On Feb. 26, Puerto Rico Gov. Ricardo Rosello sent a letter asking congressional leaders to help reverse the U.S. Treasury Department's decision to reduce a $4.7 billion disaster relief loan to $2 billion. Congress approved the loan in October. The Treasury has yet to allocate any portion of the loan. On Feb. 8, Congress approved $6.8 billion in disaster relief for Puerto Rico as part of a budget deal, including $4.9 billion to the island's Medicaid program.
Currently 61% of the island's population is insured by either Medicaid, the Children's Health Insurance Program, a Medicare Advantage plan or traditional Medicare, compared with 31% who are covered by a commercial insurer.
The rate at which Medicaid reimburses providers in Puerto Rico has historically been much lower than in the 50 states, averaging about 50% of health costs. The island also has a federal cap on total Medicaid funding because of its status as a U.S. territory. Coupled with the lower rate, that puts the actual rate at which federal funds cover costs at roughly 23%, according to a 2017 Urban Institute report. By contrast, states with the same poverty rate as Puerto Rico, 44%, would have 83% of their Medicaid costs matched by federal dollars.
"We are underpaid, and that makes it more difficult for us to perform the type of improvements that need to be done for the long term," Plá Cortes said.
As was the case when Hurricane Katrina hit New Orleans in 2005, the federal government will pay 100% of Medicaid health costs in Puerto Rico for the next two years thanks to the budget deal that passed. Plá Cortes said that will help providers begin making longer-term infrastructure improvements, but he argued a more permanent funding change is needed.
"In many cases, we need to look at how do we do better infrastructure for some of the hospitals to make sure that they can withstand any catastrophe," Plá Cortes said. "From that point of view, I think one of the issues we have is how do we get reimbursement from the government here, and how do we get a permanent source of reimbursement from the U.S. government."
Despite a blackout in San Juan last week, there has been some progress toward recovery. Around 84% of the island has electrical power, not taking into account the temporary blackout; 97% of residents have access to drinking water, and all 68 of the island's hospitals are open, according to figures posted on the Puerto Rican government's site.
Aside from Medicaid reimbursement parity, Levis said a crucial component to Puerto Rico's recovery will be if it gets the kind of investments New Orleans got after Katrina to strengthen its primary-care infrastructure. Federal support brought more than 50 neighborhood health clinics to areas of that city that were without primary-care access before the storm. Mental health services were among the new offerings, a big need in New Orleans as residents dealt with the stress of recovery.
As was seen in New Orleans, depression has become a growing problem among Puerto Rico residents. A recent report found the number of suicides there increased by 18% in 2017 compared with 2016.
"That kind of funding vehicle for transformation will be vital," Levis said.
