By Sarah Varney and Carmen Heredia
Rodriguez AUGUST 6, 2018
SAN
JUAN, Puerto Rico — Blue tarps still dot rooftops, homes lack electricity
needed to refrigerate medicines, and clinics chip away at debts incurred from
running generators. Yet despite the residual effects from last year’s
devastating hurricanes, Puerto Rico is moving ahead with major cuts to its
health care safety net that will affect more than a million of its poorest
residents.
The
government here needs to squeeze $840.2 million in annual savings from Medicaid
by 2023, a reduction required by the U.S. territory’s agreement with the
federal government as the island claws its way back from fiscal oblivion.
Overall,
Puerto Rico faces a crushing debt of more than $70 billion — much of it due to
the territory’s historically astronomical Medicaid expenses — on an island
where the average household earns $20,000 and diabetes and hypertension are
widespread.
But
physicians, health insurers and former government officials say the drastic
cuts demanded defy actuarial science and provide too little money to care for a
population still traumatized by Hurricane Maria.
The
cutbacks will give private health insurance companies the incentive to shuttle
around patients with costly chronic diseases or mental illness, critics warn.
And they do nothing to address the underlying fiscal imbalance at the root of
Puerto Rico’s health care woes, which stem from the fact that the federal
government contributes a tiny fraction of the island’s Medicaid budget,
compared to what it contributes to the 50 U.S. states.
“We are
rearranging the chairs on the Titanic,” said Dr. Jaime Torres, whose
jurisdiction included Puerto Rico when he served as a regional director of the
Department of Health and Human Services.
Already
health plans have been forced to lay off social workers and nurses like Eileen
Calderón, who once visited dozens of chronically ill Puerto Ricans each month,
finding them specialists, supervising medicine compliance and arranging rides
to doctor appointments.
“These
people who have been under our service for the last four or five years, all of
a sudden I have to abandon them,” said Dr. José Joaquín Vargas, chief medical
adviser for VarMed, the Bayamon-based company that operated the program that
employed Calderón.
Health
Crippled By Debt
If
Puerto Rico were a state, the federal government would pay 83 percent of
Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according
to a formula that takes a state’s economy into account.) But because of a 1968
law capping the amount of Medicaid money Washington sends to U.S. territories,
the federal government pays only about 19 percent, as a fixed annual payment —
a so-called block grant.
In
February, Congress approved $4.8 billion in additional funds to help pay the
island’s Medicaid bills. But the additional payments are widely viewed as a
stopgap measure; health economists say that extra money is likely to run out in
September 2019, a grim estimate shared by the territory’s fiscal oversight board. That’s a federal
control board established by Congress in 2016 to oversee Puerto Rico’s budget,
negotiate with its creditors and help restructure at least some of the island’s
debt.
Gov.
Ricardo Rosselló’s administration aims to reduce Medicaid spending and improve
access to care by putting an end to years of regional monopolies by private
health insurance companies. The insurers have locked patients into narrow
networks of health care providers. Later this year, under Rosselló’s plan, the
companies will be forced to offer island-wide insurance plans and compete for
customers.
“We do
not have the luxury” of continuing to spend inefficiently, said Ángela Ávila
Marrero, executive director of Puerto Rico’s Health Insurance Administration.
If
Rosselló’s overhaul fails to achieve adequate savings — as most observers
predict — drastic cuts are in the offing. Some 1.1 million Puerto Rican residents
on Medicaid — out of 1.6 million enrollees —
are at risk of losing coverage next fall, their health held hostage to the
island’s need to pay back its crippling debt.
Puerto
Rico’s government effectively defaulted on more than $70 billion in debt.
Economists blame a decades-long recession, a corporate tax break that ended in 2006 and
reckless spending by a bloated government.
But
also to blame, they say, and largely unnoticed in discussions of the debt, is
Puerto Rico’s staggering Medicaid burden.
Poverty
is so pervasive here that nearly 1 in 2 people qualify for public health
insurance; Medicaid expenses in 2016 totaled $2.4 billion.
Residents suffer from higher rates of chronic conditions like diabetes and
asthma, and the percentage of people who are elderly is quickly rising.
Footing
medical bills without the kind of federal assistance dispensed to states has
effectively doomed the island’s fiscal health, health economists say.
Researchers
of health care say that, putting aside interest on Puerto Rico’s debt, the
territory’s primary fiscal deficit would have been erased had Congress paid the
same share of Medicaid bills that it pays the 50 states and Washington, D.C.
“The
main issue is that we are not yet a state,” said Rep. Jenniffer González-Colón,
the commonwealth’s nonvoting member of Congress. The island must pay for
Medicaid, she added, “with local funds that we don’t have.”
Battered
Even Before The Storm
Puerto
Rico’s health care system was already convulsing in September 2017 when
Hurricane Maria struck. The federal government had issued warnings that the
island would soon run out of additional Medicaid funds provided by the
Affordable Care Act and 900,000 Puerto Rican residents would
lose coverage.
Insurance
companies, hospitals and physicians complained that the government was
chronically late paying its bills. That frustration forced hospitals to defer
maintenance and investments in new technology and fueled the exodus of
thousands of physicians to the mainland in search of better incomes.
Today,
Medicaid patients face long waits to see doctors on the island.
“If
your kid needs a neurologist, for example, the waiting period is around six to
12 months,” said Dr. Jorge Rosado, a pediatrician in San Juan. “For a genetics
specialty, it’s two to three years.”
The
$4.8 billion in relief funding from Congress is propping up Medicaid while the
Rosselló administration negotiates new contracts with health insurance
companies and enacts other measures mandated by the fiscal oversight board.
Those include a new Medicaid fraud detection system and enhanced data
collection.
Little
Time To Waste
Barring
the unlikely passage of bills that would
eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster
relief fund is projected to run out next fall. González-Colón also authored a bill calling
for statehood, which would eliminate the federal government’s unequal treatment
toward the island’s Medicaid program.
The
fiscal control board established by Congress openly acknowledges
the impending disaster. In an April
19 report, the board projects monthly costs per Medicaid
patient will rise nearly 40 percent over the next six years,
barring any changes, and that Puerto Rico “will hit a ‘Medicaid cliff.'”
Beginning
this fall, Medicaid patients will be able to pick from at least four insurers,
instead of being assigned to the one that had covered their ZIP code.
Puerto
Rico has long capped monthly payments insurers receive for Medicaid patients
regardless of how many medical services they use, a form of managed care. But
the government here believes that the insurers — without their regional
monopolies — will be forced to compete, offering better care and more efficient
delivery. They could save money by reducing unnecessary emergency room visits
or hospital stays and by negotiating discounted payment rates to providers.
The
island’s government has vowed to pay private insurers extra money to care for
those with expensive or chronic medical conditions. Insurers have cautiously
welcomed the changes.
“I
support the government on what they’re trying to do, but they didn’t price it
properly,” said Dr. Richard Shinto, the president and chief executive of
InnovaCare, an insurance company that sells plans in Puerto Rico.
He
added, “The oversight board is fixated on cuts, but we’re never going to
improve health care unless more money is put into the system.”
Government
health officials argue Medicaid patients, especially those outside the San Juan
metropolitan area, will gain access to more specialists, who are concentrated
in the capital. But the island’s clinics and hospitals fear they will be
squeezed by insurers seeking to lower costs, just as they are still reeling
from hurricane-related expenses.
Hospital
General de Castañer spent $5,000 every five days for gasoline to power the
generators at its three sites for seven months; Health Pro Med, a community
health center, spent at least $2,000 a day in added expenses, including private
flights to ferry doctors to the storm-battered island of Vieques.
Many
experts are skeptical that managed-care companies will hire the army of social
workers and nurses like Calderón needed to trudge up hillsides, knock on doors
and do the tedious work that entails solving the daily problems of poverty.
Viewed through a narrow lens, with an eye for cutting expenses, such problems
can seem far outside the purview of medicine.
Many
people displaced by the storm haven’t yet been able to return home, and that,
too, can complicate health care delivery. Carmen Ramos, executive director of
Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60
percent of the letters she recently sent to patients on her mailing list were
returned.
“The
managed-care companies need to produce revenue,” said Victoria Sale, a senior
director at Camden Coalition, a pioneer of social and health programs for the
chronically ill. “That’s a setup for concern.”
Bottom
line? The economic overhaul doesn’t rectify Puerto Rico’s fundamental problem —
it can’t sustain its Medicaid program so long as Congress treats the territory
differently than it treats states.
“Next
year, we will go back to Congress demanding the funding we deserve as U.S.
citizens,” said Torres. But, he added, “it’s time the local government started
thinking about a Plan B.”
Sarah
Varney: svarney@kff.org,
@SarahVarney4
Carmen
Heredia Rodriguez: CarmenH@kff.org, @caheredia21
https://khn.org/news/in-weary-post-storm-puerto-rico-medicaid-cutbacks-bode-new-ills/?utm_campaign=KFF-2018-The-Latest&utm_source=hs_email&utm_medium=email&utm_content=65069519&_hsenc=p2ANqtz--9mueJjs_u09xcKF0jwJaxEttSzz0NWhni81sJv8j7gc9Ddf1IdybuNIf99Cx86W5a2EIrNVeRhUp3agLGspf9NEZZ9Q&_hsmi=65069519
No comments:
Post a Comment