Health Care Services A Big For Puerto Ricans in Current Economy


As the Puerto Rican government wades deeper into negotiations with some creditors in Washington for substantial financial relief, one thing is certain – millions of Americans who live in the U.S. commonwealth are bracing for more spending cuts. And many of them are already hurting when it comes to getting health care and other basic services across the board. Danica Coto, a reporter with the Associated Press, has been closely monitoring the direct impact on Puerto Rico’s residents. She joins us now from San Juan, Puerto Rico, by Skype.

Danica, welcome.

DANICA COTO: Thank you for having me.

SINGH: How bad are things now across Puerto Rico?

COTO: Well, I think most people would agree that it’s the worst it’s ever been. The island has been mired in a decade-long recession. People here have been hit with an increase in taxes, higher utility rates, an unemployment rate that is twice that of the U.S. mainland. And now the island is getting ready to restructure a portion of its $73 billion public debt. The situation has worsened to the point where nearly half a million people have left for the U.S. mainland since 2005.

SINGH: Talk to us a little bit about what you’re hearing on the ground from people who are especially worried about the impact on health care services.

COTO: That’s still a very big concern among Puerto Ricans here. The health situation is such, here, that in the past decade, the number of doctors has dropped from 14,000 to 9,000. They can wait up to a year to receive medical care for special conditions. And those who have money and can afford it, go to the U.S. mainland to get treated. Now, Puerto Rico pays the same amount in Medicaid taxes as U.S. states. The only problem is it receives less funding in return.

So the island expects to exhaust about $6.4 billion worth of supplemental Medicaid funding by the end of this year. And both the governor and the federal control board that is overseeing the island’s finances have warned that if they do not receive additional money for that purpose that hundreds of thousands of Medicaid recipients will be dropped from the plan. And officials note that nearly half of Puerto Rico’s population is on Medicaid, and they say that a total $900 million is needed to keep the health system alive.

SINGH: Could you just explain – if I were living in Puerto Rico and I wanted to go to the hospital or just to the doctor’s office, what am I likely to encounter?

COTO: Well, it’s all different types of scenario depending on where you live. If you live outside of the capital San Juan, I mean, many people travel to the capital, as it is, because they can’t find those services – basic services that they need. I think the most acute problem lies with specialists. The island of 3.5 million people at this point has only about two pediatric urologists, one orthopedists, specializing in ankle and feet, and one pediatric cardiologist and about a handful of geneticists and endocrinologists.

SINGH: Danica, when we spoke with the governor, he talked about a lot of reforms that he planned to pursue. He expressed a great sense of optimism that even though there are going to be austerity measures adopted, spending cuts will have to happen. But he expressed optimism that the reforms that were going to take place were going to be really helpful in the coming years. Do you sense Puerto Ricans feeling the same way?

COTO: I think people are very, very upset. More than 30 or 40,000 people marched against, you know, the federal control board, who’s overseeing the island’s finances, that recently approved a fiscal plan that outlines, you know, these measures that the governor has been touting. Everybody or most everybody understands that there’s a need for change.

But the anger here is toward previous administrations that have built this debt up over decades and decades. And now many feel that they are paying for this. And obviously, they don’t like it. There’s been marches. There’s more marches planned. And I think Puerto Ricans here have hit their limit for changes.

SINGH: That’s Danica Coto speaking with us via Skype. She’s a Caribbean-based reporter with the Associated Press. Thank you for speaking with us.

COTO: Thank you very much for having me. Transcript provided by NPR, Copyright NPR.

American Samoa · Puerto Rico · Uncategorized · Virgin Islands

The American Health Care Act-Blog

I’ve been active on social media, and many are asking how does AHCA affect the US territories. So far, I just found a “summary” that was published by The Henry J. Kaiser Family. I will be digging more to find the text so I can hopefully make it easier to understand. So far, I don’t see anything on how this will work in US territories, There are no specificity to it in regards to US territories. But it already looks similar to what the ACA amendment that was in place. For those who don’t know I will try to clear this up:

Medicaid Overview:

The Medicaid program in American Samoa differs from Medicaid programs operating in each of the 50 states and the District of Columbia. Some of the key differences are:

  • American Samoa became a territory in 1900 and its Medicaid program was established in 1983. It is a 100% fee-for-service delivery system with one hospital servicing the territory. There are no deductibles or co-payments under the American Samoa Medicaid program however there are some fees charged by the hospital located in American Samoa. The territory does not administer a Medicare Part D Plan, instead the Medicaid program receives an additional grant through the Enhanced Allotment Plan (EAP) which must be utilized solely for the distribution of Part D medications to dual-eligibles.
  • American Samoa operates its Medicaid program under a broad waiver granted under the authority of Section 1902(j) of the Social Security Act.  This provision allows the Secretary to waive or modify any requirement of Title XIX, in regards to American Samoa’s Medicaid program, with the exception of three: the territory must adhere to the cap set under Section 1108 of the Act; the territory must adhere to the statutory Federal Medical Assistance Percentage (FMAP); Federal medical assistance payments may only be made for amounts expended for care and services described in a numbered paragraph of section 1905(a).
  • Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $181,307,628 in Medicaid funding to American Samoa.
  • Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in American Samoa, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing American Samoa’s FMAP to 57.2%.

Medicaid-Marketplace Overview

American Samoa was awarded $16,510,330 million for its Medicaid program in lieu of establishing a health marketplace. American Samoa must exhaust its Affordable Care Act (Section 2005) allotment prior to using these funds.

Medicaid and CHIP Standard Monthly Income Eligibility Levels

Eligibility in American Samoa differs from eligibility in the states. American Samoa does not have a TANF or SSI program and does not determine eligibility on an individual basis. Rather, the territory uses a system of presumed eligibility. Each year the percentage of the population below 200% of the poverty level is estimated and, after CMS approval of the estimate, CMS pays expenditures for Medicaid based on that percentage.

Monthly Medicaid and CHIP Enrollment Data

As of January 2015, 40,515 people are enrolled in the Medicaid and CHIP program in American Samoa.

Medicaid and CHIP Applications

  • Currently, American Samoa has no online Medicaid/CHIP application.

Medicaid and CHIP State Plan Amendments

The state Medicaid and CHIP plans spell out how each state has chosen to design its program within the broad requirements for federal funding. As always, states amend their Medicaid and CHIP state plans in order to inform CMS of programmatic and financing changes and to secure legal authority for those changes. The Affordable Care Act included many new opportunities for states to augment and improve their Medicaid and CHIP programs. As a result there has been a great deal of state plan amendment activity over the past several years in the areas of eligibility, benefits design and financing, as well as new approaches to providing health homes, long-term services and supports, and enrollment strategies like hospital presumptive eligibility. See below for a state-specific list of approved Medicaid and CHIP SPAs.

The AHCA states that there will be an allotment. The Summary specifically states that : “Convert Medicaid funding to a per capita allotment and limit growth..”

I don’t know who this will affect Guam, the Mariana Islands, Virgin Islands or Puerto Rico. I have had more luck being able to dig more information of the clinics in American Samoa and the services provided. I’ve read about American Samoa offering a women’s clinic with free services ( pap smear, HPV test, etc. ) I don’t know if the AHCA will allow funding for this clinic to continue to offer these services for free.

I will be taking the new few days, or maybe all this week to read through the text of the AHCA.

Here are the links if you are interested to dig deeper!

AHCA Summary by Kaiser Family

Congress Text- AHCA


American Samoa hospital workers without pay.

There’s disappointment, anger and frustration among employees of American Samoa’s LBJ Hospital after they discovered their pay was not in their bank accounts.

LBJ employees normally receive their pay-cheques by direct deposit on the Friday preceding payday .

But last week employees who went to withdraw money found their pay wasn’t available.

They were told their direct deposit would will be in their accounts today.

There’s disappointment, anger and frustration among employees of American Samoa’s LBJ Hospital after they discovered their pay was not in their bank accounts.

LBJ employees normally receive their pay-cheques by direct deposit on the Friday preceding payday .

But last week employees who went to withdraw money found their pay wasn’t available.

They were told their direct deposit would will be in their accounts today.

Click Here to continue reading the story.


Puerto Rico’s Health System Close to Broke amid Debt Crisis

Puerto Rico economic crisis continues as the US Territory has warned that their Medicaid funds are running out. Governor Ricardo Rossello, who heads the health insurance administration in the territory is set to visit Congress to address the issues.

Last week, Rossello sent a letter to Florida Governor Rick Scott explaining that Puerto Rico’s budget has been strained by thousands moving the US mainland, with around 128,000 who moved to Florida between 2010 and 2015. The projections of Medicaid expenditures Florida needed to serve this population, could exceed an estimated $6 billion with $3.7 billion coming from the federal government and the remaining from state funds. Rossello write, warning that the U.S. will increasingly have also feel the burden of the Puerto Rico’s crisis.

To read more, check out the link here.



Quality of Care in US territories

I want to get in contact with physicians, nurses, or anyone who has worked in the allied health profession in any or all US territories.

My research will focus on the quality of care in the US territories. For the past 8 years I have read many stories how the policies, politics and local economy has adversely affected the quality of care, and the local health insurance market, and the struggles of inadequate funding, resources, and equipment each territory faces.

This research is intended to create awareness. Living in the mainland, we at times are bombarded by the news media of the concerns we see on television and the issues that affect us, but no one ever realizes the struggles our territories face.

A survey will be conducted. In no way will we this research invade the privacy of its patients,but will rather focus on working conditions, environment, and personal experience of the allied health professional.

Data : I will be sending emails to local government agencies to the Department of Health to collect data that will be used to collect information about endemic diseases, mortality rates, nonsocomial infection, unstructured data, etc. A focus will also be done on how many patients are sent to the mainland to seek further medical treatment that is not accessible locally (specialized treatment, etc.)

Questionnaire: Those who have been seen by the local hospitals in the US territories, I would like for you to participate as well. This questionnaire will not invade your patient privacy, rather it would focus solely on your personal experience as a patient.

If you are an allied health professional who has worked in any of these US territories, or a patient who has been seen in any of the local hospitals of the US territories, please email me at lupeupega@gmail.com. All information will be confidential.

For ALLIED HEALTH PROFESSIONALS: I have found some of your blogs on google, and I am a fan! I have thoroughly enjoyed reading about your experiences working abroad and that is what inspired me to look into the health care in US territories. I would love to talk to you, and if you are keen, maybe use some excerpts from your blog to talk about in my research.

** I am currently working on the surveys and questionnaires, they wont be ready until May. I have started sending out emails to Department of Public Health in several US territories, Please be patient. This research is time consuming!

Faafetai for your time, and hope to hear from any of you!


Student Research Initiative

My intention of this blog is to document my Student Research Initiative. The purpose of this SRI is for my capstone senior project.

The issue we will be focusing is: Quality of Care in US territories.

Project Narrative: Quality care in US Territories

Part A: Project Goals and Outcomes

The purpose of this research is to assess the quality of care at US territories that residents receive and how the Affordable Care Act has helped or negatively impacted the health system.

We hope to gather information in regards to mortality rate, quality of care, and the impact of medical insurance and the financial aspect of the hospital.

Part B: Project Significance:

Healthcare is a big part of the political realm in the United States and many times this affects the economy, and puts a burden onto the healthcare system. For the past 8 years we have seen significant changes in our US territories, at times that included natural disasters, economic depressions, and shortage of specialists. The purpose of this research is to find any anomalies within the healthcare of the United States territories and the significant impact the Affordable Care Act has had, if any.

·        Our hope is to bring attention to territories that have been neglected by Congress. If we can tell a story that is of significance, we can start a change. While we may have information at our disposal a challenge will be to find information regarding public health in local territories on the internet since many of these territories have limited internet access.

·        What motivated me to look into this matter was my previous project about telemedicine in American Samoa, the limited resources at the disposal of the physicians and the LBJ Hospital in Pago Pago that is facing $6 million debt. My earlier understanding according to a former pediatric physician from LBJ Hospital said that LBJ Hospital had telemedicine service with University of Hawaii systems. The connectivity of services was bad. There was a shortage of supplies, rooms, staff.

While LBJ Medical Center claims it is owed about $5 million by the government, the ASG Treasury counter-claims that LBJ owes the government more than $6 million, which includes a $5 million loan the hospital received from the government several years ago and remains on the books unless a bill is enacted into law to write it off.

ASG Treasury and LBJ officials revealed this information during the Senate Health/LBJ Committee hearing yesterday called by committee chairman Sen. Tuaolo Manaia Fruean after senators posed questions about the financial problems faced by the only medical center in the territory.

Funding source for the loan was the one-time settlement payment of $5 million from Affiliated FM insurance after ASG sued the company for failure to pay its claims following Hurricane Val.

Samoa News reported in 2003 that the $5 million loan bill dictated the priorities set for paying LBJ’s outstanding debts, such as U.S. FICA and Medicare taxes; employee and employer contributions to the ASG Employees’ Retirement Fund; utility payables; pharmaceutical company payables; other vendor payables incurred for essential operational services; and ASG withholding taxes.

In the later part of 2005, a year after the loan bill was enacted into law, there was already a call by senators at the time to forgive the loan and have it written off the books. Since then, there were at least two measures in the Fono to write off this loan but both bills never made it out of committee.

Part C: Understanding the work of Others

·        Many of these territories are facing a shortage of specialist in the hospital. Puerto Rico has faced one of the most daunting task of trying to stack up their staff in the hospitals throughout the island. The problem? The decade long recession has put a blow to rising cost of living on the island, pay rate 10 times less than that in the United States. It’s estimated that one doctor leaves a day in Puerto Rico, and according to NPR.org, the waiting list to see a specialist is four to five months.

·        Dr (name erased due to privacy concerns) who had previously worked in LBJ hospital in American Samoa says that he had to learn to read an x-ray. Those reading was usually left up to the x-ray technician, but because there was none, he had to do the reading himself.

Part D Methods and Analysis

·        The many ways we intend to draw our conclusions is to find articles that have been covering the decade long struggle of US territories and their struggle. Most of the statistical information will depend on local Department of Public health and news articles that have tracked many disease or infections outbreaks like Zika that has plagued tropical climate countries (Puerto Rico, the US Virgin Islands, American Samoa.) We have also collected information from reliable sources such as (name deleted due to privacy concerns) who was a physician at LBJ hospital in American Samoa and Dr. Anotnio Peraza who was from Puerto Rico and moved to Miami Florida.

Part E: Timeline and Budget



Questions to Ask

Estimated time

Medical Insurance, SSI, etc

-What kind of insurance market is in place in each independent territory if any?

-Does territory have citizens pay federal tax, SSI?

2.5 weeks

Billing system

-Many territories face issues with patients not paying their debt. We want to understand how the system is set up, is it efficient, is it creating a problem.

1 week

Services offered

-What kind of services is available in the territory, and if patients who seek specialized treatment need to travel to the United States to seek those necessary treatments.

2 weeks

Statistical analysis – mortality rate, quality of care

–         Collect data that can provide a picture of how the services are being rendered, are services efficient, does the patient have to come back for the same illness that was the chief complaint, etc.

4 weeks

Adequacy of Staff

–         How many physicians, nurses, technicians are available in the territory. Assess the necessity

1 week

Territory Debt

–         Assess the debt hospitals has incurred (Past due accounts, outsourcing, lawsuits, tax, etc)

2.5 weeks

Employee accounts

–         This will be for us to interview each physician or practicing professional in regards to hospital services and its efficiency. Each doctor will be asked the same set of questions.

2 weeks