The Puerto Rico Department of Health (PRDOH) administers the Title V Block Grant that consists of the Maternal, Child and Adolescent Health Program or MCAHP housed in the Maternal, Child and Adolescent Division (MCAHD) and the Children with Special Heath Care Needs Program or CSHCNP located in the Children with Special Medical Needs Division (CSMND). The PR Title V provides services and implement initiatives in the seven PRDOH Health Regions.
To place Title V efforts in context one must first understand the general conditions of Puerto Rican society that play a crucial role in the health and wellbeing of populations.
Puerto Rico (PR), a territory of the US, is divided in 78 jurisdictions known as municipalities, each headed by a mayor. Vieques and Culebra are offshore municipalities whose residents travel to the Great Island (PR) in small planes and/or ferry for secondary and tertiary health care and other services.
Every four years, a governor, 28 senators, and 51 House members are elected to serve in the PR government. A non-voting delegate to the US House of Representatives is also elected. Puerto Ricans are US citizens, serve in the US military, and contribute to Social Security and Medicare but are not eligible to receive the Earned Income Tax Credit that gives refunds to low-income workers. Since 2021, PR residents qualify for the Child Tax Credit if they have one or more children.
The governmental structure has three major branches: the executive (called Central government), the legislative and the judicial. Each major state agency is divided into a Central office and Region offices distributed across PR.
Health Care System
In the 1990’s public healthcare was transferred from the government to contracted private insurers to provide health care services on a capitated payment plan. The PR Health Insurance Administration (PRHIA or ASES, Spanish acronym) oversees and negotiates contracts with private insurers.
The Government Health Plan (GHP) integrates physical and mental health in one facility, expands preventive medicine and screening, and provides direct access to specialists without need for referral within a Preferred Provider Network. The GHP is financed by a combination of state, municipal and federal funds (Medicaid and SCHIP). Medicaid funding to PR is limited to a fixed amount regardless of the eligible population medical needs, unlike the states that are set based on per capita income. ACA funds (non-recurrent) were added to the GHP for Medicaid assigned funds. Through ACA several benefits such as family planning and contraception methods services were added to the GHP’s coverage. Medicaid assigned additional funds to cover GHP’s expenses on health services, especially during the pandemic crisis.
In 2021, there were approximately 1,500,000 persons covered by the GHP through five insurance companies. Vital Statistics 2020-2021 data show that 66.5% of mothers’ health insurance at the time of birth was the GHP which means that it pays for most births in PR. The GHP has a Special Coverage Registry (SCR) for CSHCN. Enrollees have the option to choose the providers for services within the Preferred Provider Network of their PMG or their Health Plan’s General Network. Medications, laboratory tests, diagnostic tests and other related procedures specified are part of this coverage. PRHIA 2020 database shows 38,552 CSHCN children enrolled in this SCR. The GHP also has a SCR for ASD. When ASD is suspected, children are enrolled in a temporary coverage for up to 6 months for the diagnostic interventions. If the diagnosis of ASD is certified by one of the following GHP providers: neurologist, psychiatrist, developmental pediatrician, or clinical psychologist the child is included in the ASD Special Coverage Registry. PRHIA 2021 database shows 2,277 children enrolled in the ASD-SCR.
Puerto Rico passed Act No. 14- 2017 - “Incentives Act for the Retention and Return of Medical Professionals”- to provide income tax incentives (4% fixed rate) to retain practicing physicians and to attract those who migrated to the US.
To address the use of opioids, the Prescription Monitoring Program for Controlled Substances (under Law 70- 2017, Monitoring the Prescription of Controlled Substances) was implemented in 2018, to maintain a system of electronic prescription monitoring of controlled substances dispensed in PR.
In early 2021, the Accreditation Council for Graduate Medical Education notified the University of Puerto Rico School of Medicine, the withdrawal of the accreditation of the Neurosurgery Residency Program (the only one existing in PR) effective on June 30, 2022. The withdrawal implies that medical residents must relocate to the US.
Population
Puerto Rico is an area of about 3,500 square miles and a population of 3,285,874 persons (Census 2020) that tend to cluster in urban areas.
Puerto Rico is mainly a Spanish speaking country where most of its residents are Puerto Ricans followed by other foreign Hispanic ethnic groups like Dominicans and Cubans. Regarding racial composition, there has been drastic changes in race identification when one compares the 2010 and 2020 Decennial Census. The number of people that identified themselves as only white decreased from 75.8% in 2010 to 17.1% in 2020. Meanwhile, the number of persons that selected more than one race increased significantly from 3% in 2010 to 50% in 2020. According to race experts in PR, increased awareness of the African heritage and stronger identification as a black Puerto Rican may have contributed greatly to changes in people’s racial identification when filling out the 2020 Census.
In the 2010 Census, people in PR may have opted to report their race as white (despite skin tone) due to an unstated contempt for everything associated with being dark or black skinned. For example, in PR people make a distinction between “bad hair’’ (kinky hair linked to being black) and “good hair’’ (straight hair linked to white and Indio). Although new generations are identifying themselves as black, the euphemism “de color’’ (literally of color) is commonly used as the word black is seldom used as a direct term of reference. There is also a generalized denial of racial prejudice and discrimination in the island. While it is not possible to explain in depth the manifestation of racism in PR, suffice is to say that it takes a covert form exemplified by sly comments and racial jokes (often seen as harmless) in day-to- day interactions. On an institutional level, dark/black skinned people are underrepresented in the main media outlets and high-status positions in both the corporate world and government, according to the PR Civil Rights Commission.
In addition to Census and federal race categories, experts on the race issue in PR propose the use of local-specific racial categories for gathering data to better determine racial disparities. Indeed, research (Institute for Interdisciplinary Research at the University of Puerto Rico) reveals the association of skin color or tone with health disparities.
It must be noted that race is a culturally grounded concept that varies from one society to another. Race taxonomies in PR are based on phenotype traits such as texture of hair, skin tone, and lip and mouth shape and intermediate categories exist between white and black that are not represented in the US Census. Some examples are: “indio’’ (literally Indian, light brown and brown skinned with straight hair), “jabao’’ (fair skinned with kinky hair), and “trigueño’’ (light to dark brown skinned).
PR has been experiencing population loss in the last decades. The population decreased by 532,095 (14.3%) from 3,725,789 000 in 2010 to 3,193, 694 in 2019, according to the State Data Center of PR. Between 2020 and 2021, the population decreased by about 22,290 persons. Two main factors are linked with population decline. First, the natural population growth continues to decrease due to declining natality and fecundity rates. Second, the migration of people to US mainland in search of better job opportunities and living conditions that intensified after Hurricane María in 2017.
The MCA population constituted 40% of the total 3.2 million population in 2020. The MCA population composition was as follows: 0.8% infants; 7.8% children 1-9 years of age; 11.7% adolescents aged 10-19 (6.0% males and 5.7% females) and; 19.6 % reproductive age women between the ages 20-49.
Education
The 2019 PRCS (1YR estimate) reports that people 25 years and over with less than 9th grade was 13.9 % and those with a high school diploma was 28.2%. Of those 25 years and over with post-secondary education, 11.2% had an associate degree; 18.8% a bachelor’s degree and; 7.9% a graduate or professional degree.
Student enrollment (kindergarten to 12th grade) in the public system diminished greatly from 544,076 in 2006 to 259,535 in 2021. Between 2006 and 2018 about 508 public schools closed across the island. According to the report “Population Decline and School Closure in Puerto Rico” (Center for PR Studies, May 2019), 65% of public schools in the rural areas closed compared to 35% in the urban areas, meaning that rural areas were the most impacted by the closures.
For the incoming (2022-2023) school year, public schools will face difficulties as the PR Department of Education will have 2,888 fewer teachers. This is due to massive retirement of teachers as those retiring in incoming years will receive a lower amount in pensions as stipulated by the PR Debt Adjustment Plan (DAP).
Social and Economic Conditions
In the last decades, PR has experienced a reduction in employment in the private and public sectors. Between 2006 and 2019 employment fell by 22% according to the Bureau of Labor Statistics (BLS). Concomitantly, the labor force participation rate declined from 49% in 2006 to 45.1% in 2019.
Lack of employment is accompanied by income levels that in PR are still far behind from the states. The per capita income for PR in the 1YR 2019 PRCS was $13,345 compared with the US $35,977. The 1YR 2019 PRCS median household income was $20,474, less than half of Mississippi ($44,787), the state with the lowest US median household income in 2019.
Poverty is a significant problem in PR affecting women, children, and families. In 2019, the poverty rate in PR (43.5%) was higher than the US (10.5%) and higher than the poverty rate in Mississippi (19.6%). Children under 18 years of age living in poverty in PR were 56.8% in 2019. Family structure influences poverty rates as single female-headed families tend to be poorer than married-couple families. While the percent below poverty level in 2019 PRCS in married-couple families with children was 37.7%, the percent of families with children headed by a female with no husband present was 65.6%. Residents of rural areas in PR have higher poverty rates than those living in urban areas. High poverty rates and low-income levels leads families to rely on public assistance programs for survival. The 1YR 2019 PRCS reports that 43.2% of households in PR received nutritional assistance benefits compared to 12% in the US.
Increases in the cost of living further deepen the economic hardships of families by reducing their purchasing power. Between January 2021 and January 2022 there was an overall 4.4% increase in the Consumer Price Index in PR. Given this increase the purchasing power of a dollar in January 2022 was 80 cents a drop of 4 cents from the previous year (PR Department of Labor and Human Resources). Since January 2022, dramatic increases in groceries ((6.4%), gasoline ($1.23-1.28 per liter regular), and electricity (16.8% per kilowatts) put more stresses in people’s daily lives. Frequent power outages and massive blackouts also affect the quality of life of residents and put at risk persons who depend on health-related electronic devices.
In many municipalities, mass transportation is unavailable, and people rely on private transportation services (12 passenger vehicles) called “carros públicos’’ (public cars) that may not be available after 2 PM or even earlier. Those who have their own private cars, may have to drive a long distance from and to their homes to work, study and receive services. To cover gaps in transport, there are municipalities that provide transportation mainly to the Greater Metropolitan Area to people in need of specialized health services. While mass transportation in San Juan municipality, - capital of PR - is available, there are limitations as the waiting time in some routes can be anywhere between one to two hours. The Urban Train only covers San Juan and Bayamón municipalities and lacks sufficient connecting buses to and from its 16 stations.
Like families, the PR government has been experiencing severe economic difficulties for almost a decade: a public debt of more than $70 billion, revenue loss, high GHP expenditure, depletion of pension funds, and insufficient liquidity to operate and meets its obligations. To face the crisis, the PR government has taken measures to reduce costs and increase revenues over the past years. Some of the measures are budget cuts to state agencies, school closings, reduction in subsidies to municipalities and NGOs, and tax increases. Measures related to government employees include lay-off of public workers (Law 7, 2009), increases in employees’ contributions and retirement age (Law 2013) and fringe benefit reductions and mobilization across agencies (Fiscal Compliance Act of 2017).
In 2016 the US Congress enacted the PR Oversight, Management and Economic Stability Act (PROMESA), installing the Financial Management and Oversight Board (FMOB) with decision-making power on all fiscal matters. In May 2017, the Oversight Board filed in the federal district court for debt relief under Title III of PROMESA, a form of bankruptcy to restructure PR fiscal liabilities. The court proceedings lasted five years and ended with the approval of the Debt Adjustment Plan (DAP) that became effective on March 15, 2022.
The high cost of living, low wages, and proposed changes to the formula for determining pensions caused indignation among public workers. From November 2021 through February 2022, public workers from the Central Government and Public Corporations carried out a series of actions claiming what they call “dignified retirement” and “wage salary justice”. By “dignified retirement” is meant zero pension cuts and no changes to the formula determining the amount an employee would receive upon retirement. “Wage justice” claims are geared to salary increases in the context of rising cost of living. The main course of action was absenteeism from work, thus there was a “blue flu” (police officers), “orange flu” (medical emergencies), “red flu” (firefighters), “white flu” (hospital health workers/nurses), and “teacher flu” (teachers at the public school system), among others. This strategy was accompanied by protests on the part of each group and one collective manifestation. The governor offered each group a salary hike ranging from $500 dollars to $1,000 dollars per month.
Amid the fiscal crisis, Hurricane Maria, with 155 mph winds struck PR on September 20, 2017. The hurricane caused billions of dollars in damages leaving behind widespread destruction to homes, businesses, roads, highways, and public and private institutional facilities. The wind force destroyed Puerto Rico’s energy grid causing the longest blackout in US history. Research on the deaths related to the hurricane place the death toll at approximately 3,000 people. Nearly three years (2020) after the hurricane, there were still thousands of houses with blue tarps, damaged roads in rural and urban areas, a significant number of damaged traffic lights in the Metro Area, and many closed small businesses all over the island. Yet, it was not until 2020 that FEMA disbursed the funds for home repairs. The hurricane’s devastation also pushed people out of Puerto Rico to the US mainland.
A sociohistorical event known as “the Puerto Rican Summer of 2019” occurred during the month of July 2019. For 12 days, massive protests of people from all walks of life, ages, and different parts of the island took place clamoring the resignation of Governor Ricardo (Ricky) Roselló which led to his resignation on August 2, 2019. The protests arose in response to the leak of chat messages between governor Roselló and 11 all-male top aides and associates that provoked people’s anger and indignation as these included profane insults, mockery, and contempt for victims of Hurricane María, LGBT community, people with obesity, women, political opponents, and celebrities. These protests led to Roselló’s resignation (effective August 2, 2019), the first governor of PR to ever resign.
