[Editorial] Getting Well Under Trumpcare Light
When the announcement came April 30 that Puerto Rico would receive an assignment of $295.9 million in additional Medicaid funds, Puerto Rico Health Secretary Rafael Rodríguez Mercado behaved as though divine intervention spared Puerto Rico’s Mi Salud health plan from a rapidly approaching cliff. Not quite, just yet—we are now hanging from a branch at the edge of the cliff, praying that the weight of our system does not snap us off into oblivion.
His reaction is understandable. Our economy is in intensive care—bedridden for a decade—and we celebrate when the curtains are open to let in some light. Although the Rosselló administration and a broad coalition of foot soldiers that included representatives from the Popular Democratic Party and the private sector is to be commended for the work on both sides of the aisle in Congress, we must realize this is but a reprieve from the abyss.
The truth is that we are living in what has been called a post-growth world—a nice euphemism for contraction. It is time to come to grips with the realities of rationing tied to managed care. Add a doctrine of austerity to the Junteconomics imposed on Puerto Rico and you have a mammoth challenge.
It seems like eons ago that Puerto Rico had nearly $6.4 billion in funds under Obamacare. Puerto Rico could have opted into the health exchange programs under the Affordable Care Act, but chose instead to receive the block funds, which were to have lasted until 2019. But consecutive administrations—Penepés and Populares—blew through the money because they did not embrace the exigencies of managed care—foremost among which is the implementation of electronic healthcare records (EHR) to rein in costs per patient. Each jurisdiction under Obamacare was tasked with achieving a meaningful use of EHR—the proposed benchmark of more than 50% of physicians achieving that important parameter is important because it helps streamline care and identify overutilization of services tied to some catastrophic illnesses. As of 2016, fewer than 10% of Puerto Rico’s physicians had achieved meaningful use of EHRs.
We knew healthcare reform was so complicated and it has become more complex still. Just take the week leading up to the most recent incarnation of the run up to passing “Trumpcare Light.” In what seemed an extract from The Onion, Trump’s tweets on Puerto Rico signaled a quid pro quo healthcare negotiation with the island as a pawn. In the world according to Trump, Dems insinuated they would hold the healthcare process hostage if Republicans did not come to Puerto Rico’s rescue with funding that Trump’s administration, and specifically Health & Human Services (HHS) Secretary Tom Price, had pegged at a $900 million shortfall. The number has since come down to $600 million.
Puerto Rico has obtained a $295.9 million reprieve—not enough, which points again to the reality that Puerto Rico will have to manage its healthcare under realities that were the old normal—as we did under the administrations of former Gov. Pedro Rosselló when the island only received 15% of its healthcare funds from Medicaid compared to the 55% allotment of federal funds in 2017.
Gov. Ricardo Rosselló’s administration says it will obtain some $300 million in savings by opening the island to competitive bidding for coverage by health insurance companies. Only they know the exact savings. What we do know after investigating healthcare options for this newspaper’s Cover Story is that Puerto Rico must learn to make do with less.
Some of the strategies that could help Puerto Rico chart through the intense rationing tied to managed care, which becomes exponential under Promesa, include using the 330 centers and Direct Primary Care centers. The 330 centers, which provide primary health services, receive funding directly from HHS and, therefore, are able to skirt the congressional gauntlet. Puerto Rico has some 21 centers receiving $161 million in active grants. That is the sort of resourcefulness that can help us muddle through the Promesa morass.
It is time to forget Washington, D.C., and use our ingenuity to find solutions in this post-growth world.