Health and Social Services in Puerto Rico Before and After Hurricane Maria

Short abstract

This overview of health and social services in Puerto Rico includes 31 courses of action to better recover from health crises, build a more resilient system to future disasters, and actively promote health and well-being.

Abstract

“In September 2017, Puerto Rico was struck by two major hurricanes—Irma and Maria—that intensified existing challenges in Puerto Rico's health and social services infrastructure. In the aftermath, the government of Puerto Rico created a long-term recovery plan built on an evidence-based assessment of the damage from the hurricanes and the ongoing needs across Puerto Rico. Development of the recovery plan was supported by the Federal Emergency Management Agency, other federal agencies, local stakeholders, and analysis from the Homeland Security Operational Analysis Center (HSOAC), operated by RAND Corporation under contract with the U.S. Department of Homeland Security.

HSOAC research provided the foundation for the 31 courses of action in the recovery plan addressing the health and social services sector. These actions are a mix of social, governmental, fiscal, and economic policies and reforms. This collection of actions presents an opportunity to build a more resilient health and social services infrastructure and regional health care networks to ensure reliable access to services, promote health and well-being, and more efficiently and effectively respond to public health crises and future disasters. The actions span the areas of health care, public health and emergency preparedness, environmental health, mental and behavioral health, and social services.

The damage and needs assessment and courses of actions cover four major themes: building system capacity to respond both during disasters and routine times; strengthening the health and social services workforce; strengthening support services for at-need populations; and creating health-promoting communities.

In September 2017, Puerto Rico was struck by two major hurricanes in quick succession. The first of these, Hurricane Irma—a Category 5 storm—skirted the northeastern coast of Puerto Rico on September 7, leading to widespread power outages and water service interruptions for several days. Less than two weeks later, on September 20, Hurricane Maria made landfall on Puerto Rico as a Category 4 hurricane with peak wind speeds of up to 155 miles per hour (mph). It was the most intense hurricane to make landfall in mainland Puerto Rico since 1928. The storm's path moved directly across the main island, only 25 miles from San Juan, the area of Puerto Rico with the highest population density. The effects of the hurricanes were widespread and catastrophic, including the failure of Puerto Rico's entire energy grid, cascading failures of transportation, communications, water supply, and wastewater treatment systems, and damage to other sectors including health care, social services, and education.

In response to the damage inflicted on Puerto Rico by Hurricanes Irma and Maria, Congress passed the Bipartisan Budget Act of 2018 on February 9, 2018 (U.S. Public Law 115-123, 2018), which required the governor of Puerto Rico, in coordination with the Federal Emergency Management Agency (FEMA), the Department of Treasury, Department of Energy, and other federal agencies, to submit a report to Congress that described Puerto Rico's 12- and 24-month economic and disaster recovery plan within 180 days of enactment of the legislation. That plan, Transformation and Innovation in the Wake of Devastation: An Economic and Disaster Recovery Plan for Puerto Rico, was submitted to Congress on August 8, 2018 (Governor of Puerto Rico, 2018b).

Michael Byrne, the federal coordinating officer responsible for overseeing FEMA's response and recovery efforts in Puerto Rico, asked the Homeland Security Operational Analysis Center (HSOAC), a federally funded research and development center (FFRDC) operated by the RAND Corporation, to assist with writing the congressionally mandated long-term recovery plan for Puerto Rico. To establish an evidence-based foundation for the recovery plan, HSOAC was also asked to conduct an assessment describing the damage from the hurricanes and remaining needs across Puerto Rico.¹

This study focuses on the damage and needs assessment and related courses of action (COAs), which are a collection of activities, policies, and actions that support the human capital investments and that were developed for Puerto Rico's health and social services sector by the Health and Social Services (HSS) Sector team. The HSS Sector includes five subsectors: health care, public health and emergency preparedness, environmental health, mental and behavioral health, and social services.

Given that many of Puerto Rico's current problems have roots that long predate the 2017 hurricanes, Puerto Rico's recovery presents an opportunity to implement social, governmental, fiscal, and economic reforms that would lead to a 21st-century Puerto Rico. For the HSS Sector, this meant that recovery planning was envisioned as an opportunity to “rebuild and enhance health and social service infrastructure and regional health care networks to ensure reliable and equitable access to health and social services and health-promoting communities, including an efficient and effective response to public health crises and other future disasters,” as described in the recovery plan.

This damage and needs assessment and related actions for the Health and Social Services Sector were developed to support Puerto Rico's recovery. The assessment and COAs draw on myriad data sources as well as stakeholder interviews and roundtables, literature reviews, and media reporting. Throughout the process, our team engaged with stakeholders and subject matter experts, including senior Puerto Rico Department of Health (PRDOH) and Puerto Rico Department of Family (PRDOF) staff, researchers at the University of Puerto Rico and the Inter-American University, local nonprofits in the education sector, health and social services researchers in Puerto Rico with expertise in the field, and island professionals with experience in disaster recovery and health system reform.

Key Challenges Facing the Health and Social Services Sector Before the 2017 Hurricanes

Prior to the hurricanes, Puerto Rico faced widespread and persistent challenges. Some of these challenges were specific to the health and social services sector, while others were more foundational (e.g., over a decade of economic decline) and exacerbated the challenges faced in other sectors.

Burden of chronic disease. Before Hurricanes Irma and Maria, overall rates of chronic disease in Puerto Rico (heart disease, diabetes, etc.) were higher than U.S. averages. For example, according to the 2017 Behavioral Risk Factor Surveillance System (BRFSS), 17.2 percent of individuals in Puerto Rico reported that they had been told by a doctor that they have diabetes, compared with 10.5 percent of individuals in all U.S. states and the District of Columbia. An estimated 9.9 percent reported heart disease or myocardial infarction compared with 6.6 percent in all U.S. states and the District of Columbia. Reports of stroke were similar for both populations. However, a greater percentage of those in Puerto Rico had been told they had high blood pressure (44.7 percent) than in US. states and the District of Columbia (32.3 percent) (Centers for Disease Control and Prevention, 2015). There are also significant age, gender, and economic differences in health risk among Puerto Rico's population. Women who suffer a myocardial infarction report more deaths (8.6 percent for women vs. 6 percent for men in hospitals) than men with the same conditions (Zevallos et al., 2012). Those at the lower end of the socioeconomic spectrum were at greater risk for diabetes, and diagnosed diabetes was more prevalent among women than men (age adjusted rates were 14 percent compared with 13.5 percent, respectively, on average) in 2016. Asthma was prevalent among young people, with a higher lifetime asthma prevalence in the younger age groups.

Prevalence of mental health problems. The overall rates of psychiatric, including alcohol disorders, in Puerto Rico prior to the storms were similar to those of the United States as a whole (23.7 percent and 26.2 percent, respectively, in 2015) (Canino et al., 2016), despite the level of poverty in Puerto Rico and the link between mental health and poverty. However, the prevalence of some psychiatric illness was not evenly distributed across demographic groups or geographic areas. For example, compared with those in other health regions, residents from the San Juan health region had the highest 12-month prevalence rate for alcohol use disorder (8.9 percent), alcohol abuse (8.2 percent), and alcohol dependence (2.5 percent) (Canino et al., 2016).

Population changes creating new vulnerabilities. Puerto Rico's population has become increasingly aged over the past decade as a result of natural aging as well as outmigration. In 2010 the median age was 37 years, and persons 60 years or older accounted for 20.6 percent of the population (768,905 persons). As of 2017, the median age had increased to 41.4 years and persons over 60 years comprised 26 percent of the population (871,429 persons) (U.S. Census Bureau, S2704, 2017a). This increase is expected to continue, with 39.2 percent of the population projected to be age 60 or older by 2050 (Puerto Rico Office of the Ombudsman for Elderly, 2014). By comparison, persons age 65 or older are projected to account for 22 percent of the U.S. population by 2050.² As of 2015, 39.9 percent of the population age 65 and over was estimated to be living at or below the federal poverty level (FPL) with Social Security (80.2 percent) and the Nutrition Assistance Program (NAP; 40.9 percent) as their main sources of income (Puerto Rico Office of the Ombudsman for Elderly, 2014). Because the risk for chronic health conditions increases with age, demand for health services and other support services will increase as the population ages. The continued economic decline and outmigration of working-age adults may in turn affect the government of Puerto Rico's ability to provide these services.

Environmental hazards. Puerto Rico has had long-standing challenges with water and air pollution as well as waste management. Before the storms, the island violated drinking-water standards for volatile organic compounds, total coliform bacteria, and disinfection by-products. Puerto Rico struggled with limited landfill capacity and low recycling rates, which created a waste management crisis (U.S. Environmental Protection Agency, 2016). Moreover, Puerto Rico also had many toxic waste sites, including 18 Superfund (hazardous waste) sites on the National Priorities List, or about 3.4 per 1,000 square miles. This compares with an average of 1.4 per 1,000 square miles across the United States (U.S. Census Bureau, 2012; U.S. Environmental Protection Agency, undated). Exposure to environmental hazards in Puerto Rico has been correlated with a high prevalence of childhood asthma (Loyo-Berrios et al., 2007), adverse birth outcomes (Aker et al., 2019), and water- and vector-borne disease outbreaks (Hlavsa et al., 2015; Sheffield et al., 2014). Unenforced building codes, informal housing, and storm-related hazards (e.g., mold) also present environmental hazards to residents.

Health care workforce and access to services. Provider shortages and access issues pose functional challenges for the health care system in Puerto Rico. As of September 30, 2018, there were 105 health provider shortage areas (HPSAs):³ 39 of these were primary care, 24 dental care, and 42 mental health care, according to the Health Resources and Services Administration (Health Resources and Services Administration, undated). Seventy-two of Puerto Rico's 78 municipalities have been designated as medically underserved areas; in 32 primary care HPSAs, the ratio of the population to primary care providers is 3,500 to 1 or higher. The issue of provider outmigration is a challenge as well, with 2,132 health professionals outmigrating to the United States in 2014, of which 361 were physicians. At the same time, there has been an increase in the number of people using some services, such as mental health care. There has been limited access to preventive programs, including psychosocial supports, particularly for low-income Puerto Ricans.

Health care finance challenges. Puerto Rico's financial challenges, combined with statutory limits on Medicaid reimbursements from the federal government, have constrained the government's ability to provide health care services. Unlike in the 50 states and the District of Columbia, where the federal government matches all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) for the state, FMAP in Puerto Rico is applied until the Medicaid ceiling funds and available Affordable Care Act (ACA) funds are exhausted. Somewhat lower Medicaid and Medicare reimbursement rates relative to U.S. states, combined with cost-of-living challenges, have put a downward pressure on payments for providers.

Vital records challenges. When Hurricanes Irma and Maria made landfall in September 2017, the Puerto Rico Demographic Registry reportedly was using a paper-based reporting system,⁴ which precludes the collection and sharing of real-time information on vital events after a disaster as well as the implementation of protocols for surveillance of disaster-related deaths. Attributing mortality following a disaster or other extreme weather events can also be hindered by under-identification and other challenges, such as limited surveillance periods (Uscher-Pines, 2007) or the type of methodology used to estimate mortality (Madrigano, McCormick, and Kinney, 2015; McCormick, Madrigano, and Zinsmeister, 2016).

Lack of access to income and food assistance. Despite continued need, the number of Temporary Assistance for Needy Families (TANF) recipients has been dropping consistently over time. Possible reasons given for this downward trend during a challenging economic environment included more cases reaching the 60-month limit, which increases attrition (i.e., exit rates are higher than entry rates), emigration from Puerto Rico, or other demographic changes that could affect the size of the eligible population (Cordero-Guzman, 2017). As of 2016, 45.1 percent of Puerto Ricans had incomes below the FPL (U.S. Census Bureau, S1703, 2016a), and 467,827 households received benefits from NAP (38.3 percent) (U.S. Census Bureau, DP03, 2017b). Because this program is funded via a capped block grant, $1.9 billion for 2017, it is not able to accommodate increased need (Wolkomier, 2017). As the economic decline progresses, families will continue to “time out” of some TANF benefits, which may exacerbate the situation for many already impoverished individuals across Puerto Rico.

Economic decline. Puerto Rico's economy had been generally declining since 2006. A number of factors likely contributed to this decline, including expiration of pharmaceutical patents, outsourcing of some pharmaceutical products from Puerto Rico to India and China, and to a limited extent, the 1996 repeal by Congress of a tax credit for U.S. corporations that generated income in Puerto Rico (MacEwan, 2016). Puerto Rico also was negatively affected by the Great Recession of 2008. The economy has remained in near-continuous recession for the past decade. According to the Bureau of Labor Statistics, 2018, there is low labor force participation (just under 40 percent in August 2017) and high unemployment relative to the rest of the United States. Given the lack of economic opportunities, an increasing number of young people and working-age adults migrated away from Puerto Rico, with the resulting population downturn exacerbated by a declining birth rate (U.S. Census Bureau, S1703, 2016). This migration away from the island, in turn, further decreased Puerto Rico's workforce and, consequently, its tax base.

With many working-age adults leaving Puerto Rico, an increasing share of the remaining population has been affected by poverty or other challenges. Some groups, including children, have been disproportionately affected by poverty. Many children in Puerto Rico live in impoverished conditions, with 56 percent living in poverty (less than 100 percent of the federal poverty level, or FPL) and 36 percent living in extreme poverty (less than 50 percent of the FPL) (Annie E. Casey Foundation, 2018). Over half of children live in families that rely in some way on public assistance. More than 80 percent of the 2016–2017 student population came from families with incomes below 150 percent of the FPL (Puerto Rico Department of Education, 2017). Rural residents have been especially hard hit by Puerto Rico's economic decline (Morelock et al., 2000; Skibell, 2018).

Fiscal transparency. The government of Puerto Rico has been hampered in its ability to address the island's economic and sociodemographic challenges because of a lack of fiscal transparency and accountability to stakeholders, and the government has faced fierce criticism as a result (Marazzi, 2018; Coto, 2018). As noted in a 2015 U.S. Treasury report, annual budgets have relied on unrealistic revenue estimates, resulting in the masking of structural deficiencies, and financial disclosure is lacking in clarity and deadlines have been missed, making it difficult to track progress on reforms (Government Development Bank for Puerto Rico, 2015). Similarly, the April 2018 “New Fiscal Plan for Puerto Rico” acknowledges that “periods of fiscal irresponsibility and lack of economic planning and transparency also contributed to Puerto Rico's financial crisis” (Governor of Puerto Rico, 2018a).

The Hurricanes' Impacts on the Health and Social Services Sector

The hurricanes exacerbated existing challenges in Puerto Rico's health and social services sector.

Health Care Infrastructure Damage

Many health care facilities incurred damage from the storms, although it was not evenly distributed. Most of the western part of Puerto Rico—the Mayaguez and a part of the Bayamon health care region—was classified as having low damage (on a scale of 0–14, with 1 being lowest). In contrast, parts of the northern, southern, and eastern regions were more significantly affected, including other parts of the Bayamon, Caguas, Fajardo, Metro, and Ponce regions.⁵

In some municipalities, federally qualified health centers (FQHCs)—those community-based care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas—were the only open and operational places where emergency and acute health care services were being provided around the clock in the first few months following the hurricanes. Clinical and diagnostic centers around Puerto Rico sustained considerable damage, with 28 of the 103 listed being severely damaged. The severity of damage was most acute for non-mountainous regions (five in mountainous regions and 23 in non-mountainous regions were severely damaged). FQHCs also sustained damage, which was split evenly between mountainous and non-mountainous regions. Of the 92 FQHCs in Puerto Rico, 20 reported being damaged with operational closure or at least significant limitations, and 10 of those 20 were located in the mountain region (Federal Emergency Management Agency, 2018).

Health Impacts

Damage to buildings and to electrical, water, and communications infrastructure closed medical and social service facilities and affected health and social service agencies' ability to operate. For some facilities, this disruption lasted for several months, but it varies. Even at facilities that remained open, services were compromised by intermittent access to power and water, lack of access to client records, and limited staff, many of whom were unable to come to work. With a high proportion of the population lacking access to potable water, residents sometimes resorted to unsafe sources, such as wells and/or faucets contaminated by waterborne pathogens or chemicals. Specific incidents reported in Puerto Rico included an outbreak of leptospirosis, a bacterial infection spread when urine from infected animals gets into water or soil, which occurred in October 2017; gastrointestinal outbreaks at multiple schools; an increase in the numbers of sick students; and an increase in the incidence of conjunctivitis and influenza, increases that were later corroborated (Oda et al., 2018; Adams et al., 2019). The presence of mold and proximity to debris, pests, and vectors (mostly waterborne) also resulted in unsafe living conditions in highly impacted areas. During site visits to elder-care facilities (public and private), which FEMA conducted in December 2017 and January 2018, increases in conjunctivitis and respiratory problems were reported to the HSS Recovery Support Function.

Increases in anxiety, depression, and post-traumatic stress disorder (PTSD) were widely reported following the hurricanes. Of the 2,500 people who have visited the emergency clinic since its opening after the storm, 90 percent were referred for mental health screenings (Dickerson, 2017). In addition, although the rate of suicide had fallen in the year right before Hurricane Maria, the rate had previously spiked during the height of the financial crisis (2008–2013), and initial reports indicate that it spiked again following Maria. At least 253 people committed suicide in 2017, a 29-percent increase from 2016. Eighty-five percent of these suicides were committed by men (Governor of Puerto Rico, 2017).

The Human Cost

The official death count released by the Puerto Rico Department of Public Safety was initially 64. However, a range of estimates have been published using a variety of coding and counting methods, and the official count was increased to 2,975 based on a study by George Washington University, commissioned by the government of Puerto Rico (Milken Institute School of Public Health, 2018).

Disruption of Social Services

Impacts to this subsector include loss of and damage to physical structures and interruption of service to clients and beneficiaries. Anecdotal reports of data loss have been refuted by Puerto Rico government agencies, although limited access to existing data and/or the need to re-collect data appear to have been difficult during the process of ascertaining case status. Similarly, locating and identifying participants after the storm was hampered by data access difficulties. Like other subsectors, social services have been affected by migration away from the island: As younger generations have migrated to other parts of the United States, an increasing number of senior citizens are living alone and may therefore be more vulnerable to financial exploitation (Puerto Rico Office of the Ombudsman for Elderly, 2014).

Emerging Issues

In summary, several health care system issues emerged in the wake of the hurricanes. First, hospital and health clinic use increased as compared with the use of primary care as a result of the infrastructure disruptions. Second, changes in the population mix after the hurricanes may have negatively affected certain vulnerable communities, but it is unclear what future service needs may be for that changing demographic. Third, full health care system restoration issues need to be addressed urgently, inclusive of addressing both physical damage and workforce retention.

Themes for Recovery and Courses of Action

The COAs discussed here are a collection of activities, policies, and actions developed to support the human capital investments identified in the recovery plan. The portfolio that was included in the plan addresses four themes that emerged during the damage and needs assessment.

Building Health and Social Service Systems Capacity

One of the critical challenges that was demonstrated through Hurricane Maria was the fragility of the health care system, including social, behavioral, and environmental health services. This component seeks to address ongoing resilience in the health care system to ensure flexibility and agility in response and long-term recovery. This includes the repair and rebuilding of hospitals and primary care centers. Health and social services require reliable electricity systems to function, so efforts to create a hardened electricity grid supported by alternative energy generators will be required to keep these services available in a future emergency. The portfolio also includes elements of routine function in the system, including stronger primary care options (e.g., community health centers/primary care clinics), better financing mechanisms (e.g., Medicaid/Medicare payment systems), and better data integration and digitization of health and related information.

Strengthening the Workforce and Its Capacity to Address Health Issues

Given the shortages in some health specialties and concerns about personnel moving away, the government of Puerto Rico intends to incentivize, retain, and train the health care and public health workforce through such initiatives as loan repayment programs and policies that allow nurse practitioners (NPs) and physician assistants (PAs) from other states to provide care in Puerto Rico. In addition, the government of Puerto Rico will focus on improving workforce capabilities in public health surveillance and vital records data use, which will be important during disaster response and under normal circumstances.

Strengthening Social Systems for Populations Most in Need

There are several populations with greater needs during and after disaster, such as those who are at home, seniors, those with chronic health conditions, and so forth. Thus, this component includes services and other supports that address these challenges, to ensure continuity during and after disaster and to limit disruptions to food, medication, technology, and other supplies required by these populations. One initiative focuses on transitioning to the more financially flexible Supplemental Nutrition Assistance Program (SNAP), while another option would be to implement long-term waivers to existing NAP regulations. Other COAs focus on developing public education campaigns and training to help detect child and senior abuse, enhancing food stockpiles to support the older adult population, and hiring additional child welfare investigators to reduce the backlog of child maltreatment investigations.

Creating Healthy Communities

Healthy communities support healthy people. Transportation, municipal infrastructure, education, economic development, natural and cultural resources, and telecommunications are all required to improve and protect the health and well-being of communities. Toward that end, the government of Puerto Rico proposes a range of initiatives, including deploying Wi-Fi and broadband internet connectivity (increasing access to health information to support healthy lifestyles and chronic disease prevention and management); providing incentives to move from remote communities to urban centers (increasing access to key economic and educational services); and offering better access to transportation and community resources, such as museums, parks, artist workspaces, and community centers, as well as natural resources (promoting access to services, healthy activities, and exercise). The government of Puerto Rico also intends to reduce water- and vector-borne disease transmission through improved public health surveillance and innovative mosquito-control practices. Closing unpermitted and unregulated dumps will further remove environmental and public health threats to the people of Puerto Rico. This focus on addressing broad and interconnected social and economic determinants—particularly in education and financial sectors—can have significant impacts on the population's health and well-being.

Implementation Considerations

Given the timeline and purpose of the recovery plan, creating detailed implementation plans was beyond the scope of our work. However, we conclude by describing a range of considerations that those involved in implementing the COAs should bear in mind.

• Implementation will require additional analysis, detailed planning, and adjustments. Each of the COAs will require at least some degree of additional analysis and the fleshing out of key details.

• Cost estimates will need to be updated. Similarly, cost estimates provided for the COAs were typically based on the best available information, but should be verified and updated, if necessary.

• Key partners will need to be identified and engaged. The COAs identify likely implementation partners. However, implementers will need to review and (as needed) revise the list of partners, contact them, secure commitments, and identify a more detailed division of labor, modes of communication, and options for coordination.

• Ongoing monitoring and formative evaluation will be needed to inform midcourse corrections throughout the implementation process. Monitoring and evaluation should focus on whether programs show signs of producing both relevant outputs (e.g., health services delivered) and outcomes (e.g., improved physical health).

• Dependencies with COAs in other sectors should be considered. The implementation of some of the HSS COAs depends on COAs in other sectors. For example, the Health and Social Services COA related to expanding telehealth assumes improvements in infrastructure, particularly stable and reliable telecommunication, that are addressed by the Comm/IT (CIT) Sector team.