Puerto Rico's economy has problems. Given the state-federal funding nature of Medicaid ("Mi Salud" is Puerto Rico's Medicaid program), this almost inevitably would mean Medicaid woes as well. And this is almost certainly exacerbated by a Congressionally imposed per capita Medicaid funding cap that is far below that of the states. So, with an estimated 45 percent of Puerto Rico's population enrolled in Medicaid, the recipe for disaster is complete.
How does the disaster manifest itself? One predictable way is by the wholesale movement of Puerto Rico's doctors from the island to the mainland. The New York Times reports that "[m]ost medical school graduates do not even bother looking for jobs here [in PR]." The villains? Lower pay, a practice system still oriented around solo and small practitioners, reduced Medicare Advantage reimbursement rates, and a Medicaid funding cap. Oh, and add to that the fact that Puerto Rican's are not eligible for subsidies for health insurance exchange purchases and you might just have the perfect storm.
Propping up Medicare Advantage can hardly be the solution as the subsidization of Medicare Advantage comes at the price of raised costs in fee for service Medicare, though the providers interviewed in the New York Times seemed focused on this medical reimbursement rate focused fix. Raising the cap on federal Medicaid contribution to the level of comparable states might be a more coherent start. Recognizing the special problems of an island economy and offering particular assistance to those providers eager to stay on the island after having completed (government-subsidized) medical school education and training would be a good second step.
Sadly, the crisis in health care in Puerto Rico is not really news, the Medicaid contribution cap has been in place since 1968, after all, at least in its first iteration. The larger economic woes of Puerto Rico have brought the health care crisis into sharper focus, though.