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Prominent  U.S. Physician Argues Puerto Rico's Health Care System About to Unravel

Nov. 13, 2105─After defaulting on its debt earlier this year, Puerto Rico, already crippled by high rates of poverty and unemployment, faces a troubling economic future. But does it also face a health care crisis?

Jesse Roman, who was born in Puerto Rico and is now chair of medicine at the University of Louisville, believes it does. Roman writes in an essay published online in the Annals of the American Thoracic Society that "Puerto Rico appears to be spiraling into what some have characterized as the collapse of the island's health care system."

Roman points to recently published news reports that indicate:

  • Medicare reimbursement rates in Puerto Rico are 70 percent less than in the 50 U.S. states.
  • Half of all the island's residents depend on Medicaid, Medicaid and Medicare Advantage. Islanders eligible for Medicare are more than twice as likely to be enrolled in Medicare Advantage than their fellow citizens living in the states (60 to 80 percent compared to 31 percent).  CMS's planned 11 percent cut to Medicare Advantage will fall particularly hard on Puerto Rico.
  • Because of a cap placed in 1968 on Medicaid spending in U.S. territories, Puerto Rico will receive $400 million less this year than it would if it were a state.
  • Roman writes that the Puerto Rican health care system is further hurt because the Affordable Care Act as implemented in Puerto Rico did not require insurers to cover those with pre-existing conditions or impose an individual mandate to purchase insurance. As a result, many living on the island lack insurance.

"Without intervention, it has been estimated that Puerto Rico's health care system will suffer the immediate loss of half a billion dollars, hospitals will lose $150 million, doctors will lose $115 million and pharmaceutical companies will lose $65 million….," Roman writes, adding that there is "little hope" that the Puerto Rican government can close the gap.

Roman notes that last year, 361 (about 3.6 percent) of the physicians practicing in Puerto Rico emigrated, according to the Puerto Rican Medical Association. As a specialist in respiratory medicine and critical care, he is particularly concerned that there are only 102 specialists in these areas serving the needs of 3.5 million residents.

"Puerto Rican children living on the island show a higher prevalence of asthma than Puerto Rican children living in the South Bronx," he writes. "Death rates [in Puerto Rico] for influenza and pneumonia are among the highest in the U.S."

Roman notes in his essay that the Puerto Rican Healthcare Crisis Coalition proposes restoring Medical Advantage reimbursement rates, providing federal funds for local health insurance and asking the Centers for Medicare and Medicaid Services to "re-engineer" the Puerto Rican health care system's "patchwork" of rules.

"Clearly this is a complex problem, but one that needs tackling soon before it spirals out of control," he says. "While politics, race, and economics may cloud the issue, let's remember that the health of Americans is at stake."

The Annals of the American Thoracic Society (AnnalsATS) is an online international journal that delivers up-to-date and authoritative coverage of adult and pediatric pulmonary and respiratory sleep medicine and adult medical critical care. It is one of three journals published by the American Thoracic Society. The other two are the American Journal of Respiratory and Cell Biology and the American Journal of Respiratory and Critical Care Medicine, which has the highest impact factor in the field.