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Back to ‘normal’ isn’t good enough

By admin | February 10, 2021

With the anticipation of increasing distribution of Covid-19 vaccines, Americans are looking forward to a “return to normal.” We’ve all heard these words, intended to inspire hope. And they do, for some. But the reality is that “normal” is a privilege, one that is out of reach for millions of Americans who had been pushed up against immovable barriers and into systems of oppression long before the arrival of Covid-19.

The coronavirus has killed more than 460,000 Americans as we write this, and the toll continues to climb. Though the virus does not discriminate by race or class or gender or age, its undeniable talent appears to be exposing the devastating inequities that come with being a person of color in America.

The “normal” to which many are so eager to return was the normal that helped pave the path for this devastation. Before Covid-19, normal meant widening racial gaps in income and wealth, higher rates of food insecurity among Black and Latinx households, and less than half of low-wage workers with access to paid sick leave. These are only some of the systemic inequities experienced by people of color who have struggled within a system undergirded by racism.

Covid-19 made these disparities impossible to ignore. Normal was not equitable or just, so back to normal means that the societal vulnerabilities that fueled Covid-19 remain, placing the nation’s collective safety, security, and economic prosperity at risk.

By itself, having a new administration or Congress in place does nothing to change these realities. Temporary measures during public health emergencies do even less because they can generate a false sense of accomplishment and complacency. It’s akin to Newton’s first law: An object at rest will stay at rest and an object in motion will stay in motion unless some force is applied to it.

President Biden has committed to the boldest health equity agenda in our nation’s history. On his first day in office, he signed an executive order titled “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.” Less than a week later, on a day when the administration’s theme for the day was equity, the president signed executive orders committing the federal government to address and condemn discrimination. This commitment is laudable, but it must be followed by equally bold policies.

Let us be clear: The American people, especially people and communities of color, are in desperate need of immediate economic support and aid. But while necessary, these are transient, temporary solutions necessitated by decades, even centuries, of racist policies. A moratorium on evictions and foreclosures does not address the nation’s housing crisis, which continues to disenfranchise and discriminate against Black and Latinx Americans. An increase in access to food for children whose schools have closed does little to address the hunger that has pervaded communities of color for decades.

These short-term gains are essential, but they fail to address the conditions that created the vulnerabilities upon which Covid-19 preyed.

Normal is merely the uninterrupted systems and policies that prop up and perpetuate inequities. And only policy can fix what policy has broken, like increasing the federal minimum wage, making investments to improve the quality and availability of affordable housing, providing incentives to improve schools, and repairing and rebuilding businesses owned by people of color in underserved communities. These and other policies and plans have been researched, proposed, and researched again. Our elected leaders know what to do. They need the will and support to do it.

A return to normal fails George Floyd, Breonna Taylor, and others killed by police. A return to normal fails the tens of thousands of people of color who were unnecessarily lost to Covid-19. The energy and resolve that fueled every march and every vote in a year of record turnout must now be refocused to apply pressure and demand accountability from every elected leader.

In her inaugural poem, past National Youth Poet Laureate Amanda Gorman reminded us, among countless soul-piercing refrains, that “being American is more than a pride we inherit. It’s the past we stepped into and how we repair it.”

All Americans need to hear and heed her sage and sobering words. To build back better, we must first look back and dig deep to uncover the inequities of U.S. systems and the laws and policies that serve to prop them up — and change them.

Daniel E. Dawes is a lawyer, director of the Satcher Health Leadership Institute at Morehouse School of Medicine, and author of “The Political Determinants of Health” (Johns Hopkins University Press, March 2020). Brian C. Castrucci is an epidemiologist, public health practitioner, and president and CEO of the de Beaumont Foundation.

https://www.statnews.com/2021/02/10/back-to-normal-isnt-good-enough/

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Mental Health Resources for Latino Community

By admin | January 15, 2021

Sunshine Behavioral Health recently created a resource on mental health in the Hispanic-Latino Community (rarely discussed & with statistics).

Here are some Highlights:

Here is the link for these resources:

Mental Health Issues Facing the Hispanic-Latino Community

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Information about the Coronavirus Variant

By admin | January 8, 2021

Since there is so much recent news about a new coronavirus strain that seems to be more contagious, which has led to a third shutdown in the United Kingdom, and was recently found in the United States, we want to send you some information about it.  At this time, scientists are just beginning to gather evidence about the transmissibility of this new variant, but as a whole, they fear it is much more transmissible.  Meanwhile, the main message is that we need to continue to be very vigilant and careful as this research evolves, and the same protocols apply: mask wearing, hand washing, social distancing and staying from crowded places. 

How much more contagious is the new strain?

The strain first identified in the U.K. spreads more easily and quickly than other strains, according to the CDC. The strain was first spotted in September in southeastern England and accounted for a quarter of cases in London by November. By the week of Dec. 9, it was responsible for 60% of cases in the city.

Scientists have been tracking minor changes in the COVID-19 genetic code since the beginning of the pandemic, and at least 1,000 variants have been detected so far. But the change to the spike protein found in southeast England represents one of the first coronavirus mutations that have made it more infectious.

What makes the new strain more contagious?

SARS-CoV-2, the virus that causes the disease COVID-19, acquires about one new mutation in its genome every two weeks, according to the CDC. The U.K. variant has several mutations that affect the “spike protein” on the virus surface that attaches to human cells.  “It’s able to bind to the receptors on cells better, and therefore is transmitted better,” Dr. Anthony Fauci, the nation’s leading infectious disease expert, said last week.  Patients infected with new version of the coronavirus are more likely to have higher viral loads in their noses and throats, which in turn would raise the likelihood that they infect others through breathing, talking, sneezing, and coughing.

There is no certain figure for how much more infectious the variant may be.  Scientists initially estimated that the new variant was 70 percent more transmissible, but a recent modeling study pegged that number at 56 percent.  “The amount of evidence in the public domain is woefully inadequate to draw strong or firm opinions on whether the virus has truly increased transmission,” said Prof Jonathan Ball, a virologist at the University of Nottingham.

Is the new strain more lethal?

There is no evidence that the variant, known as  B.1.1.7, causes more severe illness or increased risk of death, according to the CDC. However, just increasing transmission would be enough to cause problems for hospitals. If the new variant means more people are infected more quickly, that would in turn lead to more people needing hospital treatment.

What do we know about the new mutations?

An initial analysis of the new variant has been published and identifies 17 potentially important alterations.  There have been changes to the spike protein – this is the key the virus uses to unlock the doorway to our body’s cells.  One mutation alters the most important part of the spike, known as the “receptor-binding domain”. This is where the spike makes first contact with the surface of our body’s cells. Any changes that make it easier for the virus to get inside are likely to give it an edge.  

Is the vaccine effective for the new variant?

Researchers believe current COVID-19 vaccines will likely protect against B.1.1.7, but data is needed. The virus would “likely need to accumulate multiple mutations in the spike protein to evade immunity induced by vaccines or by natural infection,” according to the CDC. “From what we know from experience with this mutation and other mutations, it’s unlikely to have a large impact on vaccine-induced immunity, or existing immunity from previous strains,” said Dr. Greg Armstrong, director of the CDC’s Office of Advanced Molecular Detection. Armstrong said it is unclear how the variant may respond to COVID-19 treatments, such as monoclonal antibody treatments.

How long has the variant been in the US?

Researches first identified the B.1.1.7 variant in the U.S. in Colorado on Dec. 28 in a COVID-19 patient with no reported travel history, suggesting that the virus was spreading from person to person in the community. It has also been identified in California, Florida and New York.  New York reported its first case on Jan. 4, a man in his 60s—with no history of recent travel–who is associated with a jewelry store in Saratoga Springs, north of Albany, Gov. Andrew Cuomo said. The person The CDC said it plans to launch a national strain surveillance program this month that requires each state to submit at least 10 samples biweekly for sequencing.

Where else has the new strain been detected?

The strain has been detected in at least 33 countries, including Australia, Belgium, Brazil, Canada, Chile, China, Denmark, Finland, France, Germany, Iceland, India, Ireland, Israel, Italy, Japan, Jordan, Lebanon, Malta, The Netherlands, Norway, Pakistan, Portugal, Singapore, South Korea, Spain, Sweden, Switzerland, Taiwan, Turkey, the United Arab Emirates, the United Kingdom and the United States.

South Africa has also identified a strain similar to B.1.1.7, but it emerged in October independently of B.1.1.7 and is not related to it, according to the CDC. Like B.1.1.7, the South Africa variant (B.1.351) appears to spread more easily and quickly but is not more severe. U.S. health officials said last week they did not know if the South Africa strain was also circulating in the U.S. “This new variant is highly concerning, because it is yet more transmissible and it appears to have mutated further than the new variant that has been discovered in the U.K.,” British Health Secretary Matt Hancock said.

Sources and links:

A more contagious coronavirus strain has been identified in 4 states and 33 countries. What we know.  — USA TODAY

New coronavirus variant: What do we know?   Why is this variant causing concern? — BBC News

Emergence of a Highly Fit SARS-CoV-2 Variant  — New England Journal Of Medicine

How Does the Coronavirus Variant Spread? Here’s What Scientists Know – New York Times

Viral mutations may cause another ‘very, very bad’ COVID-19 wave, scientists warn

–Science

New COVID Strain Detected in New York: What We Know  — New York Magazine

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Scholarships & Resources for Hispanic and Latinx Students

By admin | August 21, 2020

Dear colleagues,

We want to make you aware of this useful scholarships and resources guide created specifically for Hispanic and Latinx students.

This online guide showcases 20 scholarship opportunities (including many in the healthcare field) that can make all the difference in affording college. It also provides a list of valuable academic and career resources that Hispanic and Latinx students can use to maximize their success during and after college.

Here’s a link to the entire guide:

Scholarships & Resources for Hispanic and Latinx Students: https://www.edumed.org/financial-aid/hispanic-latinx-scholarships-resources/

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THE FIRST NATIONAL HISPANIC/LATINX HEALTH POLICY LEADERSHIP SUMMIT

By admin | February 21, 2020

MEDIA ADVISORY

 For Immediate release

Contact:         Luis Scaccabarrozzi

                        908-764-6513 Lscaccabarrozzi@latinoaids.org

                         Oscar Lopez

                        646-246-7396 orlintexas@gmail.com

  

THE FIRST NATIONAL HISPANIC/LATINX HEALTH POLICY LEADERSHIP SUMMIT IN WASHINGTON, D.C.

Policy-focused summit on HIV, viral hepatitis, STIs and other health issues affecting the Hispanic/Latinx community

 “OUR HEALTH — OUR FUTURE”

The policy-focused National Hispanic/Latinx Health Leadership Summit on March 2nd – 3rd, 2020 will take place in Washington, D.C. The Summit will bring together Hispanic/Latinx leaders from throughout the U.S. and Puerto Rico to (1) consolidate the Hispanic/Latinx Health Leadership Network and (2) work toward developing the Health Policy Agenda 2020-2024 and promoting statewide, countywide, citywide health agenda settings throughout the nation and U.S. territories. The overarching goal is to improve health outcomes for minorities in the U.S. and ensuring Hispanic/Latinx participation and inclusion in the path toward erasing health disparities.

 —A broad planning committee, including representatives from different states and Puerto Rico, organized the Summit.  The planning process was facilitated by the Latino Commission on AIDS.

— Over 150 leaders from the public health sector are expected to participate, including care providers, physicians, educators, health professionals, program directors, researchers, and people living with HIV, Hepatitis C, including representatives from government agencies, corporate entities, and foundations.

— Representatives from Puerto Rico will attend the Summit.

 

WHERE:       Hilton Capital Hotel – Washington, D.C.

                         1001 16th St NW, Washington, DC 20036

 

WHEN:         Monday, March 2 – Tuesday, March 3, 2020

 

                         PLEASE VISIT: WWW.HISPANICNET.ORG

 

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Trump slashed Puerto Rico’s Medicaid money as part of budget deal

By admin | December 18, 2019

By Rachana Pradhan

12/17/2019 05:50 PM EST

President Donald Trump intervened to cut the federal government’s Medicaid funding for Puerto Rico as part of a larger government spending deal, according to four sources with knowledge of the discussions.

The budget deal unveiled by lawmakers this week allocates up to $5.7 billion in Medicaid funds for the island over two years — instead of $12 billion over four years that Republican and Democratic leaders on two key congressional committees had endorsed after months of negotiating a long-term financial path for Puerto Rico.

Puerto Rico has frequently been in Trump’s crosshairs, with the president calling the island “one of the most corrupt places on Earth” and its politicians “either incompetent or corrupt.” Puerto Rico officials have also frequently been critical of the president, especially in the wake of the federal government’s response to the catastrophic Hurricane Maria in 2017.

Puerto Rico’s Medicaid program has been relying on a series of short-term funding extensions since the fall, after confronting a fiscal cliff on Sept. 30 when a temporary boost in money — one of several that Congress has enacted in recent years — was set to expire. Its latest pool of funding expires Friday.

The territory’s funding negotiations to secure a longer-term agreement for its Medicaid program, which covers roughly 1.4 million low-income people, have been particularly fraught after it experienced massive political upheaval and struggled to recover from hurricanes.

In Congress, lawmakers have pushed stronger measures to prevent inappropriate spending by territory officials and monitor its contracting practices, after federal authorities earlier this year arrested a former top Puerto Rico health official and other territory leaders as part of a corruption probe.

Republicans and Democrats on both the House Energy and Commerce Committee and the Senate Finance Committee had endorsed legislation providing roughly $12 billion in Medicaid funds to Puerto Rico over four years, a rare area of bipartisan backing. But over the weekend the president balked at that amount because he believed it was too much, three sources said, potentially throwing a wrench into negotiations to prevent a government shutdown at the end of this week. When lawmakers unveiled the spending package on Monday, it included the two-year funding provision.

A White House spokesperson characterized the Puerto Rico funding deal as a “win for President Trump and the American people.”

“This administration remains committed to properly prioritizing U.S. taxpayer dollars,” said Chase Jennings, a spokesperson for the White House Office of Management and Budget. “With the historical waste we have faced in Puerto Rico, additional funding was not needed or fiscally responsible.”

Puerto Rico officials hailed the funding agreement included in the $1.4 trillion spending bill that the House passed on Tuesday, saying they were “pleased” to have the two-year extension.

“We will continue to work hand-in-hand with the federal government to achieve a longer-term funding mechanism that provides stable healthcare to the people of Puerto Rico,” said Jennifer Storipan, executive director of the Puerto Rico Federal Affairs Administration, the primary liaison between island officials and the federal government.

But the deal wasn’t without its critics.

“With another funding cliff looming in two years under the new agreement, Puerto Rico may continue to lack the certainty it needs to commit to long-term increases of its very low payment rates to health care providers to stem their alarming exodus to the mainland, to provide coverage for such key health treatments as drugs to treat Hepatitis C, and to cover more poor, uninsured residents,” said Robert Greenstein with the Center on Budget and Policy Priorities, a left-leaning think tank.

Puerto Rico’s fiscal 2020 budget includes more than $900 million in local funds to finance its Medicaid program, which has long been underfunded because of how federal law structures its payments. Unlike the Medicaid program in the 50 states — where the federal government and states share costs without strict limits on overall spending — federal funding for territories is capped.

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On Medicare for All and other health plans, candidates should put up or shut up l Opinion

By admin | November 12, 2019

Drew A. Harris, DPM, MPH @drewaharris

Posted: November 11, 2019 – 11:58 AM

The figure is mind-boggling: $20.5 trillion over 10 years. That’s how much presidential candidate Elizabeth Warren says her plan will cost above what the federal government currently spends for health care. Cue the attacks.

So here we go again. Another election in which the question of how best to reform the U.S. health care system will be front and center. Sadly, relying on the media to understand the features of various proposals is like reading a newspaper in a lightning storm—mostly opaque with occasional flashes of illumination.

This piece is not about the relative merits of the various proposals put forth by the presidential candidates. Rather, I want to talk about how we debate health policy and point out the traps set for anyone who proposes a major change. First, a quick discussion about what’s at stake.

Almost one out of every five dollars the U.S. economy generates goes to health care. This is far and above what similarly advanced nations spend, yet U.S. citizens die earlier, are generally sicker and have poorer outcomes when they get care—and it’s predicted to get worse. Our relatively underfunded public health and social service agencies lack the resources to address the major drivers of disease: social factors such as loneliness, depression, anxiety, systemic inequities and community conditions. This is American exceptionalism at its worse.

That fifth of the economy is going somewhere. U.S. hospitals and pharmaceuticals are very expensive compared to peer nations. The system is bloated with non-clinical administrative burdens and costs—on both the provider and payer sides. Some of this is driven by complex regulations and insurance company requirements designed to improve outcomes and contain costs. The unintended consequence of an ever-more burdensome system is clinician burnout and plans for early retirement.

Like an umbrella full of holes on a rainy day, many fully insured families struggle with unaffordable out-of-pocket costs when they get sick. Sad stories abound of parents avoiding huge deductibles and copays by parking outside the emergency department hoping and praying their child doesn’t get worse and need to be seen. Even people lucky enough to have employer coverage pay almost a third of the average $20,576 premium for an employer-sponsored family plan. On top of the premium, 28% of covered workers have a deductible over $2,000, which is just an additional fee you pay when you need care. All together, the average family pays over $12,000 a year out of pocket for health care.

These are the challenges for which the presidential candidates are proposing solutions. Warren’s proposal is the most detailed. Her version of Sen. Bernie Sander’s “Medicare for All” would guarantee and expand coverage for all citizens, cover all providers and eliminate out-of-pocket co-pays and deductibles. Her willingness to explain in detail how she would pay for it sets her apart from her competitors.

Not surprisingly, most of the public discussion about her proposal focuses on overall government costs and taxes, not how it would affect families and individuals or how it would affect spending on medical care overall. The individual impact is framed as “losing” your employer coverage, not as what would be gained in exchange. In reality, people lose their health plan all the time when they change jobs, are laid off, or because the boss switches to a different insurance company. The real threat is losing access to your doctors, which happens a lot when insurance companies reconfigure their provider panels. Saturday Night Live brilliantly described an existing health plan as a “bad boyfriend” you’re afraid to break up with. It’s a case of the devil you know.

I can’t say for certain that Warren’s is the right cure for our nation’s ailing healthcare system. Maybe, an alternative like allowing people to buy into the existing federal Medicare program—the public option—is better. Perhaps, the answer might be some combination of the two.

Any healthcare reform proposal should be judged by objective metrics. Who is covered…and not? How much will people pay out of pocket when they’re healthy or sick? Will businesses benefit from lower costs and a healthier workforce? Will it reward high-quality, cost-effective healthcare providers? How disruptive will the transition to the new plan be? These are the issues people care about, not the political noise.

Any politician criticizing Warren’s effort should provide an equally detailed alternative so we can compare them head to head. At this point in our nation’s decades-long health care debate, we deserve candidates who put up or shut up.

 

Drew Harris is a member of the Inquirer’s Health Advisory Panel, healthcare consultant and assistant professor at the Jefferson University College of Population Health.

 

https://www.inquirer.com/health/expert-opinions/elizabeth-warren-medicare-for-all-20191111.html

 

 

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This Is the Most Realistic Path to Medicare for All

By admin | October 16, 2019

October 15, 2019

This Is the Most Realistic Path to Medicare for All

By J.B. Silvers

Much to the dismay of single-payer advocates, our current health insurance system is likely to end with a whimper, not a bang. The average person simply prefers what we know versus the bureaucracy we fear.

But for entirely practical reasons, we might yet end up with a form of Medicare for All. Private health insurance is failing in slow motion, and all signs are that it will continue. It was for similar reasons that we got Medicare in 1965. Private insurance, under the crushing weight of chronic conditions and technologic breakthroughs (especially genetics), will increasingly be a losing proposition.

As a former health insurance company C.E.O., I know how insurance is supposed to work: It has to be reasonably priced, spread risks across a pool of policyholders and pay claims when needed. When companies can’t do those fundamental tasks and make a decent profit is when we will get single payer.

It’s already a tough business to be in. Right now the payment system for health care is just a mess. For every dollar of premium, administrative costs absorb up to 20 percent. That’s just too high, and it’s not the only reason for dissatisfaction.

Patients hate paying for cost-sharing in the form of deductibles and copays. Furthermore, narrow networks with a limited number of doctors and hospitals are good for insurers, because it gives them bargaining power, but patients are often left frustrated and hit with surprise bills.

As bad as these problems are, most people are afraid of losing coverage through their employers in favor of a government-run plan. Thus inertia wins — for now.

But there’s a reason Medicare for All is even a possibility: Most people like Medicare. It works reasonably well. And what could drive changes to our current arrangement is a disruption — like the collapse of private insurance.

There are two things insurers hate to do — take risks and pay claims. Before Affordable Care Act regulations, insurance companies cherry-picked for lower-risk customers and charged excessive rates for some enrollees.

Those were actually the first indications of market failure. Since the enactment of the Affordable Care Act, insurers have actually had to take these risks as they were supposed to all along and provide rebates of excessive profits.

With insurers under such pressure, we’re now facing another sort of market dysfunction. Insurance companies are doing what they can to avoid paying claims. A recent report says that Obamacare plans average an 18 percent denial rate for in-network claims submitted by providers. Some reject more than a third. This suggests that even in a regulated marketplace like the Obamacare exchanges, insurers somehow manage to dispute nearly one out of every five claims.

These are systemic failures that can and should be fixed by regulation of the exchanges, better information on plan performance and robust competition. Unfortunately, consumers often still can’t make informed choices, and the options they have are limited.

But even if we fix these problems, there are two bigger factors looming that threaten the integrity of the entire system. Insurance at its root assumes that the payout required cannot be determined for each individual but can be estimated for the whole group. We can’t predict who will be affected by trauma or a broken bone, but in the aggregate, it is possible to estimate what will happen to the insured group as a whole. Some will suffer losses while the majority will be fine, and all will pay a fair average premium to cover the expenses that result.

Yet with the increases in chronic conditions and the promise of genetic information, these insurance requirements are not met. Someone with diabetes or rheumatoid arthritis will have the same condition and similar costs in each future year. And the woman with a positive BRCA gene is much more likely to develop breast cancer. In these cases, known costs simply must be paid. Instead of spreading these across all enrolled populations, they must be financed across time for the increasing numbers with such conditions. Loading private insurance companies with these expenses results in uncompetitive rates and market failure.

There is only one solution: pooling and financing some or all of these at the broadest levels. In a nutshell, that is how we get a single-payer government system.

It is how we got Medicare. The cost of care to the elderly was known at the individual level for virtually everyone, so private insurance just wouldn’t work. So we had to finance this largely predictable cost through the government and its enormous pool of taxpayers.

It has been a tremendous, albeit expensive success. For the most part, people on Medicare like it a lot. This is the reason such a disruptive change is even a political possibility.

We will face the same need sometime in the future for the rest of us. Then a form of Medicare for All will look better than the alternative — a failing private insurance system.

J.B. Silvers is a professor of health care finance at the Weatherhead School of Management at Case Western Reserve University.

 

https://www.nytimes.com/2019/10/15/opinion/medicare-for-all-insurance.html?action=click&module=Opinion&pgtype=Homepage

 

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Dr. Olveen Carrasquillo Honored as a ‘History Maker’ for Hispanic Heritage Month

By admin | October 15, 2019

The National Institute on Minority Health and Health Disparities is honoring Olveen Carrasquillo, M.D., M.P.H., professor of medicine and public health sciences and chief of the University of Miami Miller School of Medicine Division of General Internal Medicine, as a “History Maker” in celebration of National Hispanic Heritage Month.

The social media campaign highlights Hispanic researchers who have made important contributions to the Hispanic community and aims to build awareness of minority health and health disparities research in the United States.

Dr. Carrasquillo has more than 20 years of experience leading large National Institutes of Health grants and randomized trials studying diabetes, cardiovascular disease, HIV, cancer and precision medicine. The National Institute on Minority Health and Health Disparities describes him as “a national leader in primary care and health disparities who has conducted extensive research on health insurance and access to care among minority and other vulnerable populations.”

Dr. Carrasquillo is a principal investigator for the SouthEast Enrollment Center of the All of Us research program, leading participant engagement and helping recruit more than 12,000 participants in the first year. All of Us is working to enroll a million or more participants nationally to create a research resource to inform thousands of studies covering a wide range of health conditions and addressing health disparities.

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Puerto Rico’s Looming 2019 Medicaid Fiscal Cliff

By admin | September 26, 2019

Puerto Rico and its residents have experienced numerous crises and shocks in the last decades, including an economic depression dating back to 2006; a public debt crisis resulting in the largest municipal bankruptcy in U.S. history and a federally appointed fiscal oversight board pursuing deep budget cuts; a demographic crisis with population dropping by more than 600,000 residents since peaking at 3.8 million in 2004; and most recently, the devastation and cascading effects left by the hurricanes of 2017. The cumulative effect of these crises has taken a hard toll on the economic and social well-being of its people, disproportionately impacting the most vulnerable populations and communities. These interrelated crises feed on each other, propelling a vicious downward spiral.

Another potential shock is the territory’s imminent Medicaid fiscal cliff, and ensuing public health crisis. In the past, temporary lifelines to Puerto Rico’s Medicaid program have prevented a total system collapse, but by the same token, these short-term extensions of supplemental funding have thwarted efforts to completely reform the system and make it more effective.  The uncertainty caused by this situation is highly detrimental to all stakeholders, especially people whose health and well-being depends on receiving vital care but have few resources to make ends meet in this challenging economic environment.

Differences in Puerto Rico’s Medicaid Program

The U.S. Medicaid program was created to provide vital healthcare services to financially and medically needy populations.  In Puerto Rico, however, that same population that is adversely affected by a disparate and inadequate federal funding structure.  Medicaid programs in the states benefit from an open-ended federal financing structure, receiving federal funds as a function of actual costs and needs. In Puerto Rico, where median household income stood at $19,775 in 2017, compared to $42,009 in Mississippi, the poorest state, and $57,652 in the United States as a whole, the program has been chronically underfunded.  In the poverty-ridden territory, funding limitations further constrain program delivery evidenced in the form of lower eligibility levels, lower federal funding, fewer mandatory benefits, lower provider payments, and lower spending per enrollee.

Lower eligibility levels: To determine income eligibility for participation in Medicaid, Puerto Rico uses the Puerto Rico Poverty Level (“PRPL”) and not the Federal Poverty Level (“FPL”) as in the states, which results in a significantly lower income eligibility threshold. The PRPL is approximately 45% of the FPL for an individual, and 34% for a family of four.

Lower federal funding: Medicaid programs in the U.S. benefit from an open-ended financing structure, receiving federal funds based on actual costs and needs. States with the highest per capita incomes of the U.S. enjoy a Medicaid federal matching rate of 50%, while the poorest, Mississippi, received a Federal Medical Assistance Percentage (“FMAP”) of 76.4% in fiscal year 2019. If Puerto Rico’s FMAP were “calculated by the same statutory formula used for the 50 states and D.C., Puerto Rico’s FMAP would be 83%, although the unbounded FMAP would be 93.34%.” In addition to the lower federal share, Puerto Rico’s Medicaid federal financing is also subject to an annual ceiling or cap, operating effectively as a block grant. Puerto Rico receives an arbitrarily capped allotment, known as the Section 1108 cap, typically resulting in an effective Medicaid federal match rate below 15%. Puerto Rico’s federal funding was capped at $367 million in FY2019, while Medicaid expenditures in the island totaled $2.7 billion. The projected FY2020 cap is expected to be $375.1 million, despite spending projections adding up to $2.8 billion. As per current law, Puerto Rico will also have access to $446 million under the Patient Protection and Affordable Care Act (“ACA”) Section 1323, and $59 million under Social Security Administration (“SSA”) Section 1935(e), also referred to as the Enhanced Allotment Plan (“EAP”), which helps cover prescriptions drugs costs to beneficiaries dually eligible for Medicaid and Medicare, for a total of $880 million in federal spending.

Fewer mandatory benefits: Notwithstanding the great needs and demands for acute and long-term care services – which will likely continue to grow in tandem with the aging population trend and the rising prevalence of chronic health problems – Puerto Rico’s Medicaid program does not cover all mandatory Medicaid benefits. Long-term services, home and community-based services to older adults and people with disabilities with functional limitations and chronic health conditions, are examples of support offered in U.S. states but not available to the residents of Puerto Rico.

Lower provider payments: Disproportionately low provider payment rates and its negative effect on provider availability, and quality and access to care, is a major obstacle for Puerto Rico. The majority of municipalities (i.e. 72 of 78) of Puerto Rico are deemed “medically underserved areas” due to the shortage of medical and healthcare professionals. The Medicaid provider reimbursement rate in Puerto Rico for primary care services from July 2016 to July 2017 was 19% of the Puerto Rico Medicare fee compared to 66% in the U.S. Similarly, maternity services were reimbursed at 50% of the Puerto Rico Medicare fee vs. 81% in the U.S. The substantial differences between Puerto Rico’s Medicaid reimbursement rates and those in the states and the uncertainties regarding the island’s Medicaid financing structure, have played a role in the exodus of physicians and healthcare providers. The number of doctors has decreased from approximately 14,000 in 2006 to currently close to 9,000. There is a particularly acute deficiency of specialty care providers.

Lower Medicaid spending per enrollee: Total Medicaid spending per enrollee is significantly lower in Puerto Rico when compared to all 50 states. According to FY 2020 projections by the Medicaid and CHIP Payment and Access Commission (“MACPAC”), average benefit spending per full year enrollee in Puerto Rico will be $2,144, representing 64% of the lowest per capita spending state ($3,342), 32% of the median ($6,763), and 16% of the highest per capita spending state ($13,429).

Increased Healthcare Needs

Less funding has, in effect, translated to increased needs. The percent of adults reporting fair or poor health in 2017 reached 37.1% in Puerto Rico, compared to 25.3% in Mississippi, and 18.4% in the U.S. The healthiest jurisdiction, according to this indicator, was the District of Columbia reporting 10.8%.  Disparities in chronic health indicators are also significant. Diabetes prevalence in Puerto Rico in 2017 was 17.2%, compared to 10.5% in the U.S.  Asthma and high blood pressure prevalence was 12.2% and 44.7% in Puerto Rico, compared to 9.4% and 32.3% in the U.S, respectively. A robust healthcare system with adequate federal funding could help mitigate the high prevalence of chronic conditions on the island.

Necessary Congressional Action

The chronic underfunding of the island’s Medicaid program has historically placed an undue fiscal burden on Puerto Rico’s budget and prompted federal action. During the last decade, Congress has enacted legislation to provide limited, temporary supplemental funding and avoid a massive healthcare crisis. In 2009, additional federal funds for Puerto Rico’s Medicaid program were appropriated through the American Reinvestment and Recovery Act (“ARRA”), followed by the ACA in 2010, the Consolidated Appropriations Act of 2017, and most recently, through the Bipartisan Budget Act (“BBA”) of 2018 following the devastating 2017 Atlantic hurricane season. In the aftermath of Hurricanes Irma and Maria impacting the island on September 2017, Congress provided an additional $4.8 billion to Puerto Rico’s Medicaid program beyond the annual Section 1108 cap, time-limited funds that were made available from January 1, 2018 to September 30, 2019. The expiration date authorizing the use of that last tranche of funding is soon approaching, and all other temporary federal funds are expected to be exhausted shortly thereafter.

Only prompt Congressional action can help avert a health care crisis in Puerto Rico. If Congress fails to act, it could lead to catastrophic direct and indirect effects. The Medicaid and CHIP Payment and Access Commission (“MACPAC”) estimated that enrollment at the current level of benefits would need to decrease between 36% (455,475) to 53% (669,943) if no new federal funds are made available. The Fiscal Oversight and Management Board for Puerto Rico has warned that “absent action by Congress, by fiscal year 2021, the Commonwealth’s Medicaid costs are projected to comprise roughly 23% of the General Fund’s budget.”

The FMAP that applies to Puerto Rico’s Medicaid program should be computed using the same formula used for the states, considering the average per capita income of Puerto Rico relative to the U.S. national average.  To ensure that the most vulnerable populations of Puerto Rico have access to a more robust, predictable, reliable, and accessible Medicaid healthcare system, Congress must act quickly and remove the federal cap on Medicaid funding altogether and compute the FMAP using the same average per capita income-based formula as done for the states.  Providing Puerto Rico with an adequate level of federal funds for its Medicaid program will also help it return to a path of fiscal stability and economic growth. The urgency of this matter cannot be overstated. Congressional action is promptly needed to stave off another historic humanitarian crisis.

When designing the solution, policy deliberations and prescriptions must be framed within the proper context.  Policymakers must remain keenly aware of the historic critical juncture Puerto Rico is traversing and the larger moral imperatives at play. Puerto Rico’s current dire economic, fiscal, demographic, and post-natural disaster recovery and reconstruction reality must be an essential part of the broader equation. This critical juncture presents an opportunity for Congress to redress a historical wrong, strengthen Puerto Rico’s fragile healthcare system, improve access to critical health services for vulnerable populations, and make headway towards putting Puerto Rico on a stronger fiscal and economic footing.

Further, more than a last-minute temporary fix is needed to provide Puerto Rico with a reliable and sustainable healthcare system.  A permanent, long-term fix to Puerto Rico’s Medicaid program is needed to once and for all guarantee comprehensive, accessible, quality care to low-income families, children, the elderly, and people with disabilities.

https://grupocne.org/2019/09/18/puerto-ricos-looming-2019-medicaid-fiscal-cliff/

 

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