Inside Puerto Rico’s Crumbling Healthcare System

CHRISTIANE AMANPOUR, INTERNATIONAL HOST: And now, to a growing problem in America’s backyard. Puerto Rico is in the midst of a health care crisis after a series of natural disasters hit its rapidly aging population. “The Washington Post” Arelis Hernandez writes, more people are dying in Puerto Rico as its health care system crumbles. And she’s telling Hari Sreenivasan how what’s happening there could be a signal of what’s to come in the U.S.

(BEGIN VIDEO CLIP)

HARI SREENIVASAN, INTERNATIONAL CORRESPONDENT: Christiane, thanks. Arelis Hernandez, thanks so much for joining us. You and a group of folks at The Washington Post” looked at the rate of death in Puerto Rico over the last year. What did you find?

ARELIS HERNANDEZ, NATIONAL REPORTER, THE WASHINGTON POST: Well, we found that there was an excess in mortality, not dissimilar to what we saw after Hurricane Maria in 2017. But in this case, there wasn’t a hurricane to explain what was going on. We figured that about 3,300 people more than is expected based on average rates, annual rates died in 2022, part of it was COVID, but there were a lot — it went beyond that. There were a lot of other reasons for why people were dying on the island.

SREENIVASAN: Let’s start to unpack a little bit of that. 3,300 people is a lot above the kind of average that you would expect. Was it any specific group of people that were impacted more, the young or the old or the male or the female?

HERNANDEZ: Yes. Puerto Rico actually has been aging quite rapidly in recent years, and that’s aging by compression as social scientists will tell you, meaning that there’s been an out migration of young working age people from the island. And so, what you have is a population that’s significantly older that is more prone to chronic illness and who have, in some cases, a lot more difficulty reaching the health care resources that might help them to manage those diseases.

SREENIVASAN: OK. So, does that explain it all? I mean, if the young people leave, the old people are left behind, they can’t get to the ambulances or the hospitals fast enough? Is — what else is happening?

HERNANDEZ: No, no. The chronic illness, these are largely preventable diseases. These are things that point to an overall collapse or collapsing within the healthcare system and unable to deliver care to patients in a way that is adequate that helps them manage their chronic illnesses. I mean, we look at the over 65 population, but we’re also talking about folks who are 50 and older as well that are having a lot of difficulty. The other reason that this is happening in Puerto Rico is that you have many, many, many doctors that are fleeing Puerto Rico, going to the mainland, United States, in search of other opportunities.

SREENIVASAN: Why are healthcare professionals leaving Puerto Rico?

HERNANDEZ: They can’t afford to stay. The schema for insurance and the reimbursements that they get from government healthcare, whether it La Reforma in — on the island or Medicare or Medicaid, just simply doesn’t pay the bills for doctors. And they’re also overworked. There are few numbers of specialists that are there to treat a thousands of people, and they’re unable to keep up with — and there are some doctors who told me during the series of reporting that, you know, it just didn’t feel — it got them depressed to know that there were thousands of people that they couldn’t reach who needed them and they were unable to deliver the quality care because they’re having to roll through large numbers of people. It’s just not a situation that’s sustainable for medical doctors.

SREENIVASAN: So, you’re talking about these big shifts here. If you lose the younger population and you start to lose doctors, what’s left? I mean, describe the kind of health care infrastructure. You have these sad sorts of stories. Tell me about some of the people that you spoke to and how they’re emblematic of the problem.

HERNANDEZ: Absolutely. I mean, what you have left is a considerably young and old population, both of whom are severely vulnerable to some of the issues that Puerto Rico faces with climate change, for example. You have a traumatized population. For example, Wilfredo Ramos (ph) who I met in Utuado, which is a central mountain town, pretty remote. This is a guy who had a stroke. And no one found him. He lived alone in this remote home in the mountains, not super far from his family, but far enough where no one found him for three or four days. And he was bleeding out of his head for a while. I went to visit him with a — what they call a health promoter, it’s someone in the community who goes from house to house trying to find out what the particular health needs are. And this is an individual who hadn’t had his prescriptions renewed, who was struggling with anxiety and depression and sleeplessness. This is the state of so many of the people that I met in Puerto Rico, this last trip.

SREENIVASAN: And then, you also talk about just, you know, calling 911 isn’t really a surefire way to get care.

HERNANDEZ: No. The main character in our story is a woman and her family who also live in a fairly remote area of Puerto Rico. The topography is challenging. Let’s state that outright. Puerto Rico is not easy. But when you call 911, you expect a certain level of service. And in this case, the ambulance that was dispatched, a private ambulance, did not get there in time. They got lost. Asked for directions, but couldn’t reach Margarita (ph), who herself was suffering from breathing. She was struggling to breathe and having all kinds of issues, and she passed away in front of her family.

SREENIVASAN: So, what is the health department or the health system in Puerto Rico trying to do to deal with some of these challenges?

HERNANDEZ: Puerto Rico’s health care system is pretty complicated. It depends a lot on the federal government. And that’s where if you ask, you know, state officials, people with the government, they’ll immediately sort of orient their answer to why these things are happening to, you know, the colonial status of Puerto Rico. But we know that that’s only part of the story. Some of it has to do with Medicaid reimbursements that are not equal to what doctors in the United States receive for the similar, if not the same care. You have a situation where the government is right now not doing much to stand to the bleeding of young doctors, people who are studying in the universities there in Puerto Rico, who are, you know, eager to work on the island and serve their people, but are unable to because they have student loans and, you know, simply cannot make it happen. Then you have the complicated sort of interchange of insurance companies in Puerto Rico and just very basically at a ground level. If you are someone who’s looking for a specific specialist, a dermatologist, a rheumatologist and neurologist, you’re looking at, you know, anywhere from four to six months to schedule an appointment with that individual. And if you have a condition that is exacerbated by, you know, the way, you’re in big trouble.

SREENIVASAN: So, you have spent years reporting from Puerto Rico. And I wonder how much of an impact was Hurricane Maria? I mean, to me, some of this, certainly the out migration seems to have accelerated after Hurricane Maria.

HERNANDEZ: I think at the beginning, we sort of expected to some degree that the trauma and the aftershocks, if you will, of Hurricane Maria we’re going to be severe. But it’s only now that I think we’re actually seeing sort of the manifestation of that trauma of the anxiety and the depression. And remember, it wasn’t just Hurricane Maria. She was big hit for Puerto Rico, but you also had a series of earthquakes that happened. Hurricane Fiona. You had the ouster of the governor in, I think, 2019, if I recall correctly, through protests. So, it’s just been one thing after another. You have an exhausted population that has not rebounded as quickly as one might have hoped.

SREENIVASAN: So, is this kind of a longer tail of what happens when the demography shifts so much? I mean, would those 3,300 excess deaths not have happened if, for example, 120,000 young people stayed in Puerto Rico instead of left?

HERNANDEZ: That’s possible. But I also think there’s deficiencies in mental health treatment. There are deficiencies in the system overall. Yes, it would have helped if those folks had stayed. If you know, those elderly folks who consistently appear on the news of having died by themselves inside their homes, if there were people there nearby to be, you know, watching or taking care of these folks, maybe that wouldn’t have happened. But this a longer tail. And I think this is something that, as you know, as Americans on these residents on the mainland that we need to pay attention to, because these are friends that are also appearing in other parts of the mainland U.S. with the sort of flight of doctors, decreasing number of doctors, with the issues with insurance companies who make it difficult to access care in some cases. So, in many cases, I think Puerto Rice is a canary in a coal mine, if you will, of what could happen when we’re not watching and we allow the healthcare system to deteriorate in front of us.

SREENIVASAN: You’ve got so many different levels of deficiency, whether it’s human beings that are there to be doctors and nurses and fill the infrastructure that way, or, you know, topography that you can’t easily change. I mean, what can you do?

HERNANDEZ: Well, I’m not a policymaker. So, I don’t pretend to have all the solutions by any means, but I do think there are certain, you know, principles that are at play here. One, building incentives for people to stay. If you’re studying at the University of Puerto Rico, you know, a premier institution for medical science, there should be perhaps incentives to keep those folks on the island and to have them, you know, participate in the system for a certain amount of time, if they’re, you know, education is subsidized. Or maybe it’s changing the delivery system right now, because so many people live in, you know, their own communities, maybe the health care system needs to go to them instead of expecting people to come to, you know, urban centers that are sometimes difficult for them, especially if you’re elderly, to receive care. There are a bunch of different things that we think. Mental health care, maybe the federal government needs to look a little bit more closely and what — in what ways it can help support federally qualified health clinics that are in some of these communities to be able to reach those needs. Overall, I do think that there is a lack of understanding, both at the state and federal level, of what individual communities actually need. And that was clear from the very beginning that we don’t — they don’t know these communities. They don’t know where the needs are. And are able — unable to deliver in that way.

SREENIVASAN: You said that there was, on average, one cardiologist for every 17,500 people, because there’s only some 95 cardiologists on the island. Are these preventable deaths then if we basically had more cardiologists that could provide care?

HERNANDEZ: Well, again, I’m not a medical doctor, but I think some of the evidence that we’ve seen that points to that some of these absolutely could have been prevented with more first preventative care. And secondly, consistent follow up care.

SREENIVASAN: You also spent some time in Aguas Buenas a small town in the kind of rural highlands and I wonder — or central highlands, and I wonder they had a 50 percent increase in death compared to the years prior. So, is there something specific about this town, this location? Is it a rural problem? What happened?

HERNANDEZ: It’s a rural problem. It’s a place that’s lost a lot of population. And so, who are left are retired and older individuals who are living alone. It’s also a place with a really challenging sort of far flown barrios. The neighborhoods are at the tops of mountains that surround the sort of — the valley where the pueblo, the central square is. They also lost about half of their doctors. So, primary care physicians that were in town. And while Aguas Buenas is not super far from San Juan or Bayamon, these urban centers in Puerto Rico, it’s far enough where folks who depended on bus service, for example, that is no longer available can’t get to these places unless a family member takes them or they find a ride for some other means. And in Puerto Rico, culturally, to burden someone else with, you know, giving this favor or giving you a ride is something that’s frowned upon, particularly from an older generation.

SREENIVASAN: You also spent some time with these health brigades that were out there trying to get to these places. What was that like? Are they frustrated with what they’re seeing?

HERNANDEZ: They’re absolutely frustrated and they’re heartbroken by some of the things that they see. There’s a lot of, again, pockets of communities all across Puerto Rico. And when the health promoters, these brigades go into these communities, they find all kinds of problems. They’re having to, in that moment, provide dental care, provide — you know, take their blood pressure. In one of these situations, we were in Orocovis, Puerto Rico, also in the central mountains, where a woman, they took her blood pressure, the doctor who was with us, and her blood pressure was enough to have put her in a coma and she had no idea. She was just so stressed. This also a place that had been hit hard by Maria, didn’t have adequate access to water and where the electricity went out consistently.

SREENIVASAN: Given the status of where health care is in Puerto Rico today, are we likely to see an excess number of deaths again and again and again?

HERNANDEZ: It’s hard for me to predict this future, but the trends that we see and the data suggests that 2023 will also be a record year of deaths in Puerto Rico. And it’s unclear to me demographically where that will take us in 2024 or 2025, but certainly, isn’t stopping now. And you know, maybe the government authorities on the health officials are looking at COVID and trying to mitigate the destructive force that COVID has been in Puerto Rico 2021 forward pretty much. So, maybe with COVID, we’ll see these numbers normalized. But keep in mind that before, you know, hurricane Maria, these numbers were pretty much on par or lower than the United States.

SREENIVASAN: So, is there anything that’s working?

HERNANDEZ: There are some models that are in place that are specific to remote communities. There’s a group called Cosaw (ph), they’re a brigade, again, of health promoters, mostly from the communities that they serve that have kept, you know, going censuses and they know where people live and they’re able to bring that, but they depend on the, you know, generosity, nonprofits and other groups to be able to serve these communities, and that isn’t exactly consistent. There are models that are being tried. Federally, you know, qualified health clinics help with sort of bridging some of those gaps. But when it comes to major health issues where you need hospitalization, that’s where the challenges, and you have hospitals that are running into bankruptcy and all kinds of issues in Puerto Rico, closing and communities that desperately need them.

SREENIVASAN: So, how does all this factor into kind of the sovereignty versus statehood perpetual conversation that surrounds Puerto Rico?

HERNANDEZ: Well, it’s a difficult question. As I mentioned before, when you ask the state, when you ask Puerto Rico government officials, they’ll tell you this all a problem that is coming from its political status. They blame it on the Jones Act, which is that, you know, this prohibition, essentially, of ships with goods coming directly to Puerto Rico, they actually have to stop in Jacksonville, unload, put the merchandise on a U.S. ship with the U.S. flag and then send it. And that drives up the cost of things like, you know, healthy food. Puerto Rico imports a huge amount of its food, grocery food, including fruits and vegetables that are pretty expensive once they reach Puerto Rico. So, they would tell you that. They would tell you that the Jones Act has everything to the Medicaid reimbursement, that inequality and disparities that exists with the sort of the bulk sum that the federal government gives to Puerto Rico, essentially a doctor practicing in Puerto Rico gets about half of the reimbursement, say, for reading an x-ray or, you know, whatever treatment, gets about half their reimbursement from Medicaid and Medicare that a doctor in the Virgin Islands or the United States would. And that’s extremely frustrating to folks on the island. So, there are aspects of this that are directly tied to political status, but it’s definitely not the whole story.

SREENIVASAN: What can we take from what’s happening in Puerto Rico and apply it to what could happen in the mainland?

HERNANDEZ: Puerto Rico once had a hospital and health care system that was the envy of the Caribbean. It was a public system. And in the 1990s, the governor moved to privatize that system and sell off some of those assets in an attempt to sort of rein in some of the ballooning costs. Instead of it being a cost saving measure, it turned into a huge issue and plummeted the government into debt, into the debt that they’re still trying to get out from under in Puerto Rico. I’ve seen reports out of California that sounds really similar to what’s happening in Puerto Rico, again, to the sort of decreasing numbers of specialists and doctors who are available to provide appointments in a timely manner to be able to catch things before they become very serious problems. There are issues with private insurers that are, again, making it very difficult in the relationship between doctor and patient, they’re much more severe in Puerto Rico than what I’ve seen in the United States. But also, just the model towards having people come to healthcare instead of healthcare going to them, I think is something that is a major issue in Puerto Rico. It might be unique to Puerto Rico, but I do think that there are parts of this country as well that are also challenging topographically or, you know, where the population is, where we need to think about alternative models for how we deliver care.

SREENIVASAN: Arelis Hernandez, thanks so much for joining us.

HERNANDEZ: Thank you.