruptions in health care
were a particular concern for vulnerable populations, among them people
with diabetes. One in seven Puerto Rican adults has been diagnosed with
the disease, a higher prevalence than in any US state, and the survival
of some 6000 Puerto Ricans with kidney failure depends on regular
dialysis treatment.
In the days following the storm, many
of the country's dialysis centres were closed due to lack of power or
water, but by October the situation had brightened. Chris Brown oversees
the territory's centres as executive director of the non-profit Quality
Insights Renal Network 3, and said that all but 33 of the island's
dialysis patients had been in touch with their main dialysis provider at
least once since the storm hit. About half of the island's dialysis
centres had access to water either through municipal systems or wells
and all but four were up and running on generators. “The long-term
sustainability of this really comes down to: can those supplies be
maintained on a regular basis, both diesel and water?” Brown said.
Even
as Puerto Ricans attend to the health system in the wake of this
natural disaster, a man-made disaster is looming. 1·4 million Puerto
Ricans are enrolled in the territory's Medicaid programme, known as Mi
Salud, and by spring of 2018, the federal funding that supports two
thirds of its budget will run out, with no plan yet to replace it.
The
funding, allotted as a one-time measure under the Affordable Care Act,
was intended as a patch for an imbalance that is decades old. Since the
inception of the Medicaid program in 1965, the federal government has
paid a share of each state's expenses, as much as 82% for the poorest
ones. But the federal contribution to territories like Puerto Rico is
capped, regardless of their low per capita income and high poverty rate.
Between 1999 and 2011, Puerto Rico was effectively reimbursed for just
17% of its Medicaid costs.
With such little federal
support, the territory has struggled to meet the health needs of its
residents, and coping with austerity has created additional problems. To
shave off costs, Mi Salud does not offer some benefits that are
mandatory in the rest of the USA, foregoing nursing facility and home
health services for elderly people and limiting coverage of early and
periodic screening, diagnostic, and treatment services for children.
Clinicians receive very low rates of reimbursement for their services,
which has propelled an exodus of thousands of health-care workers to the
mainland in recent years, draining Puerto Rico's health system of much
needed expertise.
In May, the US Congress appropriated
US$296 million to get Puerto Rico's Medicaid programme through the
fiscal year. A spokesman for Congresswoman Nydia Velásquez said she is
advocating that a more durable solution be included in the funding bill
in response to the hurricane. If the stopgap funding runs out before
lawmakers resolve on a way to replace it, the territory will fall off a
fiscal cliff: the Medicaid and Children's Health Insurance Program
Payment and Access Commission predicts a budgetary shortfall of $877
million in 2018 alone.
This would leave Puerto Rican
lawmakers with tough choices to make. Ricardo Rivera-Cardona, who
oversaw Mi Salud from 2013–16 as executive director of the Puerto Rico
Health Insurance Administration, says: “Either you reduce benefits or
you take one million people out of the programme—which creates a huge
impact on the lives of close to a third of the population”.
The
territory's immediate needs are so urgent that it is hard to look
beyond them, but some people hope the crisis will open up space for
fresh approaches to the structural challenges the island is facing.
Maria Levis, the chief executive officer of the social impact consulting
firm Impactivo, rode out the hurricane in San Juan and has been talking
with clients around the island in the weeks since. “We have just been
hit with a storm that has devastated all of our basic systems. Our folks
are suffering and there's a lot of poverty currently. And it's a good
time to think very deeply about the type of health system we want to
reconstruct.
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