[Editorial] In U.S. Congress…Who the Healthcares?
It seems like only yesterday that the administration of former Gov. Luis Fortuño was doing cartwheels—little ones with his fingers because, as a Republican, it would not have been good form to tout the centerpiece legislation of the political opposition, the passage of the Affordable Care Act (ACA or Obamacare) in 2011. The highly contested bill passed after a legislative harangue 18 months long that saw the law’s constitutionality challenged in the U.S. Supreme Court; the ACA ultimately prevailed when Chief Justice John Roberts ruled with the majority in favor of the law in a 5-4 decision.
Under Obamacare, Puerto Rico had the option to enter the program fully or accept a block grant. Puerto Rico opted for the latter and received an assignment of some $6.4 billion over a seven-year span. The federal transfers coupled with state funding for Medicaid came to some $175 per member per month. Initial estimates by the Health Insurance Administration (ASES by its Spanish acronym), the government agency in charge of managing Mi Salud, contemplated covering 1 million medically indigent people; the drain on funds commenced when that universe grew by nearly 50% to 1.4 million people in 2015 and climbed to 1.6 million in 2016. The funds were simply not enough.
Several factors have contributed to the deficit. In simple accounting terms, prerequisites of Obamacare, which mandate state coverage for all medical indigents with catastrophic illnesses, reportedly drove the costs of compliance as high as $9 billion against the $6.4 billion that Puerto Rico receives.
Now, in their quest to put the “affordable” into the ACA, Republicans on Capitol Hill are seeking new formulas to allow states the freedom to manage their care; let the people decide. In Puerto Rico, people are deciding with airplane tickets that take them to central Florida where, for instance, Medicare affords seniors more benefits for less money.
In a missive sent out in January 2017, Gov. Ricardo Rosselló denounced that “changes in the MA [Medicare Advantage] payment formula dating back to 2011 that resulted from the Affordable Care Act have resulted in payment benchmark reductions of more than 20% for MA plans in Puerto Rico. Yet, during the same period, the U.S. average benchmark has increased by 4%. Currently, the MA benchmark in Puerto Rico has fallen to 43% below the U.S. average, and 38% below the average of the lowest state, Hawaii.”
The federal MA reduction has a devastating effect in Puerto Rico because most seniors on the island use the program to help subsidize Medicare Part B charges for physician services. With elderly people accounting for as much as 43% of the Medicaid and Medicare pie, it is likely that many MA subscribers, left without subsidies to cover Medicare Part B (physician services), will have to join the rolls of Mi Salud, exerting further pressure on the government health program.
The footsoldiers of Puerto Rico’s healthcare industry have been taking their case to Congress, using mathematics that representatives can understand both politically and financially—as in: “How will it impact me politically among my constituents and what is the cost to my state?” In the case of such states as Florida—where nearly 50% of the 500,000 U.S. citizens who have arrived from the island over the past five years have added nearly $5 billion in costs to Medicaid—U.S. representatives and senators are paying close attention. In the case of North and South Dakota, not so much.
Puerto Rico continues to work hard to convince representatives addressing the “why should I give a damn?” question, that it is in their best interests to help the island achieve parity—a task steeped in hardship when they have few [U.S.] American citizens weighing down their Medicaid rolls and when Puerto Rico has yet to achieve meaningful use of electronic health records (EHRs).
Under the new scaffold of managed care established by the ACA, doctors must achieve meaningful use of EHRs—meaning digital records must lead to better preventive care and outcomes that help tame overutilization of services. Puerto Rico continues to languish behind with less than 10% of doctors achieving the EHR “good healthkeeping” seal of approval.
Without that basic benchmark and what some in the industry have said is a lack of transparency on some levels, the crusade being waged by Puerto Rico’s healthcare brigades is made that much more difficult. There are solutions to help Puerto Rico navigate this fiscal crisis. A good start is on the technology front. It is time to come to grips with the harsh truth that managed care demands rationing of services in this devastatingly prolonged economic crisis.