'Often forgotten': How US hurricane relief and health care policies leave Puerto Rico behind

In the span of a few short years, the residents of Puerto Rico endured a series of devastating storms—including Hurricanes Irma, Maria, and Fiona—and were faced with hundreds of earthquakes. Then, the COVID-19 pandemic struck, stressing the island's health care infrastructure when it was already compromised.

"Puerto Rico has experienced multiple, compounding disasters in recent years. It's been a recipe for health care challenges, to say the least," said Anna-Michelle McSorley, a postdoctoral associate at the NYU School of Global Public Health and the NYU Center for Anti-racism, Social Justice & Public Health.

In an article published in the American Journal of Public Health, McSorley and her colleagues describe how federal policies treat the "often-forgotten US territory of Puerto Rico" differently than the 50 states. As a result, these policies exacerbate existing health disparities in the territory.

The researchers focus on three key policy differences that put the health of Puerto Ricans at a disadvantage: unequal disaster response from the Federal Emergency Management Agency (FEMA), the lack of parity in Medicaid funding, and Puerto Rico's limited political power.

"Our lens needs to gaze upstream—which is so much of what we do in public health—to say, 'This is where the policy is failing. This is where it's creating a barrier, and that is ultimately what's leading to the consequences that we see,'" said McSorley, the lead author of the study, who will join the faculty of the University of Connecticut this fall.

NYU News spoke with McSorley about the unique public health challenges facing Puerto Rico and how US policies are contributing to disparities.

How has the US response to natural disasters in Puerto Rico hampered recovery?

In the wake of Hurricane Maria in 2017, FEMA provided funding to the territory. But a 2019 study looked at how much aid was sent in the days after, and Puerto Rico received significantly less than Texas and Florida, which had also been impacted by major hurricanes in that same year.

Moreover, the federal government did an internal investigation and found that FEMA mismanaged about $257 million in Puerto Rico after Hurricane Maria.

But if we dig a little deeper to look at policies that apply to Puerto Rico distinctly, we can also look at the Merchant Marine Act of 1920, a federal law that regulates how cargo is transported by sea and requires Puerto Rico to import resources on US ships.

As a territory, Puerto Rico can't independently negotiate with other countries, so that restricts how resources can come in. It also increases the cost of nearly every product you can imagine, especially food, because of tariffs.

That policy creates an additional level of burden. Even if other governments were trying to figure out how to provide support after a natural disaster, it would need to happen by way of the US—which during the time of Hurricane Maria was also navigating several other natural disasters within the contiguous United States.

How do federal policies impact Puerto Rico's health care workforce?

Puerto Rico has a shortage of health care providers, both primary care and specialists. It's a multi-layered problem, but one contributing factor is that Medicaid reimbursement rates are lower than the rates in the states.

Approximately half of the population in Puerto Rico relies on Medicaid or the Children's Health Insurance Program, so the reimbursement rate matters quite a bit for sustaining the health care system.

Unlike the states where Medicaid operates as an entitlement program, Puerto Rico's Medicaid program is funded through a block grant that has historically been an annual fixed amount that only covered about 55 percent of expenditures.

Over the years, particularly as hurricanes and COVID-19 have hit, that percentage has varied. Congress has put into place legislation to increase the level of funding that is being sent. But the extensions that were applied to Puerto Rico to infuse additional funding are about to expire, and legislation that has been proposed to permanently cement the ability to gradually increase the percentage of reimbursement for Medicaid—with the goal being to get to a dollar-for-dollar match—hasn't really moved forward.

This leaves Puerto Rico unable to compensate their providers at a competitive rate, and the reality is that there are higher paying jobs within the 50 states with higher rates of reimbursement.

In terms of training doctors in Puerto Rico, there are excellent medical schools on the island, but there aren't sufficient residencies to meet the need for folks to stay. Many medical students have to seek residencies elsewhere—that is where we end up losing lots of health care providers.

Once they leave, they are illuminated to the fact that they can be paid significantly more and their living conditions improve. Many want to return to Puerto Rico, but options are limited. If you can land a position, you are likely in an underfunded infrastructure that can't get reimbursed at the rate that it needs to, with a high level of demand from patients who wait months to get appointments.

That dynamic is challenging and can lead to burnout, particularly post-pandemic.

How does political power play into these public health issues?

The Puerto Rican people are extremely politically active. Election day is a holiday—there are parades in the streets, flags, facepaint, and everyone is actively engaging in the political system. There is a really strong tradition of having the Puerto Rican voice heard.

While there is an ability to participate with that vigor in the territorial legislative process—Puerto Rico can vote for its own governor—they're still not a nation with self-determination. In US elections, they can't vote for president, and they don't have senators with voting power. They do elect the Resident Commissioner of Puerto Rico, a member of Congress who is part of the House, but this representative doesn't have full voting power.

This makes it really challenging when you're talking about things like FEMA money being mismanaged, or Medicaid block grants, which are congressional decisions. When you have a territory that has the ability to make local decisions but doesn't have voting power at the federal level, it creates severe restrictions and a system that is largely unjust.

Do you think Americans' perceptions of Puerto Rico play into this?

A poll was conducted among Americans shortly after Hurricane Maria. It found that nearly half didn't know that Puerto Ricans are fellow US citizens—citizens who contribute to federal tax revenue streams, follow federal laws, and serve in the military.

From a political perspective, if you're saying, "Hey, we need to send resources to this region," it's being thought of as a foreign affair. But that can complicate the matter because folks may be thinking, "Let's focus on distributing resources internally"—especially in the face of simultaneous disasters in Texas and Florida.

In the midst of other domestic challenges, if you have a perception that the territory is not a domestic space, it makes people less inclined to spread the resources.

What can be done to reduce health inequities? Does Puerto Rico's status as a territory need to change?

The status question is a hot one—whether Puerto Rico should remain as a territory, or if it should become a state or be independent. This question—which can literally break up families!—is often debated over dinner tables.

I'm a Nuyorican, born in New York and raised between both spaces. In terms of statehood or independence, I believe that the decision should be made by the Puerto Rican people—it should be for them to decide what would be the best path forward.

But I also think that part of the solution lies with the Latino vote here in the 50 states, as Latinos are a huge portion of the demographic in the United States and growing. If we could unify and see issues facing Puerto Rico as solidarity issues across the Latino population, that would be a great way to move the needle in the name of folks that can't have their vote counted.