In 1917, Woodrow Wilson bestowed on Puerto Ricans a class of U.S. citizenship that was decidedly less than what residents of the mainland enjoyed. It was the start of a long history of inequitable treatment by the U.S. government, which today has left Puerto Rico with a weakened infrastructure, a tattered healthcare safety net, and high rates of chronic disease.
In the aftermath of Hurricane Maria, many on the U.S. mainland are turning their attention toward Puerto Rico and demanding action to address what has become a major humanitarian crisis, particularly in regard to the island’s decimated healthcare delivery system. What people might not realize, though, is that Puerto Rico has been fighting losing battles on multiple fronts of its public health war for at least a decade.
Even before Maria, Puerto Rico’s healthcare system was collapsing. Chronic conditions like diabetes and respiratory illness were already commonplace, as were the complications that arise from them. Every day, more people died from conditions that should have been manageable.
Puerto Rico now has the highest childhood asthma rate in the world. In a population of approximately 3.5 million, a half million people have diabetes. Everything from HIV infection to premature births to untreated substance abuse occurs in Puerto Rico more often, and with more dire consequences, than on the mainland.
How did the situation become so dire in a territory of the United States populated by U.S. citizens? To fully answer that question, you have to go back to Woodrow Wilson and a nation about to enter the First World War. From there, you can draw a direct line to the continued inequitable treatment of Puerto Rico today, the costs of which would have been devastating to the island’s population even had Maria never made landfall.
“A citizenship of inferior order, a citizenship of the second class.”
On March 2, 1917, not long before the U.S. entered World War I, Woodrow Wilson signed the Jones-Shafroth Act, which designated Puerto Rico an unincorporated territory of the United States and granted U.S. citizenship to all Puerto Ricans. Many Puerto Ricans were actively opposed to Jones-Shafroth. Luis Muñoz Rivera, a Puerto Rican statesman who favored self-rule for Puerto Rico, explained on the floor of the House of Representatives before the Act was passed:
My countrymen, who, precisely the same as yours, have their dignity and self-respect to maintain, refuse to accept a citizenship of an inferior order, a citizenship of the second class, which does not permit them to dispose of their own resources nor to live their own lives nor to send to this Capitol their proportional representation.
Rivera was talking about the fact that Puerto Ricans would be subject to the laws of the United States without having a vote in Congress (or in the presidential election). Their resources could be freely exploited, they could be drafted into the armed services, their land could be used for military bases and exercises, and they wouldn’t have much to say about any of it. Nevertheless, Puerto Ricans became U.S. citizens, whether they liked the terms of the deal or not.
One hundred years of ‘citizenship of inferior order’ has left Puerto Rico vulnerable to political whim and dependent on the goodwill of a government that has proven inconsistent in its support. It has left far too many Puerto Ricans poor and sick—and without hope.
[If you’re interested in learning more about the historical relationship between the United States and Puerto Rico, this essay in the “History, Art and Archives” section of the U.S. House of Representatives website is worth reading.]
Jones-Shafroth marked the beginning of a hundred-year lopsided relationship between the U.S. and Puerto Rico. Although Puerto Ricans got the right to elect their own governor in 1947, and ratified their own Constitution in 1952 (it had to be approved by the U.S. Congress before it could take effect), they have remained a commonwealth. As such, they still don’t have much control over or say in the federal government’s actions in Puerto Rico, even when these actions directly impact life on the island. And as “statutory citizens” they don’t always have to be treated equally with those whose citizenship is granted under the U.S. Constitution (i.e., those who are born or naturalized in one of the fifty states).
What does all this have to do with public health? For that we’ll return to a time a little closer to our own, and the effects of an action by President Bill Clinton that pulled the rug out from under Puerto Rico’s economy.
The U.S. Giveth and the U.S. Taketh Away.
In 2006, Puerto Rico entered an economic recession, the seeds of which had been sown ten years earlier when the Clinton administration launched a phase-out of a long-standing tax credit for businesses that located their operations on the island. Thanks to this tax credit, which had been in place since 1976, Puerto Rico was home to a booming manufacturing industry, with major U.S. companies like Johnson & Johnson and Coca-Cola providing jobs for significant proportions of the population. Once the phase-out was underway, however, companies began to leave, unemployment rates crept up, and the economy faltered.
Ultimately the recession turned into a full-blown crisis, due not only to the continued decline in manufacturing and resulting job loss but also to the U.S. government’s failure to enact effective policies to help stabilize the island’s economy and the Puerto Rican government’s mishandling of public debt.
[All of the causes of the economic crisis are too complex to go into in detail here. For a helpful overview of the history of Puerto Rico’s economy from 1815 to today, you can check out this timeline created by the Center for Puerto Rican Studies at Hunter College of the City University of New York.]
Puerto Rico’s economic crisis has played a significant role in the ongoing decline in the health of its population in multiple ways. Because of the recession, almost a half million people have left the island since 2005. According to a report released by the Urban Institute earlier this year, before Hurricane Maria, emigration from Puerto Rico to the U.S. mainland was already on track to exceed that of the Great Migration, which occurred between 1946 and 1960 and was the largest emigration of Puerto Ricans to the mainland to date.
Those who have been leaving Puerto Rico over the past 10 to 12 years have typically been younger and better educated than those staying behind. As a result, Puerto Rico’s population is increasingly aging and impoverished. The unemployment rate in Puerto Rico is twice that of the U.S. mainland. Taxes and the cost of utilities have gone up while the median annual income in 2016 was a pitiful $20,078, less than half of what it was in Mississippi, the poorest state in the union.
For both children and adults living in poverty, toxic levels of stress, poor nutrition, and poor living conditions are part of day to day life, and can both cause and aggravate chronic illness. Puerto Rico, which was already experiencing somewhat high rates of certain chronic illnesses prior to the recession, saw these rates rise further as 46% of the population slid below the poverty line.
But it wasn’t just the direct effects of poverty that contributed to Puerto Ricans’ worsening health.
A Weakened Safety Net Begins to Tear.
Because of the island’s commonwealth status, the federal government invests significantly less money in the healthcare safety net in Puerto Rico than it does for states. There is no cap on the amount the government reimburses states for their Medicaid costs, though there is a minimum reimbursement level of 50% (only fourteen states receive the minimum). Meanwhile, for Puerto Rico and other U.S. territories like the U.S. Virgin Islands, there is no minimum and the federal government’s share is capped at 55%. That means that while territories cannot receive reimbursement for more than 55% of their actual costs, they can and often do receive much less. In fact, as the Hill has reported, U.S. territories actually only get reimbursed for 15% to 20% of the actual costs of running their Medicaid programs.
To put actual figures on it, under the government’s poverty formula, Mississippi (the poorest state, you’ll recall) is currently reimbursed for 75.7% of its Medicaid cost. If Puerto Rico were funded using the same formula, it would be reimbursed for 82% of its cost.
The federal government also invests less in Puerto Rico’s Medicare program, paying most Puerto Rican providers a lower rate than it pays providers on the mainland. As a result, spending per Medicare enrollee is lower than it is for any state, despite the fact that Puerto Ricans pay the same Medicare payroll taxes.
[If you want to know more about federal funding of the healthcare safety net in Puerto Rico, read this excellent piece by Anna Maria Barry-Jester on Five Thirty Eight, the source I used for much of the information in this section.]
A relief package, no matter how large, will not be enough. The U.S. must invest in Puerto Rico’s recovery over the long term, and not just with funds but also with policy.
The economic crisis has put a significant strain on Puerto Rico’s already underfunded public healthcare system. Out of necessity, Puerto Ricans now rely much more heavily on the safety net than people on the mainland. Almost two-thirds of the population relies on some form of public insurance, compared to 29% on the mainland. Almost 50% of all Puerto Ricans are enrolled in Medicaid, and the funds contributed by the U.S. government represent only a small fraction of what it will take to provide care to Medicaid enrollees over the next twelve months. A study published in the Journal of American Medicine last year found that Puerto Ricans covered under Medicare Advantage (about 75% of all Medicare enrollees in Puerto Rico) received worse care on 10 out of 17 quality of care measures than Hispanic enrollees in Medicare Advantage on the mainland. According to the authors of that study, “there are several reasons to believe that the reported disparities reflect lower availability of healthcare and lower quality of care in Puerto Rico compared with the United States.”
Finally, about 10% of the island’s population gets it care at one of the island’s 86 federally-funded community health center locations. Federally qualified health centers (FQHCs), as they are officially called, are required to treat everyone, regardless of whether or not they have insurance or of their ability to pay. Funding for the entire FQHC program (throughout Puerto Rico and the fifty states) lapsed on September 30, when Congress, preoccupied by ongoing attempts by Republicans to repeal the Affordable Care Act, neglected to reauthorize it for the 2018 fiscal year. The funds still haven’t been authorized. Barry-Jester quotes Sara Rosenbaum, a noted health policy expert who is well-acquainted with Puerto Rico’s healthcare safety net, as saying that the community health centers there currently “don’t have enough money to function.”
Doctors Flee a Crumbling Healthcare System.
The hundreds of thousands of people who have left Puerto Rico for the U.S. mainland over the past ten years have included 36% of the island’s physicians. Today, there are only 9,000 doctors in Puerto Rico, as compared to 14,000 a decade ago.
The president of Puerto Rico’s Independent Physicians Association, Dr. Joaquin Vargas, told Reuters that before the recession, the Puerto Rican healthcare system was able to provide patients with “adequate care.”
Now, people can wait up to a year to see a specialist. There are not quite 60 endocrinologists and only one pediatric allergist on the entire island. There are fewer providers of all types in rural areas than there are in urban locations—not just doctors, but physician assistants and nurse practitioners. According to the federal Health Resources and Services Administration (HRSA), 42 of Puerto Rico’s 78 municipalities have at least one federally designated Health Provider Shortage Area (HPSA). A HPSA is a geographic area where HRSA has determined there are too few primary care, dental, or mental health providers to serve the current population. One municipality has a total of seven HPSAs.
A core principle of what is known as the “chronic care model” for treating chronically ill populations—a model that has proven to be successful in helping these patients stay healthier—is that patients must partner with their doctors on an ongoing basis in order to manage their conditions successfully. With fewer doctors available to see patients regularly, monitor their symptoms, make sure they are complying with their treatment plans, and adjust their medications as necessary, the health of individual patients and of the population generally declines significantly and rapidly. Which is what has happened in Puerto Rico.
The sick get sicker.
Over the past ten years alone, rates of chronic conditions like diabetes and asthma have climbed steadily.
- Puerto Rico now has the highest childhood asthma rate in the world. In one housing project on the island, 40% of the residents under the age of 18 have been diagnosed with asthma. There have been reports that young people covered by Medicaid have had difficulty obtaining their asthma control medicines.
- In a population of approximately 3.5 million, a half million people have diabetes—about 16% of the adult population, as compared to 10% on the mainland. Over the past decade, deaths attributable to diabetes rose 22%. Further, if it’s not properly managed, diabetes often leads to kidney failure as well as high blood pressure, and Puerto Ricans are experiencing both:
- Close to 6000 people on the island require dialysis.
- Soaring rates of diabetes have likely contributed to the 50% increase in deaths from hypertension.
Diabetes and childhood asthma are just examples of how bad things have gotten. Everything from HIV infection to premature births to untreated substance abuse occurs in Puerto Rico more often, and with more dire consequences, than on the mainland (for instance, the death rate from HIV/AIDS in Puerto Rico is four times higher than on the mainland).
One hundred years of “citizenship of inferior order” has left Puerto Rico vulnerable to political whim and dependent on the goodwill of a government that has proven inconsistent in its support. It has left far too many Puerto Ricans poor and sick—and without hope.
This is where things stood on La Isla del Encanto—the Isle of Enchantment—on September 20, 2017, when Hurricane Maria hit.
The results, as we know, have been catastrophic. More than a month later, most of the island remains without power. Many are without clean water. The actual death count is unknown.
A relief package, no matter how large, will not be enough. The U.S. must invest in Puerto Rico’s recovery over the long term, and not just with funds but also with policy. We must end the inequitable funding of Puerto Rico’s healthcare safety net. We must create incentives for physicians to return to the island and for private organizations—nonprofit and corporate—to contribute their expertise, their technological innovations, and their human resources to addressing the many aspects of the public health crisis.
We must reject the notion that there can be any such thing as “citizenship of the second class.” There are only our fellow Americans, and there are 3.5 million of them on the island of Puerto Rico waiting for what they are owed.
Photo Credit: © Can Stock Photo / believeinme