United States Federal Policies Contributing to Health and Health Care Inequities in Puerto Rico

Abstract

Puerto Rico, a territory of the United States since 1898, has recently experienced an increasing frequency and intensity of natural disasters and public health emergencies. In 2022, Hurricane Fiona became the latest storm to attract media attention and cast a light on Puerto Rico’s deteriorating conditions, including infrastructural failings, health care provider shortages, and high levels of chronic illness. Although recent events have been uniquely devastating, decades of inequitable US federal policy practices have fueled the persistence of health inequities in the territory.

Here we demonstrate how existing health and health care inequities in Puerto Rico have been exacerbated by compounding disasters but are rooted in the differential treatment of the territory under US federal policies.

Specifically, we focus on the unequal US Federal Emergency Management Agency response to disasters in the territory, the lack of parity in federal Medicaid funding for Puerto Rico, and Puerto Rico’s limited political power as a territory of the United States. We also provide empirically supported policy recommendations aimed at reducing health and health care inequities in the often-forgotten US territory of Puerto Rico. (Am J Public Health. 2024;114(S6):S478–S484. https://doi.org/10.2105/AJPH.2024.307585)

On September 18, 2022, Hurricane Fiona made landfall in Puerto Rico, becoming the latest in a cascade of disasters to contribute to deteriorating public health conditions in this United States territory.^1,2 This category 1 hurricane poured as much as 30 inches of rain in some areas, which resulted in mass flooding that cut residents off from potable water, electricity, and health care services.¹ Over the past 6 years, Puerto Rico has experienced an increasing frequency and intensity of natural disasters and public health emergencies, including catastrophic Hurricanes Irma (category 5) and Maria (category 4) in 2017,³ a series of devastating earthquakes in 2019 and early 2020 (11 of them were magnitude 5 or greater),⁴ and the global COVID-19 pandemic.⁵

These compounding disasters have served to further erode public health and health care systems that have been operating under the constraints of a $70 billion government debt crisis,⁵ a crumbling public infrastructure,⁶ overburdened health care facilities,³ and a severe shortage of health care providers.⁷ In addition, between 2010 and 2019, Puerto Rico lost more than 400 000 residents to migration, representing an approximately 11.8% decline in the territory’s population.⁸

Although these disasters and public health emergencies have exacerbated health and health care inequities in Puerto Rico, the unequal burdens of deprivation, disease, and disability predate recent events. Before these compounding disasters, data from 2014 to 2017 indicate that 46% of Puerto Rican residents were living below the federal poverty level (vs 11% of residents of US states), more than 15% had a disability (vs 9% in US states), and 34% reported fair or poor health (vs 18% in US states).⁹ Despite these preexisting disparities and the recent multitude of consecutive disasters, the more than 3.2 million US citizens living in Puerto Rico¹⁰ have not been provided with equitable federal resources to adequately address the challenges they face.^11–13

In their 2020 AJPH article “Colonial Neglect and the Right to Health in Puerto Rico After Hurricane Maria,” Joseph et al. used a human rights–based approach to document contributors to health inequities in Puerto Rico after Hurricane Maria.⁹ We build on this framework to demonstrate how health and health care inequities in Puerto Rico have been worsened by compounding disasters and, ultimately, are rooted in the differential treatment of the island as a territory under specific US federal policies.

We focus on the unequal US Federal Emergency Management Agency (FEMA) response to disasters in the territory,¹¹ the lack of parity in federal Medicaid funding for Puerto Rico,¹⁴ and the limited political power of Puerto Rico under US congressional control.^9,15 In addition, we provide policy recommendations that have the potential to reduce health and health care inequities in Puerto Rico. More broadly, the observations and policy recommendations described here also have the potential to illuminate pathways to improve health for populations across the United States with similar experiences of disenfranchisement and federal underinvestment.

HEALTH AND HEALTH CARE INEQUITIES IN PUERTO RICO

Residents of Puerto Rico have a higher prevalence of diabetes, hypertension, asthma, cardiovascular disease, and heart attacks than residents of US states.^16,17 In 2016 and before the onset of the multiple public health emergencies and disasters, nearly half of the population of Puerto Rico was already living in primary care health professional shortage areas.^2,18 In fact, at 45%, Puerto Rico has the lowest retention and recruitment rate for primary care physicians in the nation, distantly followed by the District of Columbia as the next lowest at about 58%.¹⁸ Contributors to this shortage likely include providers in Puerto Rico earning less, on average, than half of the median wage of providers in the states¹⁹ and Medicaid reimbursement rates that are lower than the rates in the states.¹² These factors have led to a mass exodus of health care providers to the states in search of better working conditions and higher pay.^7,18

Health professionals who remain in Puerto Rico are overburdened with heavy patient loads, a dearth of resources, and difficult working conditions.^2,3 Although residents of Puerto Rico have overall higher levels of health insurance coverage—largely public insurance—than residents of US states,^17,20 quality of care is compromised by extensive wait times, limited appointment availability, and the need to travel longer distances to receive care.^2,7 As back-to-back hurricanes, earthquakes, and the COVID-19 pandemic impacted Puerto Rico, all of these public health and health care system conditions worsened.^3,5,17 Nonetheless, these events can only partially explain the current state of health in the territory, which has been deteriorating for decades largely because of inequitable responses and support from the US federal government.

UNEQUAL US FEDERAL EMERGENCY MANAGEMENT RESPONSE

In September 2017, Hurricane Maria decimated Puerto Rico’s physical, agricultural, social, and economic infrastructures.^3,6,9 A study published in 2019 confirmed and quantified inequities in FEMA’s funding distribution and response.¹¹ Just 9 days after Hurricane Irma made landfall in Florida in 2017, those affected had received $100 million from FEMA in response to an estimated $50 billion in damages (1:500 aid to damage ratio). In Texas, residents received $141 million in aid 9 days after Hurricane Harvey had caused an estimated $125 billion in damages (1:887 ratio). However, those affected by Hurricane Maria in Puerto Rico received only $6 million in the first 9 days after the storm in response to an estimated $90 billion in damages (1:15 000 ratio).¹¹

A 2020 audit report released by the Office of Inspector General under the Department of Homeland Security confirmed that FEMA mismanaged about $257 million in Puerto Rico after Hurricane Maria. According to the report, FEMA failed to manage the pressures of multiple and concurrent disasters occurring across the United States and neglected to appropriately enforce existing policies and procedures.²¹ In 2021, President Biden released $1.3 billion in funds to help Puerto Rico rebuild after Hurricane Maria and removed restrictions from $4.6 billion in additional aid.¹³

Although necessary moving forward, these funds arrived late and only partially compensate for the inadequate response in Puerto Rico nearly 4 years prior. These disparities in federal aid intensified the negative impacts of the economic restrictions already imposed on Puerto Rico by federal austerity programs in response to a $70 billion debt crisis in 2015.^5,9 The limited and often inappropriate response from federal authorities affected social safety nets and ultimately contributed to nearly 3000 disaster-related deaths in Puerto Rico.^11,15

The processes in place that influence FEMA aid distribution present important challenges that need to be addressed. This requires a close examination of the public law that guides this federal assistance mechanism, the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Public Law 100–707, known as the Stafford Act). Currently, the Stafford Act does not clearly articulate guidelines for disaster declarations, which are unilateral presidential decisions that initiate resource allocation. Furthermore, the law does not set clear criteria for FEMA disaster expenditures, which fall under congressional discretion.^22,23 As a result, FEMA aid distribution is largely ineffective in addressing the needs of the communities impacted by sudden and acute disasters because aid distribution is affected, in part, by political considerations.

There is some evidence indicating that US states that are politically important to a sitting president have higher rates of disaster declarations, and states with congressional representation on FEMA oversight committees receive higher amounts of aid.²³ A 2019 law review points to political bias influencing FEMA’s response after Hurricane Maria under the Trump presidential administration.²² Thoroughly reviewing the Stafford Act and addressing the presidential and congressional pathways for political influence may support more equitable resource allocation and could begin to disentangle the ties between political interests and FEMA aid distribution across the states and Puerto Rico.

Efforts toward achieving equity in resource distribution have started to emerge under the Biden administration. In 2021, Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government,²⁴ was issued to promote equitable distribution of federal resources and work against the historical underinvestment that has contributed to a cycle of compounding disasters for underserved communities in the United States. Although Executive Order 13985 applies to FEMA, there is no intentional language that promotes attentiveness to equitable aid distribution in the US territory of Puerto Rico. As climate change increases the frequency and intensity of these disasters across the nation, meaningful efforts at the federal level must be made to ensure that Puerto Rico’s needs are not overshadowed by those of the 50 states given its limited political influence and particular population needs.

LACK OF PARITY IN MEDICAID FUNDING

In Puerto Rico, approximately half of the population relies on Medicaid or the Children’s Health Insurance Program, as compared with 27% of the population in the states.^10,25 Despite this high level of need, Puerto Rico’s Medicaid program is funded through a capped block grant, which is unlike any of the 50 states.¹⁴ This annually fixed amount determined by the US Congress typically covers only 55% of the territory’s Medicaid expenditures, which leaves the underresourced local government responsible for the balance.¹²

As a result of these funding limitations, Puerto Rico’s Medicaid program has historically used a territory-specific income eligibility threshold.^14,26 To be eligible for Medicaid in Puerto Rico, individuals must have a family household income at or below 100% of the Puerto Rico poverty level, which is the equivalent of roughly 50% of the US federal poverty level. In contrast, Medicaid programs in the states operate as entitlement programs with a dollar-for-dollar federal matching rate of up to 83% for program expenditures and an eligibility threshold of up to 138% of the federal poverty level (in states that adopted Medicaid expansion under the Patient Protection and Affordable Care Act [ACA]).^20,26

This Puerto Rico–specific scenario has the potential to emerge as a significant issue across the nation, as the block grant structure has been proposed in previous legislative efforts to repeal and replace the ACA.^14,26 Research shows that if Puerto Rico’s capped funding model were applied to the states, it would significantly increase the cost burden at the state level, which would result in cuts to benefits.²⁶ This is what has occurred in Puerto Rico, where the local program does not cover many state-mandated benefits such as nonemergency transportation to medical care, nursing facility services, and home health services. Other benefits are also limited relative to the states, including preventive child visits and prescription drug coverage.^14,26

To achieve parity, the federal block grant structure applied to Puerto Rico would need to be replaced with an uncapped dollar-for-dollar state funding design to expand access to care and relieve many of the current pressures on the local Medicaid program. On December 29, 2022, the Consolidated Appropriations Act was signed into law, and the US government temporarily increased Puerto Rico’s block grant cap to 76% until 2027.²⁷ However, this midterm change fails to address the root issues of the block grant structure.¹⁴ As consecutive disasters strain these limited program resources, the territorial government’s ability to cover the approximately 1.6 million residents who rely on Medicaid continues to be threatened in the absence of a permanent solution.^12,14,20

A long-term solution was introduced by Congresswoman Nydia M. Velázquez (D-NY) in the form of the Puerto Rico Health Care Fairness, Accountability, and Beneficiary Access Act of 2021.²⁸ Although it did not move forward, the bill would have addressed many of the Medicaid funding challenges in Puerto Rico through 3 key strategies: (1) increasing the Medicaid matching rate from 55% to 83% for Puerto Rico by fiscal year 2031, (2) expanding required covered benefits by transitioning to the per-capita income structure used for state Medicaid by fiscal year 2032, and, ultimately, (3) eliminating the US territory Medicaid funding cap in Puerto Rico by fiscal year 2027.²⁸ These are all elements that can be reintroduced in a future iteration of a bill that has the potential to work toward reducing health care inequities in Puerto Rico.

While US legislators advocate for necessary changes to the block grant structure, health officials in Puerto Rico could consider expanding Medicaid coverage by leveraging Section 1115 of the Social Security Act.²⁹ Section 1115 grants the federal government authority to waive certain Medicaid federal requirements to allow for pilot or experimental projects that promote Medicaid program objectives within local jurisdictions.³⁰ Although these waivers are typically granted to states, a 2017–2018 disaster relief 1115 waiver was approved for Puerto Rico after Hurricane Maria.³¹

On the basis of this precedent, such a mechanism may have the potential to address current Medicaid challenges in Puerto Rico, including those associated with the lack of Medicaid expansion under the ACA²⁰ and the high cost of program operations under the current model that relies on multiple managed care organizations to provide health care services.³² For instance, an alternative approach to managing Medicaid block grant funds would be to opt for a single territory-wide managed or accountable care program similar to the 1115 waiver-led initiatives adopted in states such as Maryland and Massachusetts.²⁹ These Medicaid program restructuring efforts could reduce administrative costs and allow for a redistribution of resources toward high-need areas such as provider retention and expansion of covered benefits.

PUERTO RICO’S LIMITED POLITICAL POWER UNDER TERRITORIAL STATUS

Political marginalization is a well-established root cause of health inequities.^33,34 Puerto Rico is politically marginalized in the United States in terms of both public knowledge of the territory’s political status and its political representation. In 2017, a poll conducted after Hurricane Maria revealed that nearly half of individuals who reside in the states did not know that Puerto Ricans living in the territory are fellow US citizens,³⁵ despite the territory having been under US control since the Spanish–American War of 1898.³⁶ Strikingly, it was 100 years before the events of Hurricane Maria (in 1917) that residents of Puerto Rico were given statutory citizenship by the US Congress.³⁶ Decades later, as calls for self-determination increased, Puerto Rico was granted commonwealth status under the US Constitution in 1952.³⁶ However, Puerto Rico remains a territory of the United States under US congressional control without voting representation in Congress.^9,15,36

Although Puerto Ricans are US citizens, they are not able to vote in presidential elections and lack the political representation afforded to US states.³⁶ The territory does not have representation in the US Senate, and its sole resident commissioner in the US House of Representatives does not have voting power.³⁶ For context, if Puerto Rico were granted the federal representation afforded to states of a comparable size, the island area would have 2 senators and 4 representatives in Congress.³⁷ However, without this representation, Puerto Rico’s political power is weakened, and its ability to influence policies that directly affect the territory’s federal funding streams is limited. The inequitable FEMA aid distribution and Medicaid block grant structure issues are just examples of the consequences of this limited political power, which has devasting health implications for Puerto Ricans.

There is also a growing body of public health research showing that the absence of adequate political representation contributes to health inequities.^33,34,38,39 For instance, recent research has shown that felony disenfranchisement laws, which limit the ability of people with felony convictions to vote, pose a threat to health via bodily weathering processes linked to elevated stress hormone levels.^38,39 In the US states, where individuals are denied the right to political representation via racialized disenfranchisement, the targeted populations (e.g., people of color) experience more depressive symptoms, more functional limitations, and more difficulty performing activities of daily living.³⁸ Furthermore, disenfranchised citizens remain unable to influence social and health policies that dictate the resources allotted to address health and health care needs.

To address the root causes of health and health care inequities in Puerto Rico, those of us across all facets of the health sector must attend to the political determinants of Puerto Rican health inequities, including political disenfranchisement.⁴⁰ The people in the territory who live through the realities of consecutive and compounding disasters, differential allocation of federal resources, and restrictions to health care access and services produced by the Medicaid block grant structure are best suited to advocate for change. However, they are restricted in their ability to influence US federal elections and legislation despite Puerto Rico being a US territory and Puerto Ricans having US citizenship.^9,15,36 This existing disenfranchisement has the potential to be remedied through resolution of the Puerto Rico status issue.

Unfortunately, there is a long line of failed efforts toward a resolution. Since 1967, Puerto Ricans have voted in 6 plebiscites providing their views on the desire for a change in their political organization, but the territorial status persists.^15,41 On April 20, 2023, the Puerto Rico Status Act (HR 2757) was reintroduced by Representative Raúl M. Grijalva (D-AZ) in the US House of Representatives.⁴² This legislative act is distinct from several past efforts in that it does not include an option for continued territorial status. If passed, this bill would “enable the people of Puerto Rico to choose a permanent, nonterritorial, fully self-governing political status for Puerto Rico and…provide for a transition to and the implementation of that permanent, nonterritorial, fully self-governing political status.”⁴² Puerto Rican residents would be granted the right to vote on whether they would choose for Puerto Rico to be (1) an independent nation, (2) a sovereign nation in free association with the United States, or (3) a US state.⁴²

The path forward is for the Puerto Rican people to decide, but, regardless of future status, these 3 options would certainly limit federal power. More specifically defined, the Puerto Rican constituency would have the power to exercise influence over the health and safety of the population as a fully enfranchised citizenry.⁴¹ This would improve health by giving the people control over the decisions that guide domestic resource allocation. In addition, this change in the political structure could act to reduce the detrimental health effects of internalized oppression and disenfranchisement via the empowering benefits afforded through access to full voting rights in Puerto Rico.³⁹ Furthermore, by framing Puerto Rico’s political status and lack of political representation as political determinants of health, we have proposed a paradigm shift for individuals in the health and health care sectors to consider. Through this lens, the opportunity for health intervention exists at the ballot box, where the US constituency can elect federal congressional leaders who support a status change for Puerto Rico.

CONCLUSION

The compounding natural disasters and public health emergencies that have affected Puerto Rico in recent years have intensified health and health care inequities in the territory. However, deteriorating conditions have been centuries in the making and are rooted in Puerto Rico’s limited political power to influence external controlling federal forces. This contributes to a lack of parity in federal funding that produces consistently overburdened and underfunded public health and health care systems.

Therefore, we call on policymakers, health leaders, and decision makers to consider the recommendations provided and take active steps toward eliminating federal policy-based health inequities in Puerto Rico. Among the recommendations offered, we once again elevate the importance of eradicating political bias from the processes by which FEMA structures and makes its aid determinations, supporting legislation that replaces the Medicaid block grant structure for Puerto Rico, and advocating for legislative status resolutions that establish voting rights and political representation for Puerto Rico. This will bring us closer to dismantling the components of US federal policies that contribute to health and health care inequities in Puerto Rico.