On the Outskirts of National Health Reform: A Comparative Assessment of Health Insurance and Access to Care in Puerto Rico and the United States

Abstract

Puerto Rico is the United States’ largest territory, home to nearly 4 million American citizens, yet it has remained largely on the outskirts of US health policy, including the Affordable Care Act (ACA). We analyzed national survey data from 2011 to 2012 and found that despite its far poorer population, Puerto Rico outperforms the mainland United States on several measures of health care coverage and access to care. While the ACA significantly increases federal resources in Puerto Rico, ongoing federal restrictions on Medicaid funding and premium tax credits in Puerto Rico pose substantial health policy challenges in the territory. Context Puerto Rico is the United States’ largest territory, home to nearly 4 million American citizens. Yet it has remained largely on the outskirts of US health policy, including the Affordable Care Act (ACA). This article presents an overview of Puerto Rico's health care system and a comparative analysis of coverage and access to care in Puerto Rico and the mainland United States. Methods We analyzed 2011‐2012 data from the Behavioral Risk Factor Surveillance System, and 2012 data from the American Community Survey and its counterpart, the Puerto Rico Community Survey. Among adults 18 and older, we examined health insurance coverage; access measures, such as having a usual source of care and cost‐related delays in care; self‐reported health; and the receipt of recommended preventive services, such as cancer screening and glucose testing. We used multivariate regression models to compare Puerto Rico and the mainland United States, adjusted for age, income, race/ethnicity, and other demographic variables. Findings Uninsured rates were significantly lower in Puerto Rico (unadjusted 7.4% versus 15.0%, adjusted difference: −12.0%, p < 0.001). Medicaid was far more common in Puerto Rico. Puerto Rican residents were more likely than those in the mainland United States to have a usual source of care and to have had a checkup within the past year, and fewer experienced cost‐related delays in care. Screening rates for diabetes, mammograms, and Pap smears were comparable or better in Puerto Rico, while colonoscopy rates were lower. Self‐reported health was slightly worse, but obesity and smoking rates were lower. Conclusions Despite its far poorer population, Puerto Rico outperforms the mainland United States on several measures of coverage and access. Congressional policies capping federal Medicaid funds to the territory, however, have contributed to major budgetary challenges. While the ACA has significantly increased federal resources in Puerto Rico, ongoing restrictions on Medicaid funding and premium tax credits are posing substantial health policy challenges in the territory.

Cancer Statistics for Hispanics/Latinos, 2018

“…There are also several challenges for Puerto Rico’s health care system that likely impact cancer care, including an ongoing government debt crisis, outmigration of healthcare personnel, and federal disenfranchisement. For example, Puerto Rico is largely excluded from major national legislation, such as most components of the Patient Protection and Affordable Care Act . These issues are complex and interwoven; in 2015, the disparity in federal support for health care resources in Puerto Rico compared with states was estimated to account for approximately $25 billion of Puerto Rico’s >$70 billion debt .…”

Cost-effectiveness of Increasing Access to Contraception during the Zika Virus Outbreak, Puerto Rico, 2016

“…‡‡Intervention cost equals to the medical savings from ZAM cases prevented. §§Conversion factor of 0.36 applied to pregnancy and ZAM medical costs based on the ratio of per capita medical expenditure in Puerto Rico and in the United States in 2012 as in Portela et al 2015 ( 32 ); conversion factor of 0.72 applied to costs of supportive care for live-born infants with ZAM, based on the ratio of annual salary for assistant nurses in Puerto Rico and in the United States ( 33 ). …”

“…In one, we annualized the cost of LARC devices considering the expected duration of method use. In another, we adjusted observed data on US healthcare and supportive care costs to the generally lower levels of prices in Puerto Rico market by applying conversion factors of ratios of healthcare spending per capita and wages of nurse assistants between the United States and Puerto Rico ( 32 , 33 ). We also conducted a probabilistic sensitivity analysis by using Monte Carlo simulation (10,000 draws) that assumed different distributions for all the parameters used in the model (Table 1).…”

Zika virus epidemic in Puerto Rico: Health justice too long delayed

“…29,30,31 The implications of a Zika virus epidemic are potentially severe for public health, considering that Puerto Rico is structurally under-resourced due to the existing cap on congressional spending for health services on the island. 18,32 This issue has been part of public discussions and congressional hearings on the fiscal crisis on the island and the establishment of the Puerto Rico Oversight, Management, and Economic Stability Act or PROMESA, 33 but no action has been taken to ameliorate the negative consequences of the situation with regards to public health care, which has rightfully been called a humanitarian crisis. 25 Implementation of austerity measures on Puerto Rico’s government budget, particularly related to funds allocated for public services already proposed by PROMESA’s board members, raises more concerns about the prospective availability of local resources to address the health care challenges posed by the Zika epidemic.…”