By Melvin Félix & Leonor Suárez

Published on December 2, 2015

Dr. Nelson Matos often has to call insurance companies to convince them to pay for the tests his patients need. He’ll sometimes prescribe and administer medications without receiving a penny. In some cases, he’s had to help patients enroll in the government’s health plan so they can afford their treatment. “They’re little things you’ve got to do,” says the smiling 38-year-old oncologist. His patients thank him with small gifts: a bag of mangoes, a couple of avocados.

It’s been five years since Matos opened his cancer treatment center in Santa Isabel, a seaside town in the south of Puerto Rico. Most days, his waiting room is filled with cancer patients who can’t afford to travel north — to the capital, San Juan, an hour away — for chemotherapy.

“One patient told me over the phone this morning that he couldn’t come in for treatment because he didn’t have money for gas,” says Matos, sitting in his office on an August afternoon. “There’s a lot of need in Puerto Rico.”

Every week, the doctor gets lucrative job offers from the United States which he has, so far, declined. “I studied to take care of my people,” says the doctor, who grew up in Coamo, a few minutes away from where he currently works.

A lack of healthcare funding could leave 600,000 people in Puerto Rico without coverage, according to the White House.

But it’s becoming increasingly harder to stay.

Doctors in Puerto Rico grapple with a health system that discourages them from staying. For decades, the U.S. government has sent less money to Puerto Rico than to each of the 50 states to fund the federal health programs for the elderly, the poor and the disabled. A constant lack of funding has come to define the island’s public health system, which supports the healthcare services of more than 60% of the population.

Combined with an economic crisis, the shortage of funds has had its consequences: Physicians who don’t earn enough in Puerto Rico are moving to the states by the thousands. Insurance companies in the island are slashing their networks and firing specialists to be more cost-effective. Low-income patients must sometimes choose between going to the doctor and buying groceries for the week. And some rural hospitals are closing down or teaming up with other hospitals to stay afloat.

Now Washington says the healthcare funding disparity in Puerto Rico may leave 600,000 people without health coverage in the next few years. “U.S. citizens in Puerto Rico are offered fewer benefits, and the federal government contributes less on a per-capita basis in Puerto Rico than in the rest of the nation,” the Obama administration said in October, in a formal request urging Congress to help the island.  

In her bid for the White House, Hillary Clinton has described the island’s Medicare and Medicaid funding situation as “one disturbing example” of the “inconsistent and incoherent” way the U.S. government treats Puerto Rico. She said it has contributed to the economic decline in Puerto Rico, which has stacked up a public debt of 72 billion dollars after a decade-long recession.

Amparo Camacho waits for treatment in Dr. Matos' office.

Amparo Camacho waits for treatment in Dr. Matos’ office.

Running out of funds

One of the most visible effects of the economic crisis in Puerto Rico has been the historic exodus it sparked. More people abandoned the island between 2010 and 2013 than in the entire 1990s, and they have fled in such numbers that there are now more Puerto Ricans living in the United States (4.9 million) than on the island (3.5 million). Last year, more than 84,000 Puerto Ricans moved to one of the 50 states.

The population that remains behind is becoming increasingly older, and the majority of those who stay depend on government funds to receive one basic service: healthcare.

In Puerto Rico, more than two million people use Medicare and Medicaid, the two federal health programs for the neediest Americans. Nearly 1.6 million low-income Puerto Ricans use Medicaid, and some 700,000 elderly and disabled Puerto Ricans use Medicare. Of the latter, most have embraced the program’s Medicare Advantage component, which pays private insurance companies to offer a more competitive coverage than traditional Medicare.

But doctors in Puerto Rico earn less for serving these millions of patients, who make up more than 60% of the island’s population, than their colleagues do in the United States. It’s part of the reason why almost 5,000 physicians have left Puerto Rico during the last decade, and an estimated 500 more are expected to leave by the end of 2015.

For example, if a doctor agrees to take care of any number of Medicare Advantage beneficiaries in Puerto Rico, he or she will receive about $505 per patient per month, a figure that’s adjusted for what are known as the patients’ risk factors. That same doctor would receive two thirds more ($847 per patient per month, also adjusted for risk factors) if he or she cared for that group in Mississippi, the poorest state in the United States.

The funding disparity is similar in Medicaid. The program, which helps low-income Americans afford their medical expenses, splits their medical bills between the state and federal governments. The split is calculated in such a way that poor states receive a larger share from the federal government than rich states do. But that’s not the case for Puerto Rico.

Even though the island’s poverty rate is greater than that of any state, and almost doubles Mississippi’s, the federal government pays the island a fixed rate of 55% for expenses under Medicaid. Mississippi, in contrast, receives 74% of its Medicaid expenses. If Puerto Rico were treated as a state, it would be paid 83% of Medicaid expenses, the maximum a state or territory can get, according to the Center on Budget and Policy Priorities.

The Medicaid funding gap in Puerto Rico widened recently, after President Obama signed the Affordable Care Act into law. Because Puerto Rico is a territory, its residents cannot receive the subsidies that Obamacare provides for low-income Americans who enroll in health plans. These subsidies are meant to incentivize new enrollment and can help individual states save billions of dollars in costs.

Instead of the subsidies, Puerto Rico received a one-time grant of $6.4 billion to help fund Medicaid between 2011 and 2019. The Puerto Rican government has already spent a good part of that grant and, when it runs out, it may not have the money or the borrowing credit to keep the program running. As a result, some 600,000 Puerto Ricans could lose their medical coverage, according to estimates published by the Obama administration. “Insufficient and unstable funding for Medicaid has contributed to Puerto Rico’s fiscal challenges and endangered access to coverage,” said the White House in its letter to Congress in October.

Further disparities in Puerto Rico include the Supplemental Security Income (SSI) for low-income Americans and the Medicare Part D Low-Income Subsidy, two programs that don’t apply to residents of the island.

“What we’re asking for is equality: If I’m paying the same amount, then treat me the same,” said Johnny Rullán, former secretary of health of Puerto Rico. “Nothing more, nothing less.”

The challenge for Puerto Ricans on the island is that they don’t have enough political power to change their situation. They can’t vote for the U.S. president, and they don’t have legislators in the Senate or House of Representatives in Washington, D.C.

“Because it’s a U.S. territory, Congress can treat Puerto Rico differently than than it does the states for practically any reason, and it does,” said Pedro Pierluisi, an elected official who represents Puerto Rico in Washington and will run for governor in 2016. “The quality of life in Puerto Rico suffers when people don’t have the same benefits and the same rights.”

A matter of life and death

Amparo Camacho was told she had three months to live when she first arrived at Dr. Matos’s office in Santa Isabel.

“When he first saw me, I was a wreck,” said the 70-year-old woman. She’d already had a dozen tumors removed, first during a liver transplant and later when doctors removed a piece of her left lung. “The doctor told my family: ‘I give her, at most, three months.’ But he told me: ‘We’re going to start chemotherapy. Do you want that? Are you up for the challenge?’”

Amparo is a retired teacher from Guayama, a town half an hour away from Dr. Matos’s office in Santa Isabel. She’s the mother of four. She’s the grandmother of eight.

She’s also one of nearly 500,000 Medicare Advantage beneficiaries in Puerto Rico, the place where the program enjoys the most popularity in the U.S. Medicare Advantage is favored especially by Puerto Ricans who are low-income and also elderly or disabled, making them eligible for both Medicaid and Medicare. These people can enroll in a special type of plan known as Medicare Platino which, for a monthly premium, offers extra benefits like dental coverage and over-the-counter medicines that are not available under traditional Medicare or the state-run Medicaid health plan. In Puerto Rico, one out of every three Medicare Advantage beneficiaries are these kind of double-eligible Americans.

Though she’s not double-eligible, Amparo decided to enroll in Medicare Advantage when she turned 65, and now pays a monthly premium for her medical services. Her plan – administered by a private company but subsidized by Medicare funds – has covered the cost of her extensive treatment: chemotherapy, lab tests, special medications, hemoglobin transfusions and frequent visits with Dr. Matos.

The retired teacher is now struggling to pay for her treatment. She spends one-fourth of her Social Security check on the plan’s monthly premium, which was raised from $87 to $107 in October. She also struggles to afford the copays for her visits to the oncologist’s office, which in August went up from $15 to $25.

New York Governor Andrew Cuomo (right) joined Puerto Rico Governor Alejandro García Padilla during a rally in San Juan.

New York Governor Andrew Cuomo (right) joined Puerto Rico Governor Alejandro García Padilla during a rally in San Juan.

The sharp increases are a recent phenomenon: they came this year after health officials were told that there would be an 11% cutback in the Medicare Advantage funds sent to Puerto Rico in 2016. The news led to the creation of a coalition of those against the cut, led by Governor Alejandro García Padilla and various organizations of health professionals. In November, the coalition led thousands in a march along the streets of San Juan protesting the unequal healthcare funding in Puerto Rico. One of the guests was the governor of New York, Andrew Cuomo, who has also urged the federal government to treat the island more equitably.

The proposed cuts to Medicare Advantage are not official, according to a statement sent by the Centers for Medicare and Medicaid Services (CMS) to Univision Noticias. “Unfortunately, we cannot confirm … the amount of funds that will go to Puerto Rico for its Medicare Advantage program in 2016,” a CMS spokesperson said. But plans like Amparo’s have already raised their prices, in an apparent attempt to brace for the cutback in 2016. Dr. Matos’s office confirmed that several Medicare Advantage plan contracts came with similar modifications this year: lower payments to the doctor, higher charges to the patient.

The cuts would affect more than just prices for patients like Amparo; she’s now afraid that she might lose her doctor. That’s because the main insurance providers in Puerto Rico have started removing physicians from their networks, often canceling contracts with no justification to save money. Some 700 physicians have been removed from Medicare Advantage networks this year, according to a report by Ely Acevedo Denis of the local digital news outlet Noticel.

It could all have an effect on the treatment patients receive, says Jorge Luis Matta, executive director of the Auxilio Mutuo hospital in San Juan. “Up to a certain point, there will be a rationing of doctors,” says Matta. “There will be fewer physicians available for rendering services. In the case of hospitals, there will be greater pressure to deny days of stay, as a way of releasing patients as soon as possible.”

Looking for solutions

Medicare Advantage is crucial for helping a cash-strapped Puerto Rico, according to Ricardo Rivera, director of the agency that administers the island’s public Medicaid program.

Ever since the Medicare Platino program was established in 2006 for double-eligible beneficiaries, hundreds of thousands of Puerto Ricans have chosen Advantage plans over the state-run Medicaid plan. These patients pay a premium, and they help Medicare with the costs of their medical services. For each of them, the government’s Health Insurance Administration (ASES) pays only $10 a month. 

“If people currently enrolled in Medicare Advantage switch to the government’s health plan (Medicaid), we would go from paying $10 dollars to $260 per member per month,” said Rivera to Univision Noticias. “For us, the viability of Medicare Advantage is crucial for the financial well-being of the government’s health plan.”

One proposal before the House of Representatives would eliminate any disparities in federal Medicare and Medicaid funds for Puerto Rico and other U.S. territories. It would increase the amount the island receives for Medicaid and modify the formula for payment of Medicare services. This draft legislation was proposed by Pedro Pierluisi, the resident commissioner from Puerto Rico. It has six cosponsors in Congress, but four are symbolic representatives from the territories who cannot vote for or against the measure.

In December, a group of U.S. legislators, among them Sen. Chuck Schumer (D-NY), proposed allowing Puerto Rico’s residents to receive the Medicare Part D subsidy, which helps low-income patients pay for prescription medications. Another fix, suggested by the Coalition for the Health Crisis in Puerto Rico, would have the federal government provide a line of credit to ASES, the agency that administers health programs on the island, so that it can match funding that comes from the federal government. This proposal is complicated by Puerto Rico’s precarious financial situation; Standard & Poor’s, a financial services company, demoted the island’s high-risk bonds to “junk” status this year.

The option of moving away

Nearly 165 future doctors graduate each year from Puerto Rico’s four medical schools.

More than twice as many doctors left the island in 2014, according to Víctor Ramos, president of Puerto Rico’s Surgeons and Physicians Association, who says there are now some 9,000 doctors working in Puerto Rico, compared with 14,000 a decade ago.  

The professional exodus has had some serious consequences: there are now only two physicians qualified to operate on children with heart or chest problems, and one of these pediatric cardiothoracic specialists is currently 90 years old. There are also just five geneticists in Puerto Rico and a serious shortage of pediatricians, Ramos says. Outside the fields of psychiatry and ophthalmology, which are widely represented, there are few specialist doctors in the island. “For all the rest, we have a shortage,” says the leader of the surgeons’ association. 

Young professionals who graduate from the island’s medical schools have trouble finding work in Puerto Rico, according to Dr. Ubaldo Santiago Buono, who practices medicine within the Metro-Pavía hospital network. “We must remember that all these young physicians should have a place to work in Puerto Rico, and we can’t limit their career opportunities,” he says.

Santiago Buono says the lack of opportunity is exacerbated by how costs have soared on the island. “They raise the cost of water, of electricity. The cost of living continues to rise while our personal income diminishes. What can doctors do? They go to the U.S. lookingfor a better salary, or they stay and work twice as hard, diminishing their quality of life, and maybe even the quality of the service they provide.”

It also doesn’t help that the demand for bilingual Puerto Ricans doctors in the U.S. is booming.

“If doctors were to come to (the United States), they would be earning twice as much,” says Dr. Jorge J. López, a Puerto Rican who completed his residency at the Medical Center of the University of Puerto Rico and has been working in Florida for 23 years.

López, president of Florida Emergency Physicians, has recruited dozens of doctors from the island for his network, which provides emergency services in five counties in Florida. He estimates that one out of six of his physicians are Puerto Ricans. “Here the government pays more than in Puerto Rico, as do private medical insurance plans,” he told Univision Noticias during an interview in his office in Maitland, near Orlando. “In Puerto Rico, the system for compensating doctors is about 20 to 25 years behind the times: insurance companies pay less, they create obstacles to avoid payment, and they almost dictate what kind of service the patients are going to receive.”

Even the role of helping Puerto Rican doctors find work in the United States has become a business. A Florida group called Physician Placement Services offers orientations in the island for doctors who are considering moving to one of the states. 

The doctors there are bombarded with opportunities: In mid-November, for example, Dr. Nelson Matos received an email with five job offers, all based in the United States. “They’re tempting,” Amparo’s doctor says. “And it’s not just the money, but I also wouldn’t have to be fighting against the medical plans.”

He thinks it over for a few seconds, and then says, “I hope I don’t ever leave. I can’t see myself taking care of someone who isn’t from Puerto Rico.”

Special thanks to the family of Amparo Camacho, who passed away shortly after the publication of this project.