A recent survey of Puerto Rico voters found that only 32% believed statehood would bring more benefits and more funding for healthcare.
When respondents were asked the open ended question of what benefits they saw for statehood, just under one third mention healthcare improvements.
Yet underfunding of health care programs in Puerto Rico due to its current territorial status has real implications on the well being of its residents. Enhancements to Puerto Rico’s health system made possible through increased funding and related resources, made possible by elevating program standards closer to those in U.S. states, could lead to considerable improvements in health outcomes for the people of Puerto Rico.
Limited federal funding in Medicaid
Puerto Rico receives considerably less federal funding for Medicaid than U.S. states despite having a higher poverty rate. This results in lower reimbursement rates for healthcare providers, a weakened healthcare infrastructure, and limited access to services for residents.
Medicaid in the U.S. states responds to patient needs. The program operates differently in Puerto Rico. Instead of open-ended funding based on need, Puerto Rico’s territorial government receives a grant with a firm cap. The amount is less than the funding needed to serve the people in Puerto Rico who are eligible for benefits. This means that Medicaid recipients in Puerto Rico receive fewer benefits than those in the states. When the money runs out, there are no further Medicaid resources, regardless of patient need.
Disparities in Medicare
Medicare is a federal program for people 65 and older as well as for younger people with end-stage kidney disease. Eligibility does not depend on financial need.
Although Puerto Rico participates in Medicare, and Puerto Ricans pay Medicare taxes on their income, there are some key differences in program implementation in the U.S. territory. First, enrollment for doctor services under Part B of Medicare is automatic in the states upon the age of 65, but proactive enrollment is required by beneficiaries in Puerto Rico. There are significant financial penalties for late enrollment, and penalties accumulate over time.
In addition, physician reimbursements are paid at just a fraction of the rate for the states, and Medicare Advantage — which is more widely used in Puerto Rico than in the states — pays just about 40% in Puerto Rico of the rates in the states. In a 2022 letter to U.S. Secretary of Health and Human Services Javier Becerra, a group of Members of Congress complained about these disparities in Puerto Rico’s Medicare program.
“Americans in Puerto Rico pay the same Medicare payroll tax as mainland citizens,” points out Medicaid and Medicare Advantage Products Association of Puerto Rico (MMAPA) on its website, “And yet, Medicare enrollees in Puerto Rico receive the lowest level of federal Medicare spending per enrollee in the country.”
Lack of full representation
Puerto Rico has only a non-voting member in the U.S. House of Representatives, limiting its direct influence on national healthcare legislation. This lack of representation also affects the amount of grant money and other sources of federal funds received for healthcare in Puerto Rico. Puerto Rico’s current Resident Commissioner, Jenniffer Gonzalez-Colon, does not serve on any committees with jurisdiction over health care, further limiting Puerto Rico’s voice on national health issues, and Puerto Rico has no Senators. With greater presence in Washington, Puerto Rico could have related representation on all key committees of jurisdiction.
Brain drain
Many healthcare professionals leave Puerto Rico due to economic difficulties and limited opportunities, further straining the healthcare system. 72 of Puerto Rico’s 78 municipalities are officially classified as underserved.
Even in the states, many doctors limit the number of Medicare and Medicaid patients they see because of low reimbursement rates and large amounts of paperwork. In Puerto Rico, where reimbursements are even lower and half the residents are on Medicaid (another 11% being on Medicare or veterans’ benefits), it is difficult for doctors to thrive.
The costs of territory status
Recent research has found that death rates in Puerto Rico have continued to be extremely high even after the COVID-19 pandemic slowed. Chronic illnesses are rampant. Continuing as a territory is likely to prevent solutions to these problems, most of which have been ongoing for decades. All of them are direct results of territory status.
It is impossible to guess how independence would affect healthcare in Puerto Rico, since we cannot predict the nature of the government in a new nation of Puerto Rico. Statehood, however, would automatically provide equal federal funding, improved infrastructure, and a full voice in American government, as well as the full protection of the U.S. Constitution.
If only 32% of respondents to the survey foresaw that statehood would bring improvements in healthcare, it is fair to say that the group underestimated the effects.
