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How the Legacy of Colonialism Keeps Puerto Rico’s Healthcare System in Shambles

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Stan Shebs, CC BY-SA 3.0, via Wikimedia Commons

Almost half of Puerto Rico’s doctors have fled the island over the past decade,  leading to a lack of specialists and treatment and incredibly long wait times. And this isn’t just an inconvenience. People are dying from lack of care. Why is Puerto Rico’s health care system collapsing, and why are doctors fleeing the island?

We take a look at its deeply dysfunctional private medical system and why attempts to fix it, and create a universal health care plan on the island, are being hindered by Puerto Rico’s status as a US colony. Its massive unpayable debt, held by investors in the US, means that it cannot make its own economic decisions, even when it affects the livelihood of poor Puerto Ricans living there. But there might be a fix, getting rid of Puerto Rico’s debt and rethinking its colonial relationship to the US. 

 

Featuring:

  • Carolina (pseudonym for privacy)
  • Coral del Mar Murphy Marcos – journalist and author of an article on PR’s health care crisis. 
  • Paola (pseudonym for privacy)
  • Alberto Medina – Boricuas Unidos en la Diáspora

Music:

  • Daniel Birch – Indigo Strokes
  • Axletree – Goldfinch- Flight to the North
  • Mindseye – Spores
  • Soft and Furious – So What

 

Making Contact Team

  • Episode Host: Salima Hamirani
  • Producers: Anita Johnson, Salima Hamirani, Amy Gastelum, and Lucy Kang
  • Executive Director: Jina Chung
  • Editor: Adwoa Gyimah-Brempong
  • Engineer: Jeff Emtman
  • Digital Marketing Manager: Lissa Deonarain

   

TRANSCRIPT

Salima Hamirani: Welcome to Making Contact I’m Salima Hamirani. And today we’re talking about Puerto Rico’s failing Health Care system. And to start us off, we’re in Fajardo, a small town on the island’s north east coast, about 40 minutes outside of San Juan, with someone named Carolina. 

Carolina: I grew up in Florida with family here in Puerto Rico and I moved to the island permanently about seven years ago right before Hurricane Maria.

Salima Hamirani: Carolina is not her real name, but for today’s episode we’re giving our guests pseudonyms for medical privacy. And I wanted to talk to Carolina because her story is emblematic of the kind problems people in Puerto Rico face when dealing with serious health issues.

She already had some idea about what the medical system was like on the island –

Carolina: I had heard kind of anecdotally that, you know, the family that lived here or family that spent a lot of time here did not always find the doctors that they needed here. And so I was aware of people kind of traveling to other places in order to get the healthcare that they need.

Salima Hamirani: Carolina wasn’t thinking about her health when she first moved though

Carolina: I had always wanted to connect more with the family that lived here, connect more with my culture. And specifically, I, Have for many years worked in the agricultural agroecology space. I wanted to move here and be a part of that and support organizing and community efforts for food justice and food sovereignty on the island

Salima Hamirani: But then, something started happening to her heart. One day – after a period of high stress in her life – she noticed her heart was beating very irregularly – whats called an arrhythmia. And it wasn’t a slight arrhythmia, it felt pretty serious.

Carolina: I actually went to the emergency room because in the moment, um, I thought I was having a heart attack. And I went to the emergency room, I was checked out, the arrhythmia was noted and, you know, I was sent away with basically the recommendation to follow up with a cardiologist because they did see on the EKG that you know, something was not right.

Salima Hamirani: But there are aren’t that many cardiologists in Puerto Rico for a population of three point two million, so she was told she’d have to wait.

Carolina: The next appointment that I could get into was in six months. And I didn’t feel comfortable with that. I was, I was nervous. I was freaked out. I was like, what’s going on, you know, with my heart?

Salima Hamirani: Luckily Carolina had a family member who worked in the medical field, and so through the “cousin network”, she was able to push to find an earlier appointment. Which still took some time. Then she needed to get a specialized scan, which is when she hit yet another roadblock

Carolina: The electrophysiologist did determine that I needed to do a procedure. I needed to have done a procedure called an ablation, a cardiac ablation.

And so in order to do that procedure, I had to have a number of different tests: blood work, , um, echocardiogram, and also a very specific type of cardiac MRI in order to make sure that the structure of my heart was sound before going in and doing this procedure.

But when I went to make the appointment, I learned that there’s only two machines on the island that are capable of doing this particular type of MRI. One of which I was told was broken

And the other machine I called and again, was told that there was a month’s long wait and my electrophysiologist office specifically told me, you can’t wait three or four or five months in order to get this procedure. And so they instructed me to call the office of this MRI, every day and see if I could get an earlier appointment.

And that’s basically what I did for weeks on end. I would step outside of my work meetings to get on the phone with this office and basically beg for them to give me this MRI appointment earlier.

Salima Hamirani: She did eventually get a cardiac MRI and the procedure. But, from finding out she had a serious heart issue to finally getting the surgery took six months. And that’s for a serious health condition

Carolina: I mean, if I had not at every single step of the way, been pushing and calling and annoying the offices and begging and using my connections, it probably would have taken a year or more.

Salima Hamirani: And now because of her heart condition she’ll need to interact with the medical system in Puerto Rico A LOT

Carolina: I will need to see a cardiologist and, and potentially be on medication for the rest of my life. and I have to constantly interface with the healthcare system, the pharmacies, my doctors, specialists, it is kind of an ongoing source of frustration and stress.

And I do constantly have people asking me, well, isn’t it hard to live there? I mean, the medical system, the bureaucracy, all sorts of interconnecting systems that really make life like day-to-day life here sometimes, somewhat unbearable. I, I know that certain aspects of my life, especially managing chronic conditions would be a lot easier in the States. But I, I want to stay here.

Salima Hamirani: Carolina’s story is in no way unique. Experts have been sounding the alarm on Puerto Rico since hurricane Maria decimated what was already a fragile and vastly underfunded medical system. They’ve been arguing that it’s on the verge of failure unless the island is able to massively overhaul its healthcare system.

News Clip: And now to a growing problem in America’s backyard. Puerto Rico is in the midst of a healthcare crisis after a series of natural disasters hit its rapidly aging population. The Washington Post’s Arelis Hernandez writes, more people are dying in Puerto Rico as its healthcare system crumbles.

Salima Hamirani: And meanwhile – doctors are fleeing the island.

Coral del Mar Murphy Marcos:  One study by a think tank in Puerto Rico, called the Center for a New Economy. They estimated in 2023 that the island may have lost nearly half of its doctors in just over a decade. And they also reported that more than 8, 000 doctors are thought to have left since 2009.

Salima Hamirani:  That’s the voice of Coral del Mar Murphy Marcos. Coral is a journalist from Manatí who wrote an article for the Nation on the island’s healthcare system called “Puerto Rico’s Unnatural disaster.” Put another way, the island is now left with only one doctor for every 1000 patients. which means that if you want to see a doctor in Puerto Rico? get ready to wait.

Coral del Mar Murphy Marcos:  People cannot get a doctor’s appointment, and especially with, if it requires a specialty treatment, say a cardiologist, a gynecologist, even a dentist, really.

Salima Hamirani:  Those wait times aren’t just an inconvenience. In 2022, researchers found that there was an excess of 3,300 deaths on the island. That’s after correcting for the ongoing impact of COVID. Which means that Puerto Rico’s failing healthcare system is actively killing people.

Coral wanted to understand what was going on – especially because many of her peers who she’d studied with in the University of Puerto Rico, who wanted to be nurses or doctors, were struggling.

Coral del Mar Murphy Marcos:  They would be raised with the idea that becoming a doctor would, leave them with some sort of financial security and going into the healthcare system. They quickly realized that that’s not the case.

And while doing reporting, I realized that specifically, pediatricians are the doctors that are most feeling the weight of this healthcare crisis, And I, I wanted to dig deeper into seeing how pediatricians are affected.

Salima Hamirani:  Here’s what she uncovered: Coral found that one of the biggest incentives for doctors to leave Puerto Rico, was the extremely low reimbursement rates from health insurers.

Coral del Mar Murphy Marcos:  Reimbursements are what doctors get paid after seeing every patient. So after each patient, they essentially, file a document to the health insurance company, and that’s how they get paid, right? And not only do they face low rates, but doctors also cite payment delays as a pesky day to day challenge. And sometimes these delays can last for months.

Salima Hamirani:  And that might seem surprising because doctors are some of the highest paid professionals in the United States. But, that’s not the case in Puerto Rico, even though technically, its considered a part of the US

Coral del Mar Murphy Marcos:  Some times a doctor. In the states could get paid double what a doctor in Puerto Rico is paid. I spoke to one doctor, for example in Puerto Rico, that after every new patient visit, he gets 25 to 38 right per patient. Which is vastly different than in the U.S. where he could receive more than 100 for every new patient.

Salima Hamirani:  And add to this the fact that doctors have massive student loans. Medical school can cost anywhere from $150,000 to $250,00. And because they run private clinics doctors have to also pay staff, pay rent, pay for equipment and malpractice insurance. As a low average that all adds up to a little over $420,000 per year.

Coral del Mar Murphy Marcos:  And chronic power outages also seem to be adding fuel to the fire. These power disruptions not only affect doctors, but people with health, health conditions that rely on power, say someone with diabetes that need refrigeration for their insulin. As we’re recording this actually my family doesn’t have power a day before a tropical storm is supposed to hit the island. So that just sort of speaks to how frequent these power outages are,

Salima Hamirani:  Doctors fleeing are at the basis of why healthcare is so dismal in Puerto Rico. But why are doctors paid so little?

Well there’s basically two reasons – first, we need to understand a little bit more about the structure of the island’s health care system which was a little confusing for me to understand.

Puerto Rico has Medicaid – like the US – which is run through its government’s health plan called Vital. Like in the US, Medicaid is meant to insure low income people who would not be able to buy insurance on their own. And here’s where it gets confusing –

Coral del Mar Murphy Marcos:  Although it’s a public program, it’s run by four major private health insurance companies they’re First Medical, uh, MMM, Menonita and Triple S.

Salima Hamirani:  These companies are hired by the government to set up competitive rates, figure out what doctors are in network or not, and deny or approve treatment. And here’s where we find the first problem: the private companies running the public health care plan are corrupt.

Coral del Mar Murphy Marcos:  They have been labeled a health cartel. For example, in, , 2023, all four of these companies that I mentioned faced fines that totaled up to 300 million dollars because they failed to pay doctors the minimum rates established for their services in the first half of the year. And even before that in 2019, the former executive director of Puerto Rico’s health insurance administration, she was indicted after a scheme to steal federal Medicaid dollars through a corrupt bidding process with private contractors. So the system is really no stranger to corruption.

Salima Hamirani:  And that’s just part of the problem, which is already pretty serious. The second issue: Puerto Rico doesn’t receive the same level of funding for its health care system as the other official 50 states. And actually, this is true of all US territories like Guam, and Samoa.

Even though Puerto Ricans pay the same in social security and Medicare taxes, they only receive about a third of the funding per person, compared to rest of the states. Even though far more people depend on the government health plan.

Coral del Mar Murphy Marcos This imbalance is really, really noticeable, especially in a territory where over 40 percent of the population lives under the poverty line. 

Salima Hamirani:  For comparison, 19% of the population of Mississippi, which is the poorest state in the US, lives under the poverty line. In fact, the federal government of the US usually gives the poorest states MORE Medicaid assistance because clearly, they need it more. But not in Puerto Rico.

And within that dismal funding set up – children are the most at risk.

So there are two tiers of money available – Medicare is for people over 65 and its usually given priority. Medicaid is for low income families.

Coral del Mar Murphy Marcos Medicare pays a lot more than Medicaid. So sometimes doctors, say a cardiologist, will rely mostly and will give priority to people with Medicare. But pediatricians don’t have that luxury. Pediatricians can only rely on Medicaid and it pays a lot less.

I even interviewed one who, moved to Phoenix, and I spoke to him and asked him some of the reasons why he left. And he cited some of the same reasons we were talking about before: payment delays, low reimbursement rates. It just wasn’t worth it. It’s just not feasible being a pediatrician. And he just got a one way ticket and left. He said, in Phoenix, in the hospital he currently works in, he doesn’t face these payment delays. He’s not planning to go back, sadly.

Salima Hamirani:  There is currently only one pediatric heart surgeon left on the entire island.

And it’s not just the migration of its medical staff. Puerto Rico also doesn’t have medical equipment, it often doesn’t have electricity and the smaller island Vieques, which is a part of Puerto Rico, doesn’t even have a hospital. Its only partially functioning hospital was destroyed in 2017 during Hurricane Maria.

But it wasn’t always this way. Once, Puerto Rico’s almost entirely public health care system was a model for the rest of the Caribbean. And the reasons it changed, and why it’s not so easy to go back, means we have to talk about the big elephant in the room – Puerto Rico’s status as a US colony. Stay tuned, we’ll be getting a history lesson, right after the break.

Lucy Kang: I’m jumping in to remind you that you are listening to Making Contact. If you like today’s show and want more information, or if you’d like to leave us a comment, visit us at our new website, focmedia. org. There you can access today’s show and all of our prior episodes. Okay, now back to the show

Salima Hamirani:  Welcome back to Making Contact, today we’re talking about Puerto Rico’s failing health care system.

Paola: Between shortages in medical professional, lack or losing power very often, you know, all of these things that come into play both in regular life in Puerto Rico, but then just become aggravated when it has to do with health care. That’s a concern.

Salima Hamirani: That’s Paola, again not her real name. Paola left Puerto Rico for grad school about seven years ago. And she wanted to share her reasons for why she decided not to go home. Which is basically that she cannot rely on the medical system.

Paola: I have IBD, uh, ulcerative colitis. When i left it definitely wasn’t a reason why I left. I didn’t as chronically ill. And I think i was kind of, I was freshly diagnosed and not knowing what this meant for the rest of my life. It really takes time to understand that. Basically, it tends to either stay the same or get worse over time. And so I had a few years where it did definitely get worse. 

That means that I now have to get more Invasive and intense medications to just have some quality of life. So the medication that I’m on is an immunosuppressant. And it’s given by IV infusion. So that means that I have to visit an infusion room in the hospital every so many weeks to get that medication.  But I would say that on average throughout the year, I would see between infusions and doctors, I’ll see a medical professional a couple times a month. And I don’t know if I would be able to do that back home because there is just such a shortage of medical staff

Salima Hamirani: After Paola left Puerto Rico, her condition got progressively worse. So when the time came to decide what was next for her and her husband, they realized that healthcare had become a deciding factor.

Paola: My husband is also from Puerto Rico, and I don’t think that neither of us, but probably especially him, ever thought we would not be back on the island for the long term, the rest of our lives, basically. So coming to terms with that was really hard. Coming to terms with, putting down roots in, in the U. S. was very strange and very conflicting and I think even now it’s been, I mean, we moved here like seven years ago and even now, once a month, we’ll have a crisis of should we be here? Should we go back? What are we doing? So this is still an ongoing dilemma in our hearts and in our minds,

Even now that we rethink all the time, how much we would want to be back home, on the island, every time we try to think about all the considerations, all the concerns that we have about going back, we kind of find a solution for all of them except this right. The healthcare that I need. 

Salima Hamirani: Will there ever be a way that someone like Paola can return to Puerto Rico with a serious health condition? Well, that depends. Fixing Puerto Rico’s health system means grappling with the island’s history

Coral del Mar Murphy Marcos: For over a century, Puerto Rico has been under US control. Um, this colonial relationship has deeply influenced the island’s public health system.

Salima Hamirani: That’s Coral Del Murphy Marcos, the reporter you heard from in the beginning of the show. 

Coral del Mar Murphy Marcos In the early 20th century, healthcare was rudimentary, so the focus was primarily on combating tropical diseases like malaria and TB with limited resources and infrastructure.

Salima Hamirani: For most of its history, Puerto Rico was ignored by the US. But then Cuba had a revolution, and Kennedy and the then governer of Puerto Rico Luis Muñoz Marín, decided to develop Puerto Rico to create a wealthier capitalist country with a strong middle class to ward off the spread of communism. They called this plan “operation bootstrap.”

Coral del Mar Murphy:  As the island industrialized The health care system saw some improvements in the 1960s. Hospitals were built, and more medical professionals were trained, and a lot of them were, were government workers. So it was, it was truly a public health care system.

Salima Hamirani: Despite being a colonial capitalist country, Puerto rico basically had a socialist medical system. Doctors were paid by the government and 63 % of healthcare facilities were government run. Two thirds of the population had free healthcare. But it didn’t stay that way. 

Coral del Mar Murphy: Fast forward to the 1990s when the then governor Pedro Rosselló introduced La Reforma, which is a healthcare overhaul that basically privatized nearly every public hospital and clinic in Puerto Rico. So a lot of these doctors insead of being public workers, we’re now under private entities.

So La Reforma was pitched as a way to boost doctor’s wages and incentivize them, but it’s 2024 and the opposite has happened. 

Salima Hamirani: That’s why, in Puerto Rico, at least on the left, there’s been a call to reverse parts of La Reforma. and recreate a universal health care system all across the island. But there’s one huge barrier. And it has to do with Puerto Rico’s political status and its colonial debt. 

Coral del Mar Murphy So technically, legally speaking, it is a commonwealth, but a lot of people are starting to question exactly what this means. And. Whether we should just call Puerto Rico plain and simply a colony.

Salima Hamirani: So why has that narrative shifted and what does it have to do with the collapsing medical system in Puerto Rico? To end the show we sat down with Alberto Medina from Boricuas Unidos en la Diáspora to talk about Puerto Rico’s debt.

Alberto Medina: The debt and the fact that the debt restructuring process is in the controls of the fiscal control board in, in Puerto Rico appointed by Congress is a huge impediment because the fiscal control board has basically instituted a massive austerity program in Puerto Rico, including cuts to the health care system, that in many ways, many of us believe have have made the crisis worse.

Salima Hamirani: Similar to many former or current colonies, Puerto Rico has a massive unpayable debt which arose from a combination of local financial mishandling and laws in the US which made the island a tax haven in many forms since it became a US territory. In 2016, Puerto Rico defaulted on the debt. It owes 71 billion dollars, which is almost 70% of its Gross Domestic Product. 

Alberto Medina: It was considered the biggest municipal bankruptcy in U. S. history if we, if we consider Puerto Rico part of the U. S. which is, of course, a different discussion.

Salima Hamirani: Puerto Rico was unable to declare bankruptcy on its own because of a law passed by congress stipulating that territories – or colonies – just aren’t allowed to. So management of the debt went straight to the federal government of the United States.

Congress created a debt restructuring process called PROMESA which would ensure that Puerto Rico repaid the money it owed to the various vulture funds who had basically invested in the debt. In order to do this, in 2016 they created something called “the Fiscal Control Board.”

Alberto Medina: which is, a body of unelected bureaucrats appointed by the President of the United States, based on recommendations from the U. S. Congress. That is basically completely in charge of Puerto Rico’s finances, not just the debt restructuring process, but, you know, they get to approve the budgets, they can veto. You know, Puerto Rican laws, if they, , determine that the laws don’t comply with the board’s fiscal plans for Puerto Rico. It can override the actions of Puerto Rico’s legislature of Puerto Rico’s Governor, so, it’s, it’s a big impediment to any meaningful action and and improvements.

Salima Hamirani: The Fiscal Control Board is an extremely controversial theme in Puerto Rico, where it’s often referred to as “the Junta.” 

Alberto Medina: It is basically in charge of the island’s finances, which in many ways makes it in charge of the entire island because the government is what you can pay for and what you budget for, and the board is in charge of all of that.

Salima Hamirani: In order to force Puerto Rico to pay its debt, the Fiscal Control Board has implemented extreme austerity measures across the island. Not only is the health care system failing, but the educational system is also on the verge of collapse because of massive cuts to salaries, pensions and schools. This means that Puerto Rico is limited in its choices about how to tackle its health care system, or any public service. 

But, Alberto argues – as would many Puerto Ricans, that they cannot let the US control its sovereignty

Alberto Medina: there are proposals from from various parties and movements in Puerto Rico to have a universal health care system. There’s many other, you know, proposals to, for example, try to bring doctors back from from the U. S. and reverse some of that exodus of of medical professionals. There’s been legislation proposed, for example, to rein in the power of the insurance companies that have also played a role in the deterioration of the healthcare system. You know, as, as with many things in politics, we need to push and we need to try. And, if the board gets in our way, then we need to try to remove the board

Salima Hamirani:  Which is completely possible. There are several ways to fight Puerto Rico’s debt crisis, one – ending the Fiscal Control Board, which has never had a clear timeline for its existence.

Alberto Medina: The fiscal control board was created by an act of Congress and another act of Congress could eliminate it. Um, you know, the Democratic Party actually to its partial credit, put the elimination of the physical control board in its party platform at the most recent convention. , now, you know, I have my doubts that they’re actually planning to follow through with that, but I think it at least shows that they that there is some level of understanding that the board hasn’t worked, that it’s undemocratic, that it’s bad for for Puerto Ricans.

Salima Hamirani:  The other fix? examining what’s in the debt itself. Which oddly wasn’t part of the restructuring plan by Congress.

Alberto Medina: One of the things that many, many organizations in Puerto Rico have called for is for the debt to be audited because there is a widespread belief that some of this debt or much of it actually was issued illegally.

Congress could have very well written it that the debt should be audited before the process.

They did not do that. The board has completely refused to audit the debt. So there could very well be, you know, billions of dollars in illegal debt that Puerto Rico may not have to be on the hook for, 

Salima Hamirani:  Both of these measures could return economic sovereignty to Pueto Rico and allow it to start fixing some of its crumbling public infrastructure. The debt is a particularly brutal form of colonialism and why so many in the younger generation, like Coral’s peers, have opted to call Puerto Rico a colony instead of a territory of a commonwealth.  Some are even calling for outright independence from the US – a topic that’s also controversial on the island, but one that many younger puerto ricans are starting to embrace. 

Alberto Medina: I, and my organization and organizations like ours believe the long, long term solution is to address the status issue and, you know, in our case, what we believe in and push for is for Puerto Rico’s independence. You know, as a colony, Puerto Rico has not had the tools of strong, sustainable economic development. Puerto Rico cannot do its own trade deals, cannot set duties and tariffs, you know, cannot control its fiscal policy. It does not have the good tools of economic development, so it has had to rely on really bad tools, like issuing massive amounts of debt, to try to survive. After 126 years of Puerto Rico being a colony of the United States that is the real, deep solution to all of Puerto Rico’s problem, that doesn’t just address the symptoms, but the actual disease.

Salima Hamirani: That does it for today’s show. This is a story we’ll be keeping an eye on from Puerto Rico. And there’s a lot at stake in this year’s elections on the island.. There are candidates pushing for universal healthcare and more independence from the US. There are also conservative candidates pushing for a heightened connection to the US. Including trump supporting candidates. Visit us online and on our social media to stay up to date on this story, the debt, and the elections – www.focmedia.org. 

I’m Salima Hamirani, thanks for listening to Making Contact.

Author: Jessica Partnow

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