Cutting off Puerto Rico’s Medicaid is not a ‘fiscal cliff.’ It will push people off a cliff—to die

The National Guard / Flickr puerto rico hurricane...
The National Guard / Flickr

After Hurricane Maria devastated Puerto Rico in September of 2017, we saw photos like the one above, of funerals across the island. The disaster death toll post-Maria was the highest in modern U.S. history.

What is distressing, and almost unfathomable, is the fact that we are heading toward an even higher death toll—and this one will be completely man-made, and preventable.

I want us to start talking, hollering, and pressuring the Senate about the dire consequences facing our fellow citizens in Puerto Rico—now.

Not at the last minute.

Not after the damage has already been done.

More than 1 million Puerto Ricans are already seeing cuts to food stamp benefits. Democrats’ fight being waged with Trump and McConnell over disaster aid funding has not succeeded.

I’ve read articles with headlines that talk of the “Medicaid fiscal cliff” for Puerto Rico—which don’t convey the severity of the disaster in the making. There are going to be a lot of Puerto Ricans who will be doomed to die if they lose both medical treatment and the life-sustaining drugs they need.

That “fiscal cliff” is the cutoff of additional money that increased coverage on the island until September 2019.  When the money goes, at least 900,000 people will lose coverage.

This is not simply a matter of “Oh well, they will have to flee the island and move to the mainland.”

It is not just “Oh well, they should become a state,” as if the status issue is going to be resolved any time soon.

And though some Democratic presidential candidates have mentioned Puerto Rico, or talked of future plans, those words don’t translate into medicine and treatment, while Trump continues to use PR as a punching bag to rile up his base.

What is going to happen will kill more people than Hurricane Maria did—unless we begin to take action NOW.

When I saw this recent tweet from Hillary Clinton, I nodded my head—and thought about Puerto Rico.

I thought about this article from Project Hope:

Diabetes in Puerto Rico: An Update on a Public Health Crisis, One Year After Hurricane Maria

Diabetes and related conditions have been a problem in Puerto Rico for decades. Approximately 16 percent of the adult population has diabetes, compared to 9.4 percent in the general U.S. population. In the last ten years, deaths from diabetes increased on the island by nearly a quarter.

The destruction wrought by the deadliest hurricane to hit the U.S. in over a century significantly compounded the problem.

“Every day I’ve been depressed thinking how I’m going to get insulin and food,” said Argelia.

Insulin must be stored at a temperature below 46 degrees Fahrenheit. Even when there is a sufficient supply, the lack of consistent electricity on the island makes storage and transport difficult. To make things even more challenging, thousands of doctors have left Puerto Rico since the storm: 60% of all general practitioners and over 8,000 specialist doctors have emigrated from the country.

We’ve had advance warnings:

Puerto Rico’s Wounded Medicaid Program Faces Even Deeper Cuts

“We are rearranging the chairs on the Titanic,” says 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,” says Dr. José Joaquín Vargas, president and chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

After a lifetime of work on the U.S. mainland picking corn and asparagus and processing chickens in poultry plants, Maldonado returned to Puerto Rico a decade ago to help care for his ailing mother, who has since died. Today the retiree finds himself living day-to-day on the island. He receives $280 a month in Social Security and $89 a month in food stamps — or about $3 a day for food…

The emergency government support that helped pay for some health care and medically related transportation needs of Puerto Ricans after Hurricane Maria is running out. Private donations of water and food have slowed. And it’s not clear who, if anyone, will carry on with that work.

This is only one chronic illness I’ve highlighted. People on the island depend on Medicaid to treat a host of ills and meet medical needs.

According to the Medicaid and CHIP Payment and Access Commission (MACPAC)

As of December 2018, 1,234,140 individuals were enrolled in Medicaid and an additional 82,408 were enrolled in CHIP—approximately 40 percent of the population (Departamento de Salud 2018, CMS 2017a).

Before I started digging into research on Puerto Rico’s Medicaid situation, I had never heard of MACPAC.

It’s the Medicaid and CHIP Payment and Access Commission created as part of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) in 2009. The authorizing language for MACPAC was added to the Social Security Act. The statute called for the creation of a non-partisan federal agency to conduct policy and data analysis relevant to Medicaid and CHIP, and make recommendations to Congress and the Secretary of Health and Human Services about the programs. Broadly, this means that MACPAC is a trusted source for in-depth analysis of Medicaid and CHIP issues and an apolitical voice in health policy debates.

MACPAC is made up of 17 commissioners; these commissioners serve three-year terms and bring an array of diverse backgrounds and experience to their work. The agency also has a full-time staff that supports its work.

You can access their reports on Puerto Rico here.

Jaime R. Torres, president of Latinos for Healthcare Equity, laid out part of the problem in this opinion piece for The Hill:

2019 Medicaid funding cliff could cause mass migration from Puerto Rico

Puerto Rico, with a total population of 3.4 million, covers 1.3 million residents under Medicaid at a total cost of $2.62 billion a year. If it were a state, the federal Medicaid reimbursement rate would cover most of the cost. But because Puerto Rico is a U.S. territory, it is ruled by discriminatory, archaic and unacceptable Medicaid rules that limit the federal funding the island receives to cover these U.S. citizens. Unlike in the states, where federal Medicaid funding is not capped and the federal share varies based on states’ per capita income, federal funding for Medicaid in the territories is subject to a statutory cap and a fixed federal matching rate. Because of this, Puerto Rico’s Federal Medical Assistance Percentage (FMAP) is capped at 55 percent when it would be closer to 83 percent if it was calculated similarly to rates set for U.S. states. Under these unequal, discriminatory regulations, Puerto Rico experiences a significant burden to cover its medically indigent. This steep fiscal burden has contributed significantly to Puerto Rico’s troubled fiscal situation, which helped lead to the government declaring bankruptcy. It also helps explain why health outcomes on the island are generally worse than in the states, with residents having higher rates of heart disease, diabetes and infant mortality.

Now these problems may become even worse. In February 2018, Congress approved additional funding for Puerto Rico through the Bipartisan Budget Act (BBA), which provided $4.8 billion for Puerto Rico. These relief funds expire at the end of September 2019, which means that just a few months from now, 900,000 Puerto Rican residents could lose their Medicaid coverage. Not only would this be disastrous for those already struggling on the island, but it could also financially burden southern states like Florida and northeast states like Massachusetts, Connecticut, New York and Pennsylvania, where residents of Puerto Rico most commonly migrate. If health conditions continue to worsen on the island, residents will have no choice but to move to where they have historically sought better health services on the mainland. This health-driven migration could cost about $9.7 billion for the federal government and $6.1 billion divided among various states. By comparison, the cost of providing these services in Puerto Rico would total less than $4 billion.

This potential mass migration is 100 percent preventable. Congress can act to immediately end the unequal funding of Medicaid for Puerto Rico and achieve stability in the island’s health care system.

(my bold)

While the threat of mass migration to the mainland is real, if people on the island lose health coverage, that is not a viable option for far too many Puerto Ricans. They may be too old, too sick, too poor, and too afraid to leave what little they have to face relocation. Many will choose, or be forced, to stay, and die, when they lose the medicines and treatments keeping them among the living.

Others may opt to terminate their lives.

We have already seen a spike in suicides and mental health issues in Puerto Rico post-Maria, which was reported by major mainland news outlets in a spate of articles:

     Suicide rates spike in Puerto Rico, five months after Maria

     Listless And Lonely In Puerto Rico, Some Older Storm Survivors Consider Suicide

     Puerto Rico’s suicide rates spiked after Maria. And the mental health crisis isn’t over.     6 months after Hurricane Maria, Puerto Rico has a suicide crisis and a housing shortage

That coverage has pretty much disappeared in the mainland media; however, it is still being reported on the island:

(translation)The number of suicides in Puerto Rico continues to rise

During the second month of 2019, 23 deaths were reported due to suicide in Puerto Rico, the police department confirmed Friday. Added to the 24 cases that were listed during the month of January, the figure rises to 47 suicides.

In 2018, a total of 221 suicides were reported, police said. In 2017, according to data from the Administration of Mental Health Services and Control of Addiction (ASSMCA), there were 253 deaths due to suicide.

This is not hyperbole. This is about the reality Puerto Ricans are facing. The stress for so many who see the months going by and the cutoff date approaching is something I can’t even begin to communicate in just words. That stress is doubled and tripled by the knowledge that nothing is being done by the U.S. government.

There is anger. There is fear. There is depression. There are feelings of total abandonment.

Yes, there are those who soldier on, and no longer expect the national or local government to do diddly-squat, those who either are attempting to go it alone or are receiving aid from a wide variety of charities. However, charities cannot ever replace those who are ultimately responsible for Puerto Rico: the government of the United States of America.

It is April. Congress has gone home. It will also be gone the entire month of August.

Time flies by.

I dream of a day when people across the U.S. will give a damn. Sadly, I doubt I’ll ever see those dreams become reality.

It will always be too late if it is only going to be “heartfelt thoughts and prayers.”

Prayers will not raise the dead.

I wonder: Who among the living has the power to stop this tragedy before it happens?

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