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.