Healthcare, Funding, Power Woes Still Plague Puerto Rico One Year After Maria

A new issue brief from the Henry J. Kaiser Family Foundation reports on healthcare and recovery efforts 1 year after Hurricane Maria struck Puerto Rico and the US Virgin Islands (USVI), with residents still struggling to regain what they lost, a lack of capacity due to damaged facilities or lack of staff, and financing woes that will make moving forward difficult if they are not addressed.

Read more about the death toll in Puerto Rico.

Although Puerto Rico’s initial death toll was 64, researchers estimated in various reports that the number was far higher as residents died from lack of power to fuel medical equipment, lack of medicine or emergency care in the storm’s aftermath, and other probable factors. A recently released study commissioned by the governor of the island found total excess mortality of 2975 deaths in the 6 months after Hurricane Maria and revised its official death toll, although it called the number an estimate.Here is a look at some of the hurricane-related problems still facing the US territories 1 year after Hurricane Maria:

Healthcare and vulnerable populations

Healthcare providers are still seeing increased needs related to chronic conditions and medication adherence, particularly for diabetes. Access to dialysis treatment in USVI and on Vieques in Puerto Rico remains limited.

The elderly, people with disabilities, and other special needs populations remain the most vulnerable and need the most help obtaining medical services. Among Puerto Rico residents who have a debilitating chronic condition or disability or have a household member who does, 41% of those surveyed in a recent Washington Post/Kaiser Family Foundation (WaPo/KFF) survey said that a health condition had appeared or worsened because of Hurricane Maria.

In addition, vulnerable populations have been affected by outward migration, as relatives or other caregivers have left for the mainland. A draft Puerto Rican government report estimated that outmigration tied to Hurricanes Irma and Maria in the 2 years after the storms could match the 14% population loss from 2006 to 2016, although the final recovery plan removes this estimate.

The number of domestic air passengers leaving—another signal of outmigration trends—was roughly 125,000 people higher than expected in the 12 months ending in March 2018.

Provider gaps

In both territories, the hurricanes have worsened infrastructure limitations and an inability to offer competitive salaries, which have been longstanding barriers to recruiting and retaining staff. There are staff shortages in certain subspecialties or geographic areas, and patients must sometimes wait up to 9 months for specialist appointments following referrals.

Puerto Rico’s government has offered tax incentives and other strategies to try to fill gaps, but provider reimbursement rates in the continental United States are higher than those in the territories. Some community health clinics reported a 3% to 5% increase in patients due to the loss of private providers.

Mental health concerns

Anxiety about the current hurricane season has also increased mental health needs, and high levels of anxiety, depression, and posttraumatic stress disorder (PTSD) are a continued issue for residents trying to cope with the loss of homes, jobs, power and water disruptions, and delayed repairs.

The WaPo/KFF survey found that 22% of residents reported they or a family member either received or needed mental health services following Hurricane Maria, and 13% of those surveyed reported starting new or higher-dose prescription medication for emotional problems since the storm.

Suicide rates in Puerto Rico also remain high compared with 1 year ago, with an 18% increase in cases of suicide in the 9-month period after the hurricanes. In addition, there was a 13% increase in total calls to the main suicide hotline.

In USVI, provider shortages have exacerbated mental health issues. A behavioral health unit was lost due to storm damage, and first responder therapists who served patients immediately after the storms have largely left the territory.

Power woes

There are still frequent outages in Puerto Rico, despite the fact that the power authority there said it restored power this summer. That does not hold true for the offshore islands of Vieques and Culebra, which remain disconnected from the territory’s main electrical grid due to damage to underwater power lines. For now, they are powered via large generators until repairs are finished, a process expected to take 2 years.

Financing struggles

A certified fiscal plan calls for an $841 million cut in healthcare spending in Puerto Rico by fiscal year 2023. The reduction is causing anxiety among healthcare providers, as it calls for managed care organizations (MCOs) to shift from operating in 8 regions to a single territory-wide region.

Some officials think the changes could expand networks and access to care, but others are concerned about which providers will be included in the new MCO networks, because exclusion from the networks would be a major challenge.

In addition, both Puerto Rico and USVI fear the effect of the loss of additional support from Medicaid, which is scheduled to expire at the end of September 2019. Discussions with the federal government have started, but no decisions are expected until after the midterm elections in November. The federal budget bill in February 2018 included temporarily raising Medicaid support to a 100% federal match for another year, but without another adjustment, the territories’ rate will drop back down to 55%.

Why 55%? Because Puerto Rico and the USVI are territories and not states, their Medicaid funding is capped at a statuatory amount. States receive federal Medicaid funding on an open-ended basis, with a federal match rate that varies based on state per capita income. The rate the territories would receive would be much higher if it were based on per capita income like the states.