Community health centers in Puerto Rico could suffer in economic turmoil

Puerto Rico's federally qualified community health centers, which treat a growing number of the island's underserved residents, could be hardest hit by the U.S. territory's continuing financial troubles that are devastating its public healthcare programs.

The centers, which serve nearly 1 in 10 patients on the island, are particularly dependent on Medicaid funding, according to a recent study by the Milken Institute School of Public Health at George Washington University (PDF).

Medicaid accounts for 54% of community health center revenue, as compared to 42% across the U.S.

“We can't buy equipment or contract with employees if we don't have the money in our budget. We have to work with what we have,” said Leyda Nazario, president of the board of directors for the San Juan-based Puerto Rico Primary Care Association, which oversees the island's federally qualified community health centers.

Puerto Rico is struggling with a $72 billion debt crisis and is facing over $3 billion in federal funding cuts, including significant cuts to Medicaid and Medicare, which together serve more than 75% of the island's 3.5 million people.

The island already receives lower Medicaid funding levels than the rest of the U.S., with per capita spending about 70% lower than the national average. Reimbursements to the territory's widely used Medicare Advantage plans are 40% lower than comparable plans on the mainland, according to the study.

Medicare Part A spending for hospital care is also about a third lower than on the mainland, and the program must cover a far greater range of services because Part B coverage for physician services like those provided by health centers is not automatic like it is on the mainland. The study noted 18% of Puerto Ricans were only covered by Part A, and the absence of a Medicare low income subsidy program has put additional stress on the Medicaid program.

The Affordable Care Act provided an additional $5.4 billion in federal Medicaid funding to Puerto Rico between 2011 and 2019, but the island has to come up with $1.8 billion by 2018 for Medicaid or it will have to significantly cut the program.

Community health centers in Puerto Rico would also suffer from expected 11% cuts in payments to Medicare Advantage plans. Roughly 9% of patients who use community health centers have Medicare, most through Medicare Advantage. Medicare Advantage is much more popular in Puerto Rico than in the U.S. because the island leans on it to make up for inadequate Medicare funding. Puerto Rico has a 75% participation rate in Medicare Advantage compared to 32% on the mainland, and 16 out of Puerto Rico's 20 community health centers participate in the program.

Unlike their mainland counterparts, Puerto Rican centers aren't able to benefit from the cost savings that come from physician extenders, because nurse practitioners are not covered by Puerto Rican insurers, and physician assistants aren't allowed to practice on the island. They therefore have a higher average physician-to-patient ratio than mainland centers.

Community health center officials in Puerto Rico say they're also concerned about the sustainability of their clinics if direct funding from agencies like the federal Bureau of Primary Health Care, a part of the Health Resources and Services Administration, isn't expanded.

Alicia Suarez, executive director of the Puerto Rico Primary Care Association, said the grants have allowed centers to expand their services, buy new equipment, expand their hours and invest in information technology. But cuts to already low Medicaid and Medicare funding could be catastrophic, Suarez added.

The White House has said a territorial bailout is not on the table, so activists are pressuring Congress to pass legislation that would allow the territory to file for bankruptcy protection. Presidential candidates have weighed in on this idea, mostly commenting along party lines. The Obama administration has also proposed expanding Medicaid benefits.

The GWU study found that despite all of their troubles, Puerto Rican health centers outperform their mainland counterparts on 10 measures of quality or health incomes, including rates for toddler immunization, Pap testing and colorectal screening, as well as the percentage of hypertensive patients with blood pressure controlled. Leyda believes this stems from the centers' strong investment in education and prevention.

“We have to prove here that we use the money that we receive from them in a very positive way and to increase the quality of life of our patients, Leyda said. “We have to be creative … in providing health services for our population.”

Pedro Pierluisi, Puerto Rico's nonvoting representative in Congress, warns that as U.S. citizens, Puerto Ricans with the means to do so, could fly to the mainland to receive care, putting a strain on the U.S. healthcare system.