Individuals born in the U.S. territories are U.S. citizens or nationals, but the territories differ from the states on key demographic, economic, and health status indicators. Most of the territories have a larger share of people living in poverty and longstanding fiscal challenges. Recent hurricanes, typhoons, and the North Korean missile crisis exacerbated pre-existing fiscal issues by damaging infrastructure and limiting tourism. In addition, a larger share of residents in the territories report that they are in fair or poor health than in the states. However, Medicaid, the program that serves low-income and vulnerable individuals, operates differently in the territories. The most fundamental difference is that federal funding for Medicaid in the territories is subject to a statutory cap and a fixed federal matching rate, unlike in the states, where federal Medicaid funding is not capped, and the federal share varies based on states’ per capita income. This brief draws on a survey of and interviews with territory Medicaid officials, as well as other research, to examine key issues and trends in their Medicaid programs.1 Key findings include the following:
The expiration in September 2019 of temporary federal Medicaid funds provided through the Affordable Care Act (ACA) and for Puerto Rico and the U.S. Virgin Islands after the hurricanes is expected to result in what some territory officials describe as a “devastating fiscal cliff.” All of the territories have increasingly relied on the ACA funds to finance their Medicaid programs.
Medicaid enrollment trends have been relatively stable in the territories, except in Puerto Rico and the U.S. Virgin Islands, where enrollment increases followed recent hurricanes, although future trends are somewhat uncertain.
Medicaid benefits and delivery systems vary in the territories. Only Guam offers long-term services, and Guam, American Samoa, and the Northern Mariana Islands provide nearly all Medicaid services through one public hospital. Puerto Rico is the only territory to operate a managed care delivery system, with new reforms implemented in November 2018.
Most of the territories have struggled with provider shortages, which are often tied to persistent outmigration and poor infrastructure and are most prominent for specialty care and mental health services.
Looking ahead, long-term Medicaid financing reforms such as increased federal matching rates, increased spending caps, or elimination of the caps could help the territories meet the health care needs of their Medicaid populations. Conversely, the expiration of temporary Medicaid funds without new resources to address the resulting fiscal cliff could have negative consequences for Medicaid coverage and services.
ALBANY — Nearly 3 in 5 physicians in New York state support measures that would allow doctors to prescribe lethal medications for terminally ill patients who wish to end their lives, according to an online survey conducted on behalf of an advocacy group.
Of the 601 doctors sampled, 56 percent supported medical aid in dying — alternatively referred to as physician-assisted suicide among detractors. The findings were released Monday by Compassion & Choices New York, which supports legislation authorizing the practice.
“We were only surprised at the results in so far it showed how strongly doctors supported having this option,” Corinne Carey, the group’s campaign director, told POLITICO. “The doctors’ support has been among the top concerns of lawmakers that we’ve talked to.”
Support from doctors increased to 67 percent in favor and 19 percent opposed, according to the survey, when they were informed of the provisions of the Medical Aid in Dying Act, NY A2694 (19R), which requires two physicians to determine that an adult patient has fewer than six months to live. But physicians were less likely to say they’d be willing to write such a prescription, with 42 percent saying they would and 35 percent saying they would not.
The report was intended as a counterweight to a similar survey undertaken by the Medical Society of the State of New York, which has roughly 30,000 members and has long opposed aid in dying.
That effort was undermined by a low response rate and design flaws that made it susceptible to being gamed by some of the most-ardent voices on the issue, who were able to easily forward it to like-minded colleagues and distort the results. The ensuing fallout has sown dissent among MSSNY’s members.
A presentation of the survey’s results to the Legislature by the society’s president, Thomas Madejski, last year rankled bill sponsor Assemblywoman Amy Paulin (D-Scarsdale) and other supporters, who felt it was misleading and downplayed the methodological concerns.
“We wanted to try to get an accurate picture of how doctors in our state feel about this,” Carey said. “The Legislature deserves to know the truth.”
Compassion & Choices’ survey was conducted by a sampling of New York physicians listed in a database maintained by Medscape, which is owned by WebMD. A handful of specialties like dermatology and plastic surgery, in which the issue is largely outside their practice, were excluded, and primary care providers made up nearly half of those surveyed.
Last year, Hawaii became the seventh state to legalize the practice, though Vermont is the only state east of the Mountain Time Zone to have done so.
Opposition to the practice does not fall neatly along partisan lines, but comes most vocally from disability rights advocates — who fear vulnerable people would be subject to coercion — and religious groups, who object on moral grounds.
A Quinnipiac University poll released last May found that voters in New York supported medical aid in dying 63 percent to 29 percent, but that was nearly flipped — 61 percent opposed to 34 in favor — for those who attend religious services weekly.
With their new majority in the state Senate, Democrats are finally preparing to pass long-stalled progressive legislation. Perhaps the most expansive and expensive item on the agenda – and among the most controversial – is the New York Health Act, which would establish a single-payer health care system in the state, and one study estimated it would cost $139 billion in 2022. Many incoming lawmakers campaigned on the promise that they would get it done, but even if it does pass, it likely won’t be implemented right away.
The Democratic-controlled Assembly has passed the legislation every year since 2015, but in that time it never came up for a vote in the state Senate thanks to the Republican majority. Now that the chamber will be in Democratic hands, the legislation seems far more likely to pass.
A single-payer health care system means that a single entity covers the cost of all health care, which is still delivered by private or nonprofit providers. Everyone pays into a single plan run by the government, which in turn is the only provider of coverage paying claims. Assemblyman Richard Gottfried’s single-payer bill has proposed one public option and a ban on the sale of private insurance unless it offers additional coverage not included in the state plan.
One major obstacle the New York Health Act must overcome is a less than enthusiastic governor. Although Gov. Andrew Cuomo has expressed support for single-payer health care as a concept, he has repeatedly said that it would be better implemented at the national level. In a recent interview on WCNY, he expressed doubt that the state would be able to finance the $150 billion program, since that would nearly double the state’s budget. “There will be rhetorical desire to do things,” Cuomo said. “Governmentally there will have to be a reality test to get all things to fit in the budget.”
Although this sounds like it could put a serious damper on the future of the legislation, Gottfried called the governor’s stance “a perfectly reasonable position for a governor,” noting that Cuomo is already far more progressive than other governors by simply supporting the concept of single-payer health care. Gottfried said he has been in talks with the administration and expects those conversations to accelerate now that passage is more realistic.
Gottfried said that stakeholders who have remained quiet in the past are coming forward to voice their concerns. Most recently, Gottfried and state Sen. Gustavo Rivera, the bill’s Senate sponsor, have been negotiating with New York City public unions over concerns that union members would pay more or have fewer benefits. “What we’re talking about is modifications just to accommodate concerns that people are raising now that it looks like it can easily pass both chambers this session,” Gottfried told City & State. “People who we haven’t heard from are starting to come forward and say, ‘Gee, could you add this nuts and bolts?’ or ‘Tighten it up here.’’”
Gottfried said making tweaks to the bill will continue at least a couple weeks into the session, which begins in early January. However, Gottfried said that he and Rivera will not make any major structural changes to the bill and said the Assembly is “well positioned” to pass the bill this upcoming session.
Rivera expressed more caution, telling City & State that he feels confident that the chamber will engage in meaningful conversations about the bill, which it has never done before, but did not want to make any promises about a timeline for passage. “This is not a simple thing that we’re trying to do,” Rivera said. “We want to make sure that we don’t put anything up for a vote, to be signed by the governor, unless it’s ready to go.”
Bill Hammond, a health policy expert at the right-leaning Empire Center for Public Policy, argued that no amount of change to the New York Health Act would actually make the legislation viable. “I think (Gottfried and Rivera’s) posture right now is not to acknowledge the sacrifice, it’s to make it even more attractive to whatever interest group thinks they’re going to lose,” Hammond told City & State. He added that any changes would likely add to the already astronomical cost of the bill.
But Gottfried maintained that a single-payer system will lead to lower overall health care spending despite the introduction of a new payroll tax because the average New Yorker would no longer pay insurance premiums and copays. He cited the Rand Corp. study, commissioned by the New York State Health Foundation, which found total health care spending could be lower under the New York Health Act than under the status quo. “To me, the issue is not about where your check goes,” Gottfried said. “What people really care about is how much are they going to have to spend, and how much they will be able to keep under the New York Health Act.”
However, Hammond pointed out that since there is no precedent for the system in the country, the details of the new tax plan have not been worked out yet and it is hard to accurately predict the cost of the program, so the Rand study could be wrong. He added that it also hinges on the federal government providing waivers to in order to divert Affordable Care Act, Medicare and Medicaid funding into the single-payer system, an unlikely prospect with the current administration. “There’s all kind of doubt and uncertainty about who’s going to pay more and who’s going to pay less,” Hammond said.
Rivera dismissed the idea that the New York Health Act depends on receiving those federal waivers, saying they would be helpful, but not necessary. “We believe, both my colleague and myself, believe that there are ways within the system that we could actually extend the New York Health Act as a wraparound service that would ultimately not require waivers,” Rivera said. He added that since the single-payer system would take years to put into place, he remained hopeful that a different, more sympathetic administration would be in the White House by then.
Another sticking point in evaluating and passing the New York Health Act is the fact that the previous legislation contained no specific language on tax rates for the proposed payroll tax, forcing Rand to use a hypothetical tax schedule. Gottfried said no language about tax brackets will be added to the legislation that he and Rivera will introduce and that it will be worked out after the bill’s passage since the program will take years to implement. He added the absence of this information will not pose an impediment to passage and that it could be easily added in if it becomes necessary.
Despite the many obstacles the legislation appears to face, Gottfried said that he and Rivera have learned from their previous mistakes, such as not including a revenue stream, and they remain confident New York will lead the country in single-payer health care. “Anything has to start with somebody,” Gottfried said. “And New York is ideally suited to be the state that begins single-payer coverage.”
For nearly 150 people around the NY Capital Region who’ve been hounded for years by debt collectors, the mail should have recently brought some good news. News that seemed too good to be true.
If it came in a yellow envelope with a return address of Rye, New York from a group called “RIP Medical Debt,” it wasn’t. Too good to be true, that is. Your years-old medical debt has been forgiven. Paid off. No strings attached.
“A lot of people get our letters and think they’re too good to be true and throw them out,” said Daniel Lempert, a spokesman for RIP Medical Debt. “That’s why we try to get the word out.
Thanks to a fundraising campaign by a group out of the Finger Lakes, the medical debt of some 1,284 people around upstate New York totaling $1.5 million has been forgiven. In the Capital Region, 146 people had $298,507 worth of old debt wiped out — all because Judith Jones and Carolyn Kenyon, of Ithaca, got the idea to raise money for a good cause.
The women are members of the Finger Lakes chapter of the Campaign for New York Health, which advocates for universal health coverage through passage of the New York Health Act. The pair were looking to do some good, and maybe make a political statement at the same time. So when they came across RIP Medical Debt, a nonprofit that buys bundled portfolios of medical debt for pennies on the dollar and forgives it, they were intrigued.
“The further we got into it, the more we realized what a serious issue medical debt is,” said Jones, a retired chemist. “When you start to learn how bad the problem is, it makes you want to do more.”
RIP Medical Debt was founded in 2014 by two former debt collection industry executives, Craig Antico and Jerry Ashton. Dissatisfied with the way they saw debtors being treated, the pair teamed up to create a nonprofit that would buy up medical debt incurred by people who are hard-up financially, for the sole purpose of forgiving it.
Working with third-party credit data providers, the nonprofit searches bundled debt portfolios to locate accounts meeting its criteria for financial relief. It then negotiates to buy portfolios at a steep discount — on average, a penny on the dollar — so it can forgive the debt.
The return on investment is what made the group so appealing, Jones said. It took her and Kenyon four months to raise $12,500, which RIP then used to purchase $1.5 million worth of debt.
Prior to these purchases, the medical bills have passed through several collection agencies and months or years of collection pursuit. It’s this type of debt that really damages a person’s credit, impacting their ability to buy or rent a home, buy a vehicle, secure a loan, or even get a job.
“As medical costs rise to unspeakable levels, so does un-payable medical debt,” RIP says on its website. “Medical debt has destroyed the financial stability of large segments of America’s most vulnerable communities: the sick, the elderly, the poor, and veterans. It also particularly targets the middle class, driving many families who are barely getting along into poverty.”
The statistics are sobering.
More than 1 in 3 Americans say they struggle to afford the cost of medical care, with 43 million now owing $75 billion in past-due medical debt. It’s not for lack of health insurance, either. Three out of every four people who end up in medical bankruptcy had insurance.
While many have taken on extra jobs or worked more hours to cover these bills, some are turning to charity for help. One in every three GoFundMe fundraisers, for example, are for medical bills, according to CEO Rob Solomon.
“One thing that really struck me in my research was the medical debt incurred by women who had metastatic breast cancer,” Jones said.
A number of recent studies and surveys have documented the negative financial toll that treatment takes on cancer patients. Several studies, meanwhile, have found this toll is even associated with a higher risk of death.
More than 11 million Americans took on added credit card debt in 2013 to cover medical expenses. The same year, 15 million depleted their savings to pay for medical bills. Another 10 million were unable to pay for basic necessities, including rent, food and utilities, because of medical bills.
“We really just want people to be aware of what a terrible problem medical debt is,” Lempert said. “And we want recipients of these letters to know this debt is finally off their credit report.”
Comprehensive plan is estimated to reduce U.S. health consumption expenditures by nearly 10 percent, while providing decent health care coverage to all Americans
AMHERST, Mass. – A team of economists from the University of Massachusetts Political Economy Research Institute (PERI) has found that the Medicare for All Act of 2017, introduced to the United States Senate by Senator Bernie Sanders, is not only economically viable, but could actually reduce health consumption expenditures by about 9.6 percent while also providing decent health care coverage for all Americans.
In a nearly 200-page report released at the Sanders Institute Gathering, the first major event hosted by the think tank founded by Jane O’Meara Sanders and David Driscoll, the senator’s wife and son, the economists outline seven major aspects of transforming the U.S. health care system, detailing step-by-step the actions needed to be taken to achieve truly universal health care and its potential impacts on individuals, families, businesses and government. The analysis, which was in development for 18 months, has received praise from 11 distinguished experts in the fields of economics and health care studies who have rigorously reviewed the researchers’ findings.
“The most fundamental goals of Medicare for All are to significantly improve health care outcomes for everyone living in the United States while also establishing effective cost controls throughout the health care system. These two purposes are both achievable,” says lead author Robert Pollin, Distinguished Professor in economics at UMass Amherst and co-director of PERI. “As of 2017, the U.S. was spending about $3.24 trillion on personal health care—about 17 percent of total GDP. Meanwhile, 9 percent of U.S. residents have no insurance and 26 percent are underinsured—they are unable to access needed care because of prohibitively high costs. Other high-income countries spend an average of about 40 percent less per person and produce better health outcomes. Medicare for All could reduce total health care spending in the U.S. by nearly 10 percent, to $2.93 trillion, while creating stable access to good care for all U.S. residents.”
The PERI research team of Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim and Michael Ash, found that Medicare for All would reduce annual health care spending to $2.93 trillion from the current level of $3.24 trillion. Public health care revenue sources that presently provide about 60 percent of all U.S. health care financing, including funding for Medicare and Medicaid, would provide $1.88 trillion of financing for the new system. Removing the other costs attributed with the current system would leave a gap of $1.05 trillion, which the economists suggest could be raised with a set of four proposals that will generate enough revenue to create a surplus of 1 percent for the system.
The researchers propose:
Continuing business health care premiums, but with a cut of 8 percent relative to existing spending per worker. Businesses that have been providing coverage for their employees would thereby see their health care costs fall by between about 8-13 percent. ($623 billion)
A 3.75 percent sales tax on non-necessities, which includes exemptions for spending on necessities such as food and beverages consumed at home, housing and utilities, education and non-profits. The researchers include a 3.75 percent income tax credit for families currently insured by Medicaid. ($196 billion)
A net worth tax of 0.38 percent, with an exemption for the first $1 million in net worth. The researchers state that this tax would therefore apply to only the wealthiest 12 percent of U.S. households. ($193 billion)
Taxing long-term capital gains as ordinary income. ($69 billion)
Under these recommendations, the researchers find that the net costs of health care for middle-income families would fall by between 2.6 and 14 percent of income. For high-income families health care costs will rise, but only to an average of 3.7 percent of income for those in the top 20 percent income group, and to 4.7 percent of income for the top 5 percent.
The researchers also find that based on 2017 U.S. health care expenditure figures, the cumulative savings for the first decade operating under Medicare for All would be $5.1 trillion, equal to 2.1 percent of cumulative GDP, without accounting for broader macroeconomic benefits such as increased productivity, greater income equality and net job creation through lower operating costs for small- and medium-sized businesses.
“Medicare for All will produce large cost savings for both businesses and households,” says co-author Jeannette Wicks-Lim, associate research professor at PERI. “Under our proposal, all businesses that now provide health care coverage for their employees will receive an across-the-board 8 percent cut in premiums. For families, our results show that Medicare for All will promote both lower average costs and greater equity. For example, middle-income families who now purchase private insurance on the individual market would see their health care costs fall by an average of 14 percent under Medicare for All.”
“This study is the most comprehensive, detailed, authoritative study ever undertaken of Medicare for All, and it points powerfully and unassailably in support of MFA,” said economist and public policy expert Jeffrey Sachs, University Professor at Columbia University, in reviewing the researchers’ analysis. “Medicare for All promises a system that is fairer, more efficient, and vastly less expensive than America’s bloated, monopolized, over-priced and under-performing private health insurance system. America spends far more on health care and gets far less for its money than any other high-income country. This study explains why, and shows how Medicare for All offers a proven and wholly workable way forward.”
In his review of the report, William Hsiao, K.T. Li Professor of Economics at the Harvard University T.H. Chan School of Public Health, said the study “presents an objective, unbiased, comprehensive and thorough economic analysis of Medicare for All. Professor Pollin and his co-authors have set a new high standard for transparency and clarity in presenting their analyses, estimations, and conclusions. The research methods they used to estimate both the cost increases and savings are sound. The assumptions they used to generate cost estimations are based on the latest empirical evidence. Consequently, the conclusions of this study on the overall costs and savings of Medicare for All are reasonable and scientifically sound.”
“This stellar economic analysis of a single-payer, universal health care system for the U.S. is the first to sufficiently document each step of the calculations, enabling reproducibility of the findings. It is also the first study that thoroughly addresses the transition to and financing of a universal health care system for the U.S.,” said Alison Galvani, director of the Center for Infectious Disease Modeling and Analysis and Burnett and Stender Families’ Professor of Epidemiology at Yale University, in her review of the report. “Underlying the analysis is an interdisciplinary evidence base that has been compiled from literature spanning economics, health policy and clinical care both within the US and internationally. The methodology is sound and the assumptions are conservative with regard to their conclusions. Specifically, lower-end figures from the expert literature are used in the calculation of savings, whereas anticipated expenditures are based on the higher end of empirical distributions. Despite stacking the deck against Medicare for All, this analysis convincingly demonstrates the substantial improvements in cost efficiency that could be achieved by Medicare for All. I am confident that the Pollin et al. study will become recognized as the seminal analysis of a single-payer universal health care system for the U.S.”
Pollin and Wicks-Lim were joined in crafting the analysis by UMass Amherst colleagues James Heintz, associate director and Andrew Glyn Professor of Economics, Peter Arno, senior fellow and director of health policy research, and Michael Ash, senior research fellow and professor of economics and public policy.
The complete report, “Economic Analysis of Medicare for All,” can be found online here.
The full set of reviews of the report by economics and health care studies experts can be found here.
Brittany fully realized that most mentally capable, terminally ill adults with six months or less to live who qualify for medical aid in dying do not have the ability, resources or time to pick up and move to one of the states that allow this end-of-life care option. That’s why she dedicated the last few weeks of her life to advocating for lawmakers to pass similar laws in states nationwide.
Today, I continue to fulfill my promise to Brittany to carry on her message, which has inspired California, Colorado, the District of Columbiaand Hawai’i to pass laws authorizing medical aid in dying since she died on Nov. 1, 2014.
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And thanks to previously passed laws in Oregon, Washington, Vermont and a Montana Supreme Court ruling in a lawsuit filed by Compassion & Choices, nearly 20 percent of Americans live in a jurisdiction where this end-of-life care option is available. But my mission is far from accomplished.
More than two dozen states have considered medical aid-in-dying bills since last year. They include New Jersey, where I have met with lawmakers repeatedly to urge them to pass the Aid in Dying for the Terminally Ill Act and will do so again on Oct. 29.
I also will speak at a Day of the Dead celebration on Nov. 1 in New York City to honor my fellow Latinos who died in needless agony because they did not have this end-of-life care option and to urge the New York legislature to pass the Medical Aid in Dying Act.
The good news is that hospice and palliative care does provide relief from suffering in most, but not all cases.
In fact, medical aid-in-dying laws require doctors to advise patients who request medical aid in dying about all their end-of-life care options, including hospice and palliative care, resulting in earlier and more effective utilization of these other options, as The Los Angeles Times reported last year. Between 80 percent to 90 percent of terminally ill patients who utilize medical aid in dying are already enrolled in hospice care, according to reports in states where this option is available.
To be clear, no terminally ill person, doctor, hospice professional, nurse or pharmacist has to participate in medical aid-in-dying laws if they object to doing so.
Unfortunately that fact seems irrelevant to opponents. They prefer to impose their ethical and moral views upon a huge majority of Americans and insist no one should have this end-of-life care option.
Two well-meaning opponents of medical aid in dying are Kristen Hanson and her late husband, JJ Hanson, a young Marine Corps veteran of the Iraq war, who had a similar brain cancer diagnosis to Brittany’s. But JJ knew no two diagnoses are identical, even if the disease has the same name.
Despite our opposing views on end-of-life care, I had the distinct pleasure of meeting JJ Hanson before he died last year. I consider him my friend and still keep his texts and voicemails. By the end of our conversations, he understood the suffering Brittany had endured before deciding to utilize medical aid in dying, enabling her to pass peacefully in her sleep. “I’m glad she was able to have a gentle dying experience,” he said kindly.
Likewise, I am glad to know that my friend JJ’s death played out in accordance with his beliefs.Brittany, like JJ, was striving to live as long as possible.
In her case the tumor was massive and after enduring her eight-hour surgery the available treatment options would have stolen her quality of life. The average life expectancy of a patient with a Glioblastoma Multiforme is 15 months. It ended John McCain’s life in 12 months, Brittany’s after 10 months.
I celebrate that JJ was one of the outliers, the lucky ones to outlive the average. He navigated his cancer for 3-1/2 years. But in the end, death was still the result. Brittany refused to let cancer defeat her spirit or soaring personality.
Death was inevitable, but she was going to die on her terms, not the cancer’s.
Hope comes in more forms than simply the hope that medical treatment will achieve a total cure and postpone death indefinitely. Brittany’s hope was to live each day to the fullest and to leave lasting memories of adventure, bravery and joy rather than of her pain and needless suffering.
My hope is that one day every American will have the option of medical aid in dying so that they can pass peacefully in whatever way they decide is appropriate.
That is why I urge every state legislature to pass these laws. It is important for lawmakers to recognize that medical aid in dying does not cause more people to die. It just allows more dying people to peacefully stop needless suffering at life’s inevitable end.
Dan Diaz lives in California, but travels to states across the country to urge lawmakers to pass medical aid-in-dying laws.
NEW HAVEN, CT – Dr. Daniel Colón Ramos, a Puerto Rican scientist, associate professor at Yale University and a co-adjunct professor at the Institute of Neurobiology at the University of Puerto Rico, was selected last month to receive two important recognitions from of the National Institutes of Health (NIH), one of the leading scientific agencies in the United States.
The first prize given to Dr. Colón Ramos is the NIH Director’s Pioneer Award, which supports highly innovative scientists who lead bold research projects with an exceptionally broad scientific impact. The prize is awarded in recognition of the advanced studies carried out by Dr. Colón Ramos in the area of ??neuroscience. The second prize received is the Landis Mentoring Award for Outstanding Mentoring, a new award that recognizes excellence and leadership by professors who have distinguished themselves by training new scientists and serving as mentors. In the ten years that Dr. Colón Ramos has been a member of the faculty at Yale, he has trained 27 scientists, most of whom have continued into impressive careers related to science. Altogether, the prizes reach a sum of $3.6 million, which Colón Ramos will use to continue his research in neuroscience, specifically to understand how the brain works and how memories are formed. The grant will also be used to promote the professional development of future young scientists in his laboratory.
“It moves and deeply honors me that the laboratory has been recognized with these awards. We seek to create an environment where new ideas flourish and challenge the way we think, not only in terms of the scientific paradigms we study, but also in terms of those who belong to science, and to whom science must serve,” Dr. Colón Ramos asserted. “I dedicate these awards to my country, Puerto Rico, where I had my first mentors and my first encounters with science, and a place that has influenced my interests and the way I think to this day.”
Dr. Daniel Colón Ramos was raised between Barranquitas and Guaynabo, Puerto Rico. He completed his baccalaureate at Harvard University, his doctorate at Duke University and his postdoctoral training at Stanford University. His laboratory at Yale University studies how brain cells, neurons, make precise connections—called synapses—with each other and how that architecture serves as the basis for the behavior of animals and humans. Outside the lab, Dr. Colón-Ramos has also sought connections, specifically between scientists and Puerto Rico. He is trustee of the Puerto Rico Science, Technology and Research Trust and co-founder and president of the Board of Directors of Science Puerto Rico (CienciaPR), the largest network of Puerto Rican scientists in the world and a non-profit organization that takes advantage of the knowledge of its rich and diverse community to democratize science, transform scientific education, and promote the development of young scientific leaders.
“We are extremely proud of these recognitions that Daniel has received. Our organization is a living example of his innovative vision, and his commitment to the development of future Puerto Rican scientists and science,” commented Dr. Giovanna Guerrero-Medina, Executive Director of CienciaPR.
President Donald Trump took to Twitter on Thursday morning to challenge the official count of the number of people who died in Puerto Rico in the aftermath of Hurricane Maria, which struck nearly a year ago.
“3000 people did not die” in Puerto Rico, the president tweeted.
The death toll from the Sept. 20 storm, a Category 4 hurricane, has been a point of contention between officials and residents who live there. George Washington University (GWU) researchers released the findings of an in-depth investigation commissioned by Puerto Rico’s government. They estimated 2,975 people died as a result of the storm.
The president questioned that report’s credibility, insinuating that the count was a ploy by his political opponents and that it included people who died from causes unrelated to the storm.
“This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico,” he tweeted. “If a person died for any reason, like old age, just add them onto the list.”
The tweets prompted a sharp rebuke from Puerto Rico Gov. Ricardo Rosselló, who called for recovery efforts to remain above the political fray.
“The victims and the people of Puerto Rico do not deserve to have their pain questioned,” the governor’s statement said.
Here is a brief look at the issue of casualties and Puerto Rico’s response to Hurricane Maria.
How many people died?
Calculating a death count is not an exact science. Estimates are influenced by a variety of factors including the period analyzed and the definition of a disaster-related death, according to Columbia University professor John Mutter.
The Puerto Rican government accepts GWU’s estimate of 2,975 deaths as the official count. Local officials had originally said 64 people died in Hurricane Maria, counting only fatalities directly attributable to the storm, such as drowning deaths or mortal injuries caused when buildings collapsed. During the summer they acknowledged that toll had risen to more than 1,400.
The GWU researchers calculated their estimated death toll, which is about double that tally, by comparing the number of people who died in the six months after Hurricane Maria to historical averages in previous years.
The university issued a statement Thursday, disputing Trump’s comments. The investigation was “carried out with complete independence and freedom from any kind of interference,” according to the press release.
Prior to the GWU study, other researchers and one newspaper released estimates that also garnered media attention.
One study, published in the New England Journal of Medicine, put the number of excess deaths at 4,645 in the three months following the hurricane. A studyby The New York Times used vital records from the government to calculate an excess of 1,052 deaths in the first 42 days after the disaster.
Still, the numbers are important, said Mutter, who researches disaster management and worked on collecting the number of deaths in New Orleans after Hurricane Katrina. These death counts are a key way the public measures a disaster and perception drives donations for relief, he said.
Why was it so confusing getting a death toll?
When Hurricane Maria made landfall in Puerto Rico, it devastated the island’s infrastructure, which can limit access to health care and impact mortality, especially among residents who are frail or dealing with chronic health issues.
The storm knocked out electricity for the entire island, which took nearly a year to restore fully. At least 80 percent of communications towers were not operational, crippling phone services. Medical centers across the island relied on generators for power, which sometimes failed and jeopardized patients. Some medical facilities in Puerto Rico were irreparably damaged, like the only hospital on the island of Vieques, which housed its only dialysis center. Residents must now leave the island three times a week for treatment.
Many roads on the island were impassable because of debris or erosion. Roads near rivers, like those in the mountainous, rural province of Utuado, washed away. Bridges also fell, leaving some communities isolated and unable to access assistance.
Hurricane Maria also cut off drinking water to more than half of Puerto Rico. The lack of electricity meant water pumps could not work. Some people turned to other sources, like natural springs and rivers, for drinking water. At least 26 people died of leptospirosis, a bacterial infection caused by exposure to water or soil contaminated with the urine of infected animals, according to reportingfrom CNN and the Centro de Periodismo Investigativo, a nonprofit group that promotes investigative journalism.
In addition to the physical disruption, the GWU researchers noted that officials in charge of certifying deaths did not have a process that automatically noted when a death was a consequence of the hurricane or its aftereffects.
How did the federal government do in its response to Hurricane Maria?
According to the federal government, not very well.
A report released earlier this month by the U.S. Government Accountability Office (GAO) details how the Federal Emergency Management Agency (FEMA) struggled to meet the needs of Puerto Rico and the U.S. Virgin Islands after the storms.
The agency didn’t provide adequate staffing to the disasters on the islands, according to the GAO. It faced a 37 percent staffing shortage as of Sept. 1, 2017. Of the personnel deployed to the islands, some “were not physically able to handle the extreme or austere environment of the territories,” the report said. The lack of bilingual employees also led to delays since many Puerto Ricans speak Spanish.
Transporting materials to the island was also an issue for the agency, as both islands are located more than 1,000 nautical miles from the mainland, the report said.
FEMA Administrator Brock Long addressed some of those issues Tuesday in an interview on CNN. “We threw as much as we could towards Puerto Rico,” he said.
He added that FEMA’s prime concern is preventing deaths from natural disasters, but also that “there’s a difference between direct deaths of, you know, the winds, water, collapsed buildings, things that kill people directly versus the indirect deaths. Indirect deaths are always higher than the direct deaths after many events. … But what I really believe is that we have to concentrate on the pre-disaster mitigation, fix the infrastructure that was crumbling before the storms in the commonwealth, so that we prevent this from ever happening again.”
He noted that FEMA is now the largest employer in Puerto Rico as repair efforts continue.
What has the Puerto Rican government done in response to the death counts in Hurricane Maria?
After the GWU findings were released, Gov. Rosselló changed the official death count and accepted responsibility for the territory government’s failure to adequately respond to residents’ needs. He also said he would form a commission to consider the recommendations suggested in the GWU study on how to improve the island’s response to disasters.
However, how many changes the territory’s government can make remains to be seen. Puerto Rico’s purse is under the control of a fiscal oversight board put in place by Congress to address the island’s debt crisis, which stands at more than $70 billion.
BY DANIEL E. DAWES, OPINION CONTRIBUTOR — 09/01/18
Today, we laid to rest arguably one of our country’s most notable war heroes, Sen. John McCain (R-Ariz.). The past week has been filled with a number of moving tributes and in-depth coverage of his legacy on the battlefield and on the Senate floor.
While our political views differed in many areas, I gained a new level of respect for Sen. McCain the night he saved ObamaCare with a simple thumbs down. It is a gesture that now serves as a bookend for his Senate career and one that saved the health coverage for millions of Americans, particularly those with mental health and substance use challenges.
While the rest of the country pauses to honor his legacy, many on Capitol Hill are already focused on undoing it by urging the governor of Arizona to appoint a senator to McCain’s seat who they can trust will repeal ObamaCare. While we are having no shortage of political issues that we need to mobilize behind, I urge mental health advocates to keep up the fight against those looking to strip away care that took more than a century and a half to obtain.
Contrary to how it’s viewed, mental health is not a fringe issue. An estimated 44 million Americans experience mental health conditions every year and approximately 350,000 people die prematurely from mental illness and substance use.
Furthermore, one in two individuals will be diagnosed with a mental illness or disorder in their lifetime, suicides are rising across the United States, opioid overdoses are the leading cause of death for people under 50 (one in five individuals struggling with opioid addiction can’t get behavioral health services and treatments) and depression is projected to be the leading cause of disability in the next 20 years. The economic burden to the United States for failing to adequately address this issue each year is a staggering $467 billion.
The passage of ObamaCare marked the first time in American history that federal law mandated that mental health and substance use disorder benefits should be an essential health benefit along with rehabilitative, habilitative, and prevention and wellness coverage.
It expanded parity protections, promoted the integration of behavioral health and primary care within delivery and payment system reforms, prioritized depression and substance use screenings as preventive services at no cost to the consumer, and provided other opportunities for behavioral health prioritization.
This coverage victory was the result of a hard fought battle that started more than a century and a half before ObamaCare was passed. Dorothea Dix, teacher, activist and humanitarian, began a movement to advocate for health reforms to address the issues surrounding those with mental health challenges in the early 1800s. She spent years lobbying state legislatures to provide adequate institutions for treatment and care, until she determined it was only the federal government that could effectively carry this national crusade.
Dix’s initiative eventually landed on President Franklin Pierce’s desk in 1854 where it was vetoed. And so the federal role in mental health care — extremely limited federal participation or non-participation — stood for a century until administrations starting in 1942 began enacting piecemeal legislation on mental health culminating in comprehensive care being granted by the passage of ObamaCare.
We must not go backwards. If the GOP purports to care about the opioid epidemic and Mitch McConnell says they will be considering a bipartisan opioid bill in late September, then it goes without saying that keeping McCain’s legacy of saving ObamaCare is the only way to do this. There is no way that the GOP can be both for helping those with opioid addiction and for repealing ObamaCare.
So, I call on mental health champions and regular Americans to channel the spirit of Dix and others. Definitely take this time to mourn the legacy of John McCain. Then get right to work on stopping those hellbent on upending the gains seen under ObamaCare.
Fight to protect the legacy of a Senator who saw past the pressures of his party to do what is right for the American people. And the legacy of millions of Americans with mental challenges who have benefitted from the Affordable Care Act and millions of others still yearning for that help and support.
If mental health advocates care about achieving equity in behavioral health, then we must speak up and act now. Because if we don’t, I fear that a century from now we’ll still be fighting the never-ending battle for a more accessible, equitable and inclusive health system.
Daniel E. Dawes, JD, is the author of “150 Years of Obamacare” and serves as the senior adviser to the Satcher Health Leadership Institute at Morehouse School of Medicine and Associate Professor at Nova Southeastern University. He founded and chaired the National Working Group on Health Disparities and Heal
SAN JUAN, Puerto Rico– Hurricane Maria killed far more people in Puerto Rico than initially thought, accounting for an estimated 2,975 deaths on the island from September 2017 through February 2018, according to a new analysis. The study found that those in low-income areas, and elderly men, were at greatest risk of dying.
The independent analysis was commissioned by the governor of Puerto Rico and conducted by researchers at George Washington University’s Milken Institute School of Public Health. CBS News obtained a report on the findings from Carlos Mercader, executive director of the Puerto Rico Federal Affairs Administration.
To arrive at the 2,975 figure, the study looked at historical death patterns from 2010 to 2017 to estimate how many people would have died had Hurricane Maria not hit the island. That figure was then compared to the actual number of deaths from September 2017 through February 2018 — obtained in records provided by the Puerto Rico Vital Statistics Records division of the Puerto Rico Department of Health — to determine what the report describes as the “estimate of excess mortality due to the hurricane.”
The study found that while all age groups and social strata were affected by the hurricane, the risk of death was “45% higher and persistent until the end of the study period for populations living in low socioeconomic development municipalities.”
It also found that men age 65 and older were at heightened risk of death through February, the end of the study period.
“Overall, we estimate that 40% of municipalities experienced significantly higher mortality in the study period than in the comparable period of the previous two years,” the report says.
In the aftermath of the devastating storm, which barreled into Puerto Rico last September, Puerto Rico’s government initially reported 64 deaths blamed on the hurricane. Since then, several studies have indicated the actual death toll was much higher, though researchers have arrived at a range of different figures.
In May, a Harvard University study said Maria was likely responsible for more than 4,600 deaths from the day of the storm, September 20, until December 31, 2017 — a figure that was based on results of a door-to-door survey of 3,299 randomly selected homes across the island. Earlier this month, Puerto Rico said in a report to Congress there were 1,427 more deaths “than normal” in the four months after Hurricane Maria and Hurricane Irma, which churned on a path just north of the island two weeks before Maria hit. That report said, however, those 1,427 deaths “may or may not be attributable to the hurricanes.”
The latest study says that from the period ranging from September to December 2017 alone, there were an excess of 2,098 deaths, and 2,975 from September 2017 to February 2018.
The report offered insight as to why the initial count of 64 was so much lower than this new figure.
“The official government estimate of 64 deaths from the hurricane is low primarily because the conventions used for causal attribution only allowed for classification of deaths attributable directly to the storm, e.g., those caused by structural collapse, flying debris, floods and drownings,” the report says. “During our broader study, we found that many physicians were not oriented in the appropriate certification protocol. This translated into an inadequate indicator for monitoring mortality in the hurricane’s aftermath.”
The report goes on to say that “physician unawareness of appropriate death certification practices after a natural disaster and the Government of Puerto Rico’s lack of communication about death certificate reporting prior to the 2017 hurricane season substantially limited the count of deaths related to Maria.”
The report, which analyzed processes related to death certification, says that physicians and forensic physicians are among those in Puerto Rico who are authorized to complete death certificates, but that most physicians have no formal training in how to do so. They are therefore unaware of “appropriate death certification practices, especially in a disaster setting,” the report found.
“Those interviewed said they did not receive information about how to certify deaths during, or in conditions created by, a disaster,” the report says.
It also says there was a communication problem between the Puerto Rico Vital Statistics Registry and other government agencies and those involved in the death certification and registration process.
“Many stated that the Puerto Rico Department of Health (DoH) and the Puerto Rico Department of Public Safety (DPS) did not notify them about the CDC special guidelines for correct documentation of cases, on the importance of correctly documenting deaths related to the hurricane or on an emergency protocol for handling these cases,” it says.
