Issues such as lack of transportation, food insecurity, and housing instability were all problems prior to the storm, but they've only gotten worse and led to a humanitarian crisis responsible for thousands of deaths.
In August, a study conducted by researchers at George Washington University's Milken Institute School of Public Health at the behest of the Puerto Rican government estimated there were nearly 3,000 excess deaths in the six months following the time Hurricane Maria made landfall last September compared with earlier periods. The new figures prompted the government to revise its official count of the number of deaths caused by the storm, which they previously reported as 64.
But the rise in mortality in the aftermath of Hurricane Maria is only part of some of the short- and long-term health challenges many of the island's residents face.
Health outcomes among Puerto Rico residents were a concern prior to the storm. Rates of infant mortality were 7.57 deaths for every 1,000 residents in 2015, according to a 2017 analysis by the Urban Institute, compared with 5.8 per 1,000 in the mainland U.S. Cancer, heart disease, diabetes and Alzheimer's disease were the leading cause of death and reflect an aging population where nearly 20% of residents are age 65 or above.
Levis said the prevalence of such chronic conditions has only grown after the hurricane, and the unmet need for health services throughout the island has increased. As of June 30, more than 1.6 million of Puerto Rico's population of 3.4 million were living in designated primary-care health professional shortage areas that are in worse shape than is typical. Less than 2% of health needs are being met in those areas of Puerto Rico compared with 48% of needs being met in such shortage areas nationally, according to the U.S. Health Resources and Services Administration.
Levis said boosting the island's ability to attract, or at the very least retain, its healthcare workforce would be a big step toward improving its emergency preparedness. Over the past decade, many healthcare professionals have left for the mainland U.S., where they can find higher pay.
A fiscal report released in April by the Puerto Rican government projected the impact of hurricanes Maria and Irma would cause an additional 600,000 people to leave Puerto Rico by 2023, compared with over 300,000 who left in the past decade, with the majority being young professionals such as doctors and nurses.
The declining population's impact has been twofold for the island's health system. Not only are there fewer skilled health professionals, but many of the remaining residents are elderly or too sick to leave, putting an even greater burden on healthcare providers.
Levis said a big contributor to the exodus of medical personnel has been the lack of parity between Puerto Rico's Medicaid reimbursement rates and those in the states.
Roughly 49% of the island's residents are covered by either Medicaid or the Children's Health Insurance Program, yet those programs have historically received less money than their counterparts in the states. As a territory, the island gets a fixed federal match rate of 55%, while state rates are based on per capita income.
Congress passed a budget bill in January providing Puerto Rico with 100% in Medicaid federal-matching dollars through September 2019.
But many argue for a more permanent solution to secure the funds needed to address current health challenges as well as to help providers prepare for future health emergencies caused by disasters.
“We're just looking right now to retain much-needed medical personnel,” Levis said. “Reforms at the federal level without a doubt would help Puerto Rico retain medical and clinical personnel and also provide the resources to prepare the island for further disaster.”