NYC Gazette

In recent years, Puerto Rico has faced a series of devastating natural disasters, including Hurricanes Irma, Maria, and Fiona, alongside numerous earthquakes. These events have severely strained the island’s already compromised health care infrastructure, further exacerbated by the COVID-19 pandemic.

“Puerto Rico has experienced multiple, compounding disasters in recent years. It’s been a recipe for health care challenges, to say the least,” said Anna-Michelle McSorley, a postdoctoral associate at the NYU School of Global Public Health and the NYU Center for Anti-racism, Social Justice & Public Health.

In an article published in the American Journal of Public Health, McSorley and her colleagues highlight how federal policies treat Puerto Rico differently than the 50 states. These policies contribute to existing health disparities on the island.

The researchers identify three key policy differences that disadvantage Puerto Ricans: unequal disaster response from FEMA, lack of parity in Medicaid funding, and limited political power for Puerto Rico.

“Our lens needs to gaze upstream—which is so much of what we do in public health—to say, ‘This is where the policy is failing. This is where it's creating a barrier, and that is ultimately what's leading to the consequences that we see,’” said McSorley.

Following Hurricane Maria in 2017, FEMA provided aid to Puerto Rico but significantly less compared to Texas and Florida after similar hurricanes. Additionally, a federal investigation revealed mismanagement of approximately $257 million by FEMA in Puerto Rico post-Maria.

Federal laws like the Merchant Marine Act of 1920 also impose restrictions on how resources are imported into Puerto Rico. This law requires imports via U.S. ships only and increases costs due to tariffs.

Puerto Rico faces a shortage of healthcare providers due to lower Medicaid reimbursement rates compared to those in U.S. states. Around half of Puerto Ricans rely on Medicaid or CHIP; however, unlike states where Medicaid operates as an entitlement program funded proportionately with expenditures covered dollar-for-dollar by federal funds—Puerto Rico's program operates through a block grant covering about 55 percent historically.

Legislation has intermittently increased funding levels but proposed permanent changes aimed at achieving equal reimbursement rates have stalled. Consequently—Puerto Rican healthcare providers often seek better-paying jobs within U.S., leaving local medical schools struggling with insufficient residencies forcing students elsewhere resulting in loss-of-practitioners for Island’s underfunded infrastructure.

Politically active yet limited in influence—Puerto Ricans vote locally but lack full representation federally—they cannot vote for president nor have senators with voting power although electing Resident Commissioner part-of-House without full-voting-rights making congressional decisions difficult especially regarding issues like FEMA funding mismanagement or Medicaid grants distribution—a largely unjust system per experts observing these dynamics closely influencing public perceptions negatively impacting equitable resource allocation amidst other domestic crises competing priorities complicating matters further when territories perceived foreign-affairs instead internal-domestic-spaces reducing inclination spread-resources equitably across nation-states inclusive all-citizens equally deserving support-services necessary-survival-post-disasters ensuring sustained-recovery-long-term-healthcare-needs met effectively addressing root-causes systemic inequities entrenched deeply historical 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