How U.S. Hurricane Relief and Healthcare Policies Are Leaving Puerto Rico Behind

In the span of a few years, the residents of Puerto Rico have weathered a series of devastating storms – including Hurricanes Irma, Maria and Fiona – and faced hundreds of earthquakes. Then the COVID-19 pandemic struck, straining the island’s healthcare infrastructure at a time it was already compromised.

“Puerto Rico has experienced multiple, escalating disasters in recent years. It is a recipe for health care challenges, to say the least,” said Anna-Michelle McSorley, a postdoctoral fellow at the NYU School of Global Public Health and the NYU Center for Antiracism, Social Justice and Public Health.

In an article published in the American Journal of Public HealthMcSorley and her colleagues describe how federal policy treats the “often forgotten U.S. territory of Puerto Rico” differently than the fifty states. As a result, these policies exacerbate existing health disparities in the territory.

The researchers focus on three key policy disparities that put the health of Puerto Ricans at a disadvantage: unequal disaster response from the Federal Emergency Management Agency (FEMA), the lack of equity in Medicaid funding, and Puerto Rico’s limited political power.

“Our lens needs to look upstream – which is so much of what we do in public health – to say, ‘This is where the policy is failing. This is where it’s creating a barrier, and that’s ultimately what leads to the consequences that policy has.’ we’ll see,” said McSorley, the study’s lead author, who will join the faculty at the University of Connecticut this fall.

NYU News spoke with McSorley about the unique public health challenges Puerto Rico faces and how U.S. policies contribute to inequities.

How has the U.S. response to natural disasters in Puerto Rico hindered recovery?

In the aftermath of Hurricane Maria in 2017, FEMA provided funding to the area. But a 2019 study looked at how much aid was sent in the following days, and Puerto Rico received significantly less than Texas and Florida, which had also been hit by major hurricanes that same year.

Additionally, the federal government conducted an internal investigation and determined that FEMA mismanaged approximately $257 million in Puerto Rico after Hurricane Maria.

But if we dig a little deeper to look at the policies that apply specifically to Puerto Rico, we can also look at the Merchant Shipping Act of 1920a federal law that regulates how cargo is transported by sea and requires Puerto Rico to import raw materials on U.S. ships.

As a territory, Puerto Rico cannot negotiate independently with other countries, so that limits the way raw materials come in. It also increases the cost of almost every product you can think of, especially food, because of the tariffs.

That policy creates an additional level of burden. Even if other governments were to try to figure out how to provide support after a natural disaster, it would have to come through the U.S. — which was also dealing with several other natural disasters in the contiguous United States at the time of Hurricane Maria.

How do federal policies impact Puerto Rico’s healthcare workforce?

Puerto Rico has a shortage of healthcare providers, both primary care and specialists. It’s a multi-layered problem, but one contributing factor is that Medicaid reimbursement rates are lower than rates in the United States.

About half of Puerto Rico’s population relies on Medicaid or the Children’s Health Insurance Program, so reimbursement rates are critical to maintaining the health care system.

Unlike states where Medicaid operates as an entitlement program, Puerto Rico’s Medicaid program is funded through a block grant that has historically been an annual lump sum that covered only about 55 percent of expenses.

Over the years, especially as hurricanes and COVID-19 hit, that percentage has varied. Congress has introduced legislation to increase the level of funding being sent. But the expansions applied to Puerto Rico to generate additional funding are about to expire, and legislation proposed to permanently strengthen the ability to gradually increase the Medicaid reimbursement rate — with the goal of a dollar per month to reach. -dollar match – hasn’t really progressed.

This leaves Puerto Rico unable to compensate its suppliers at a competitive rate, and the reality is that there are better paying jobs in the 50 states with higher compensation.

When it comes to training doctors in Puerto Rico, there are excellent medical schools on the island, but there are not enough residencies to meet the need for people to stay. Many medical students have to look for a place to live elsewhere – we will ultimately lose many healthcare providers there.

Once they leave, they are enlightened by the fact that they can get paid significantly more and improve their living conditions. Many want to return to Puerto Rico, but options are limited. If you are able to secure a position, you are likely to be in an underfunded infrastructure that cannot be reimbursed at the rate needed, with high demand from patients waiting months for an appointment.

That dynamic is challenging and can lead to burnout, especially after the pandemic.

How does political power play a role in these public health issues?

The Puerto Rican people are extremely politically active. Election day is a holiday: there are parades through the streets, flags, face painting, and everyone is actively involved in the political system. There is a very strong tradition of making the Puerto Rican voice heard.

While there is an opportunity to participate in the territorial legislative process with that force—Puerto Rico can vote for its own governor—they are still not a self-determination nation. They cannot vote for the president in American elections, and they have no senators with voting rights. They choose the Resident Commissioner of Puerto Ricoa member of Congress who is part of the House of Representatives, but this representative does not have full voting rights.

This makes it really challenging when you’re talking about things like FEMA money being mismanaged, or blocking Medicaid subsidies, which are acts of Congress. When you have a territory that has the ability to make local decisions, but no voting rights at the federal level, it creates severe restrictions and a system that is largely inequitable.

Do you think American perception of Puerto Rico plays a role in this?

Shortly after Hurricane Maria, a poll was conducted among Americans. It thought so almost half did not know that Puerto Ricans are fellow US citizens–citizens who contribute to federal tax revenue streams, follow federal laws, and serve in the military.

From a political perspective, if you say, “Hey, we need to send resources to this region,” that’s seen as a foreign issue. But that can complicate matters, because people may think, “Let’s focus on distributing resources internally” — especially in light of the simultaneous disasters in Texas and Florida.

Amid other domestic challenges, if there is a sense that the area is not a domestic space, people are less likely to disperse resources.

What can be done to reduce health inequalities? Should Puerto Rico’s status as a territory change?

The status question is current: whether Puerto Rico should remain a territory, or whether it should become a state or be independent. This question – which can literally tear families apart! – is often discussed at the dinner table.

I am one Nuyoricanborn in New York and raised between both spaces. In terms of statehood or independence, I believe the decision should be made by the Puerto Rican people; it should be up to them to decide the best path forward.

But I also think part of the solution lies in the Latino vote here in the fifty states, as Latinos make up a large portion of the demographic in the United States and are still growing. If we could unite and see the issues facing Puerto Rico as issues of solidarity among the Latino population, that would be a great way to move the needle on behalf of people whose votes cannot be counted.