What would you do if you or a family member couldn’t go to the doctor? What if the medical specialists in your town or city all left and went elsewhere? How would you function, or even stay alive, without your prescribed medications?
This is what 900,000 U.S. citizens of Puerto Rico and 18,000 U.S. Virgin Islanders are facing. Guam, Samoa, and the Commonwealth of the Northern Mariana Islands are also confronted with this same critical situation. It has been called the “Medicaid fiscal cliff,” which does not describe with enough urgency what this means to the people who will be affected by a loss of health care funding.
The Henry K. Kaiser Family Foundation reports in its Medicaid Financing Cliff: Implications for the Health Care Systems in Puerto Rico and USVI:
The expiration of temporary federal Medicaid funds without legislation to provide additional funds would result in significant funding shortfalls and have severe consequences for territory budgets, coverage, and health care systems more broadly. The local governments in Puerto Rico and USVI would not be able to make up for lost federal funds and therefore would not be able to sustain current service levels. Some territory officials and providers described the potential effects of the funding expiration as “devastating,” “catastrophic,” and “scary.”
Back in April I wrote, in “Cutting off Puerto Rico's Medicaid is not a 'fiscal cliff.' It will push people off a cliff—to die”:
This is not hyperbole. This is about the reality Puerto Ricans are facing. The stress for so many who see the months going by and the cutoff date approaching is something I can’t even begin to communicate in just words. That stress is doubled and tripled by the knowledge that nothing is being done by the U.S. government.
There is anger. There is fear. There is depression. There are feelings of total abandonment.
Yes, there are those who soldier on, and no longer expect the national or local government to do diddly-squat, those who either are attempting to go it alone or are receiving aid from a wide variety of charities. However, charities cannot ever replace those who are ultimately responsible for Puerto Rico: the government of the United States of America.
It is April. Congress has gone home. It will also be gone the entire month of August.
Time flies by.
I dream of a day when people across the U.S. will give a damn. Sadly, I doubt I’ll ever see those dreams become reality.
It will always be too late if it is only going to be “heartfelt thoughts and prayers.”
Prayers will not raise the dead.
I wonder: Who among the living has the power to stop this tragedy before it happens?
Here we are in September. Enhanced Medicaid funding ends Sept. 30. The House will be in session only 14 more days this month.
Most people who are not closely following politics do not pay much attention (if any) to the legislative process, even though it is through that process that we can address life-and-death matters. We need to get the word out to focus the public eye on eliminating this catastrophe in the making.
Two bills—one in the House (HR 1354 or “The Territories Health Equity Act of 2019) and its companion bill in the Senate (The Territories Health Equity Act of 2019 -S 1773)—if passed and signed by Trump, will avert a crisis that could kill thousands upon thousands of our territorial citizens.
The House bill has 39 co-sponsors and as of July 9 of this year has been referred to the House Committee on Energy and Commerce.
Democratic Rep. Stacey Plaskett of the U.S. Virgin Islands reintroduced the House version back in March.
Delegate to Congress Stacey Plaskett on Wednesday again called for equitable treatment of United States territories when it comes to healthcare funding, announcing that she is reintroducing the Territories Equitable Health Act that seeks to lift the cap on the federal Medicaid match that exists only for U.S. territories.
“This has been an issue for decades. It has become an even more significant issue in the aftermath of the natural disasters that the territories have all experienced in the past two years,” Plaskett told reporters at a press conference in Washington.
In the Virgin Islands, even though residents pay the same taxes for Medicaid, Medicare and Social Security as employees anywhere in the country, federal law has set a cap on the federal match for Medicaid payments at 55 percent. Federal Medicaid match in the 50 states and Washington D.C., however, are open-ended; these jurisdictions enjoy a federal match from 50 percent up to 81 percent for the poorest states.
Here are the co-sponsors in the House:
Cosponsor |
Date Cosponsored |
Rep. Gonzalez-Colon, Jenniffer [R-PR-At Large]* |
02/25/2019 |
Rep. Radewagen, Aumua Amata Coleman [R-AS-At Large]* |
02/25/2019 |
Rep. San Nicolas, Michael F. Q. [D-GU-At Large]* |
02/25/2019 |
Rep. Serrano, Jose E. [D-NY-15]* |
02/25/2019 |
Rep. Velazquez, Nydia M. [D-NY-7]* |
02/25/2019 |
Rep. Jackson Lee, Sheila [D-TX-18] |
03/08/2019 |
Rep. Bass, Karen [D-CA-37] |
03/14/2019 |
Rep. Beatty, Joyce [D-OH-3] |
03/14/2019 |
Rep. Bishop, Sanford D., Jr. [D-GA-2] |
03/14/2019 |
Rep. Blunt Rochester, Lisa [D-DE-At Large] |
03/14/2019 |
Rep. Brown, Anthony G. [D-MD-4] |
03/14/2019 |
Rep. Clarke, Yvette D. [D-NY-9] |
03/14/2019 |
Rep. Clay, Wm. Lacy [D-MO-1] |
03/14/2019 |
Rep. Cleaver, Emanuel [D-MO-5] |
03/14/2019 |
Rep. Clyburn, James E. [D-SC-6] |
03/14/2019 |
Rep. Davis, Danny K. [D-IL-7] |
03/14/2019 |
Rep. Demings, Val Butler [D-FL-10] |
03/14/2019 |
Rep. Evans, Dwight [D-PA-3] |
03/14/2019 |
Rep. Fudge, Marcia L. [D-OH-11] |
03/14/2019 |
Rep. Hastings, Alcee L. [D-FL-20] |
03/14/2019 |
Rep. Horsford, Steven [D-NV-4] |
03/14/2019 |
Rep. Jeffries, Hakeem S. [D-NY-8] |
03/14/2019 |
Rep. Johnson, Eddie Bernice [D-TX-30] |
03/14/2019 |
Rep. Johnson, Henry C. "Hank," Jr. [D-GA-4] |
03/14/2019 |
Rep. Lawson, Al, Jr. [D-FL-5] |
03/14/2019 |
Rep. Lee, Barbara [D-CA-13] |
03/14/2019 |
Rep. Lewis, John [D-GA-5] |
03/14/2019 |
Rep. McEachin, A. Donald [D-VA-4] |
03/14/2019 |
Rep. Meeks, Gregory W. [D-NY-5] |
03/14/2019 |
Rep. Moore, Gwen [D-WI-4] |
03/14/2019 |
Rep. Pressley, Ayanna [D-MA-7] |
03/14/2019 |
Rep. Thompson, Bennie G. [D-MS-2] |
03/14/2019 |
Rep. Watson Coleman, Bonnie [D-NJ-12] |
03/14/2019 |
Rep. Soto, Darren [D-FL-9] |
04/12/2019 |
Rep. Espaillat, Adriano [D-NY-13] |
04/12/2019 |
Rep. Roybal-Allard, Lucille [D-CA-40] |
04/12/2019 |
Rep. Garcia, Jesus G. "Chuy" [D-IL-4] |
05/01/2019 |
Rep. Omar, Ilhan [D-MN-5] |
06/25/2019 |
Rep. Cohen, Steve [D-TN-9] |
07/11/2019 |
If your congressperson is not listed, contact them to find out where they stand, and ask them to vote yes when (and if) the bill gets to the floor of the House.
If they are listed, contact them and let them know you approve and they have your support.
The Senate bill was introduced on June 11 by Sen. Bernie Sanders and co-sponsored by Sens. Jeff Merkley, Kirsten Gillibrand, Richard Blumenthal, Kamala Harris, Cory Booker, Elizabeth Warren, and Ed Markey. It is currently sitting in the Senate Committee on Finance, chaired by Sen. Chuck Grassley. Grassley has responded, along with other Republicans, with “concerns.”
In addition to the preceding bills, on June 19, 2019, Congresswoman Nydia Velázquez of New York introduced H.R.3371: Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2019, which was referred to the House Committee on Energy and Commerce. It was co-sponsored by Reps. Darren Soto, Jose E. Serrano, Raul M. Grijalva, Adriano Espaillat, Alexandria Ocasio-Cortez, Jesus "Chuy" Garcia, Jenniffer González-Colón (Puerto Rico’s Republican resident commissioner and sole representative in the U.S. Congress), and Kathy Castor (summary here).
What is distressing is that I still see little or no awareness of or interest in pleas for people to pressure the Senate and the House to get this done.
The information is out there.
As you can see, 16 people (17 with me) liked this tweet, and 15 shared it.
The Kaiser Family Foundation has been tweeting about it regularly.
The foundation has pointed out that the Medicaid fiscal cliff will cause a mass migration to the mainland for those who can leave—and will wind up costing more, if the states on the mainland have to absorb an influx of people from Puerto Rico.
2019 Medicaid funding cliff could cause mass migration from Puerto Rico
Under these unequal, discriminatory regulations, Puerto Rico experiences a significant burden to cover its medically indigent. This steep fiscal burden has contributed significantly to Puerto Rico’s troubled fiscal situation, which helped lead to the government declaring bankruptcy. It also helps explain why health outcomes on the island are generally worse than in the states, with residents having higher rates of heart disease, diabetes and infant mortality.
Now these problems may become even worse. In February 2018, Congress approved additional funding for Puerto Rico through the Bipartisan Budget Act (BBA), which provided $4.8 billion for Puerto Rico. These relief funds expire at the end of September 2019, which means that just a few months from now, 900,000 Puerto Rican residents could lose their Medicaid coverage. Not only would this be disastrous for those already struggling on the island, but it could also financially burden southern states like Florida and northeast states like Massachusetts, Connecticut, New York and Pennsylvania, where residents of Puerto Rico most commonly migrate. If health conditions continue to worsen on the island, residents will have no choice but to move to where they have historically sought better health services on the mainland.
This health-driven migration could cost about $9.7 billion for the federal government and $6.1 billion divided among various states. By comparison, the cost of providing these services in Puerto Rico would total less than $4 billion. This potential mass migration is 100 percent preventable. Congress can act to immediately end the unequal funding of Medicaid for Puerto Rico and achieve stability in the island’s health care system. Through legislative fixes, Congress can change the formula of how the cap is calculated by covering the cost of all residents at or under 100 percent of federal poverty level, as is currently applied to the 48 contiguous states and Washington DC. This is one of multiple solutions that could help stabilize Puerto Rico’s health care system, getting rid of the cap would go a long way towards increasing the island’s financial assistance and getting its residents back on their feet.
The problem as I see it is that all this wonky information shared with other people concerned with health care policy issues does not communicate to the general public. It is “the fierce urgency of now” spoken of by the late Rev. Dr. Martin Luther King Jr. so many years ago:
We are now faced with the fact that tomorrow is today. We are confronted with the fierce urgency of now. In this unfolding conundrum of life and history, there is such a thing as being too late. This is no time for apathy or complacency. This is a time for vigorous and positive action.
There have been televised hearings. I have no idea how many people watched them. Not many, would be my guess.
The House Natural Resources Committee held a hearing on Medicaid funding for Puerto Rico, the Virgin Islands and other insular territories of the U.S.A. Representatives from the territories expressed in detail the impact of the current Medicaid funding challenges and the approximately 1.5 million citizens that may lose their health care access once Affordable Care Act funding expires September 30, 2019
Testimony and transcripts of the House committee hearing are available at Hearing: The Insular Areas Medicaid Cliff.
July 11
We have also acted decisively to address the dire humanitarian crisis looming in the territories. Today, we will consider a bipartisan bill that will provide four years of additional funds and an enhanced matching rate to Puerto Rico, and six years of additional funds and enhanced matching rates to the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, Guam, and American Samoa. It also makes important program integrity improvements that will bring greater transparency and accountability to these programs.
PBS NewsHour highlighted the doctor shortage back in January of 2018. As more and more medical professionals are forced to leave for the mainland, the existing health care system deteriorates.
From 2006 to 2016, the number of doctors in Puerto Rico dropped from 14,000 to 9,000, an exodus hastened by Hurricane Maria. With so many doctors leaving the island, many low-income families must travel long distances for medical appointments, and they can wait for months to see specialists. Special correspondent Sarah Varney of Kaiser Health News reports.
-
Sarah Varney:
From 2006 to 2016, the number of doctors here declined from 14,000 to 9,000. Families who lost their doctors are filling up waiting rooms, like here at a Varmed pediatric clinic in Bayamon, a suburb of San Juan.
Physicians say running a medical practice is a losing business in Puerto Rico. At San Jorge Children's Hospital in San Juan, a pediatrician earning about $89,000 a year can double his salary just by moving to the States. The low salaries reflect the island's widespread poverty.
Nearly two out of three children and half of all Puerto Ricans rely on Medicaid, and the territory receives far less money from Congress than poor states to pay doctors.
With so many pediatricians and other doctors leaving the island, many low-income families here must travel long distances for medical appointments. And they can wait for months to see specialists.
Sara Pallone braves the San Juan traffic with her son, Thiago, who was born with severe low muscle tone. A nurse travels with them. She drives an hour each way to Centro Medico, San Juan's public hospital, for her son's countless appointments.
Today's visit to a neonatologist was originally scheduled for last September. But since the hurricane, it has taken eight-and-a-half months to reschedule. The family scrambled for safety during the storm. They were turned away from two hospitals and a storm shelter that didn't have a generator to power Thiago's oxygen machine that he needs nearly all the time.
-
Sara Pallone (through translator):
We were five days without oxygen, and the baby started doing very poorly,so we had to get him right to the medical center. When we were there, the generator broke down, so we couldn't get the oxygen there either. And instead of trying to transfer him from hospital to hospital, they sent us home.
-
Sarah Varney:
But surviving the hurricane was just the first hurdle.
-
Sara Pallone (through translator):
And when the hurricane came, all of the appointments were canceled without warning. Many of the doctors didn't communicate with us to tell us they were canceled. We felt abandoned, like my son's life wasn't worth it.
-
Sarah Varney:
That sense of abandonment is pervasive in the island's Central Mountains. Telephone and power lines are still being restored.
Cables dangle from trees, roads remain badly damaged and power goes off and on. All of that has made it difficult to get medical care for even basic needs, like the flu or vaccinations.
At Salud Integral en la Montana, a community clinic in Orocovis, the lack of electricity and refrigeration ruined the supply of vaccines. Some children, like ®MDNM¯Tanya Burgos, missed their vaccinations for months after the storm.
But it's not only physical health challenges. Dr. Nelson Almodovar, a pediatrician at the clinic, says children, like 4-year-old Hiram Cruz Ortiz, are still showing signs of trauma from Hurricane Maria. He's anxious and refuses to sleep alone, and Dr. Almodovar wants him to see a psychologist.
Those added demands for care combined with the shortage of doctors makes staffing this operation difficult.
Gloria Amador runs seven clinics and four emergency rooms in this remote region. She says, while it's hard to get specialists to come here, she has many vacancies for primary care doctors as well.
October 2017, Lara Merling and Jake Johnston
Already in the midst of a fiscal crisis, Puerto Rico faces a long road to recovery from Hurricane Maria, a devastating storm it was ill-equipped to handle. The urgent efforts to address both the humanitarian needs and damage caused by the storm must also extend to solving the island’s imminent Medicaid crisis, a preexisting condition that plagued Puerto Rico before the hurricane and that has been exacerbated by it.
This paper examines the inadequate federal support received by Puerto Rico for its Medicaid program, and shows that ― barring immediate action from the US Congress ― the territory will not have sufficient funds to continue operating in 2018. While the cost of living is higher in Puerto Rico than the US average, health care services are the only item that is significantly less costly on the island.
Using 2016 Medicaid costs and looking at known migration patterns, we calculate what the federal government and states are likely to pay for providing Medicaid for Puerto Ricans moving to US states from 2018 to 2027 using two different migration scenarios. Under the more pessimistic scenario - a higher out-migration rate - more likely in the wake of Hurricane Maria, the cost for providing Medicaid to new Puerto Rican migrants stateside is $19.4 billion for the federal government and $12.3 billion among states, as compared to a total of $7.8 billion in Puerto Rico.
Mainstream media has failed.
Over the last two years, since Hurricanes Irma and Maria tore into the USVI and Puerto Rico, it has been difficult to sustain media focus and mainland interest regarding conditions on the islands. There have been a few spikes when Donald Trump hurls yet another insult by tweet, or when for a brief moment the media was covering the massive protests demanding the resignation of Gov. Rosselló; however, all too quickly conditions on the islands fade from public view once again.
Those people who are paying attention are mostly those of us who either are Puerto Rican or Virgin Islanders, or have family and friends there. I have been engaged in political action about Puerto Rican concerns for 50 years, and I am neither Puerto Rican nor Latinx.
I am very afraid that even the massive death toll that will ensue as a result of the loss of health care may not be enough to ensure long-term solutions for the people who live in our U.S. colonial territories.
What you can do.
At the beginning of the year, I made a resolution to continue to focus on these issues. At that time I suggested that folks download the #TakeAction4PR toolkit, which was put together by a broad coalition of groups after the one-year anniversary of Hurricane Maria.
That suggestion still stands.
Armed with information, you can help spread the word and get other people in your family and social circles involved.
Call and email your elected representatives.
It lets them know that people are paying attention.
Thank you in advance.