Earlier this month, the US House Energy and Commerce committee held hearings inviting one government representative overseeing the administration of Medicaid from each territory to testify their respective needs for long-term program funding. What was crystal clear is the dire need for health care support in the United States territories. Currently, the five US territories are facing a humanitarian crisis with supplemental federal funding set to be exhausted starting September 30, 2019. Commonly referred to as the “Medicaid cliff,” Puerto Rico Guam, Virgin Islands, American Samoa and the Commonwealth of the Northern Mariana Islands will return to insufficient capped funding if Congress does not act. What further compounds the Medicaid cliff is that half of all resident Puerto Ricans live below the federal poverty level, and a humanitarian crisis remains following hurricanes Irma and Maria. Puerto Rico still lacks the economic and health system infrastructure to deliver care to people in need. The plight of Puerto Rico and the territories is a clear example of how poorly devised and applied health policy can deepen inequity and formalize discriminatory barriers to health care.

How is Medicaid different for Puerto Rico and the Territories?

The Medicaid program for the five US territories is structured differently than it is for the states. Medicaid funding for the territories is capped and has a fixed federal share or matching rate. This is drastically different from Medicaid in the states where the federal share reflects a state’s per capita income and the flow of federal funding can ebb and flow with enrollment. While the Affordable Care Act (ACA) provided a temporary funding increase for the Puerto Rico Medicaid program the structural funding barriers remain and continue to limit access to care. This is yet another example of how Medicaid block granting fails to serve the needs of the people.

The Hurricanes and their Effects on Puerto Rico:

It is difficult to quantify the ongoing devastating damage of the hurricanes on Puerto Rico – while thousands of people died as a result of the hurricanes, many lost their lives in the aftermath due to a lack of access to care and continue to face barriers to care. The elderly population was hit particularly hard. In the Energy and Commerce hearing, Puerto Rico Medicaid Representative Ms. Angela Avilla emphasized how these deaths could have been minimized and/or avoided had there been adequate funding to sustain much needed long-term facility/nursing home work forces.

Additionally In 2018, there was a reported 16 percent increase in suicide rates after the hurricanes. In the aftermath of a natural disaster, the U.S. government should continue to prioritize the spectrum of health services needed for individuals facing physical and mental challenges. The Medicaid program can and should be a major player in addressing these needs.

Puerto Rico’s Medicaid program currently serves 1.5 million people, nearly half of its total population. Because of their recovering economy, they do not have the state funds to meet the health care needs of the most vulnerable members of the community. To limit funding to Puerto Rico and the Territories risks millions of lives, and is a blatant example of discriminatory policy with respect to health access.

What Can Advocates Do?

Hundreds of thousands of residents are at risk of being uninsured if Puerto Rico and the territories reach the Medicaid cliff. The inconsistencies which exist in federal treatment between territories and the U.S. states are concerning and reinforce a separate and unequal narrative. Congress has an opportunity to fulfill their responsibility to the American people by working to fix the injustices faced by the five territories. Now is our time to apply pressure to our representatives and urge them to protect the health and well-being of our territories, as they would for any of the 50 states.

Blog Author: Akil Reynolds, Health Equity Intern, Community Catalyst