My cousin Lydia is a 48-year-old woman from Puerto Rico and a U.S. citizen. Her 15-year-old son Juan Jose has muscular dystrophy, which has weakened his muscles to the point where he is unable to walk.
Puerto Rico needs full payments from federal programs
He needs close monitoring by a team of medical specialists and a lifetime of physical and occupational therapy in order to be functional and independent. When Juan Jose was 6, his condition forced him into a wheelchair, but because his Medicaid plan in Puerto Rico would not cover wheelchairs—much less his long-term medical care—he and his mother left Puerto Rico for the continental U.S. to get the medical services he needs.
Sadly, their story is not unusual. Decades of chronic federal underfunding through Medicare and Medicaid have severely strained Puerto Rico's healthcare system, where Congress imposes two caps on federal contributions to Medicaid. A percentage cap sets the maximum federal contribution in Puerto Rico to 50% of costs—yet this is the minimum percentage the federal government contributes in the States. Even more prohibitive is an annual spending cap that structures federal contributions as a block grant with a specific dollar amount. This cap essentially limited federal Medicaid funds for Puerto Rico in 2008 to roughly $20 per participant per month, compared with $330 per participant per month in the States. Put another way, Puerto Rico shoulders approximately 80% of the costs of its Medicaid program. That's why Medicaid plans in Puerto Rico cannot cover a simple wheelchair.
Another problem: Medicare pays Puerto Rico hospitals, on average, 28% less than it pays hospitals in the 50 states. Puerto Rico is the only jurisdiction that does not receive 100% of national payment rates for Medicare services. Instead, the formula for our hospitals is based on a blend of 75% national rates and 25% Puerto Rico rates, which are significantly lower than national rates. This blended formula cost Puerto Rico's hospitals more than $24 million in Medicare reimbursements last year.
Not surprisingly, these glaring funding disparities affect not only the quality of care patients receive in Puerto Rico, but also hospital bottom lines. The island's hospitals are slashing their budgets, laying off key staff, cutting investments in new technologies, and delaying renovations to aging facilities—most of which date to the late 1970s. Some of our hospitals have been forced to further compromise access and quality by cutting inpatient beds and outpatient services. One hospital recently closed an entire inpatient floor with 52 medical and surgical beds. And like the mainland, Puerto Rico has been hit hard by the economic downturn, so things may get even worse before they improve.
Then there is the steady exodus of our desperately needed caregivers. Hospitals and other healthcare facilities simply cannot pay their clinical staff enough to keep them in Puerto Rico. Time and again, we lose our young doctors and nurses to the mainland, where they can earn higher wages. The flight of talented healthcare professionals has left severe workforce shortages in Puerto Rico that often deny patients the services they need. For example, there are currently only 207 general surgeons practicing in Puerto Rico, or one surgeon for every 18,000 residents. It's not nearly enough.
And it doesn't have to be this way. As President Barack Obama wisely pursues an immensely ambitious healthcare reform agenda, Puerto Rico's healthcare goal is far more modest: hospital funding and reimbursement
parity with the 50 states. After all, Puerto Rico participates (if in disparate fashion) in the very programs that will be at the core of national healthcare reform—Medicare and Medicaid.
Thankfully, legislators such as Rep. Charles Rangel (D-N.Y.)—whose hometown, New York, is home to 800,000 Puerto Ricans, the largest group anywhere outside of Puerto Rico—and members of the Senate Finance Committee have recognized the importance of healthcare parity for Puerto Rico. HHS Secretary Kathleen Sebelius recently confirmed that Medicaid and Medicare parity for Puerto Rico is “firmly on the table” in federal healthcare reform debates in Washington.
But these leaders can't do it alone. The millions of Puerto Ricans living in all 50 states must mobilize and urge their elected officials—some of whom are of Puerto Rican descent themselves—to advocate forcefully for Congress to remedy decades of chronic underfunding of hospitals in Puerto Rico. Their families and friends in Puerto Rico deserve nothing less.
Because if these Medicare and Medicaid funding inequalities are not addressed, the quality of care in Puerto Rico will continue to decline, and hospitals and providers will be forced to make even more drastic cuts in services. More and more Puerto Ricans will have no choice but to travel to the mainland to get the medical care they deserve—and should be able to receive—at home.
The benefits of healthcare reform must extend to the 4 million U.S. citizens who live in Puerto Rico. Puerto Ricans pay into Social Security and Medicare. They deserve the same high-quality medical care that patients receive in the 50 states.
We are all Americans. We only ask that when Puerto Rico comes to the table in this year's health reform debate, President Obama and Congress fulfill their promise to give Puerto Rico its fair share of Medicare and Medicaid funding.
Jaime Pla Cortes is president of the Puerto Rico Hospital Association.
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