Puerto Rico’s Community Health Centers: Struggling to Recover in the Wake of Hurricane Maria Geiger Gibson / RCHN Community Health Foundation Research Collaborative Peter Shin, PhD Jessica Sharac, MSc, MPH Rachel Gunsalus Brad Leifer, MSLIS Sara Rosenbaum, JD About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long- standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at https://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at www.rchnfoundation.org. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 Executive Summary need for vector control to prevent mosquito bites and other insect infestations. On September 20, 2017, Hurricane Maria hit Restoring health centers’ ability to serve their communities Puerto Rico as a Category 4 storm, devastating will depend on a major infusion of federal aid through both a U.S. territory whose heavily impoverished Medicaid and health center grant funding. population already was facing critical economic and health challenges. Community Background health centers play an especially important The catastrophic aftermath of Hurricane Maria has placed a role in Puerto Rico’s health care system; in spotlight on Puerto Rico’s deep poverty, fragile economy 2016, twenty health centers operating in 86 and vulnerable health care system. As Table 1 shows, the mostly rural sites provided comprehensive Commonwealth of Puerto Rico’s residents are extraordinarily poor: nearly half the population (46%) have primary health care to more than 352,000 below-poverty incomes ($20,420 for a family of three in children and adults – over 1 in 10 residents. 2017),1 a figure more than three times the poverty rate in One month after the hurricane, 89% of health center sites the 50 states and the District of Columbia (DC) (15%). Even are open but are operating under challenging conditions. before Hurricane Maria struck, Puerto Rico’s working-age Only 13% of 70 assessed sites have had power restored as residents were more than twice as likely to be unemployed of mid-October. Many are able to provide only limited hours (10% versus 4%). The island’s residents are nearly twice as and services under post-storm conditions, and all health likely to report being in fair to poor health (34% versus centers face an enormous need for drugs, vaccines, 18%) and report higher rates of chronic but manageable medical equipment, and other resources essential to diseases, such as diabetes and heart disease. Puerto Rico proper functioning. Health centers report an urgent need also faces health risks more likely to be associated with for a wide range of vaccines and drugs, and report treating tropical climates; prior to Hurricane Maria, Puerto Rico conditions identified with catastrophic public health events reported nearly 35,000 confirmed cases of the Zika virus, that elevate the risk for infectious disease: acute infections, compared to approximately 5,100 cases on the U.S. conjunctivitis, scabies, leptospirosis, gastroenteritis, mainland.2 asthma, dermatitis, and viral infections (including influenza Their poverty and elevated unemployment mean that and suspected dengue and Zika). Over half of 70 assessed residents of Puerto Rico are heavily dependent on public health centers report that their communities have only health programs. Residents are much less likely to have intermittent access to drinking water, and 70% report that employment-based health insurance compared to those in their communities need food. All health centers report the the 50 states and DC (35% versus 60%). Because of the 1 Office of the Assistant Secretary for Planning and Evaluation. (2017). 2017 Poverty Guidelines for the 48 Contiguous States and the District of Columbia. U.S. Department of Health and Human Services. https://aspe.hhs.gov/poverty-guidelines 2 Centers for Disease Control and Prevention. (2017). Zika Virus - 2016 Case Counts in the US. https://www.cdc.gov/zika/reporting/2016-case-counts.html Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 depth of Puerto Rico’s poverty, the Affordable Care Act invested additional resources into expanding the reach of Medicaid rather than funding a federally-subsidized private health insurance Marketplace.3 As a result, 49% of all residents are insured through Medicaid or CHIP, compared to 20% on the U.S. mainland. Puerto Rico’s Health Crisis Triggered by Hurricane Maria Following on the heels of Hurricane Irma, Hurricane Maria was particularly devastating for Puerto Rico, greatly endangering population health and safety. The initial wind intensity as the Category 4 event made landfall severely disrupted the island’s already-fragile infrastructure. Structural damage to homes and buildings resulted in uninhabitable living conditions for a large swath of the population; thousands of displaced residents remain in emergency shelters. In addition, the storm crippled telephone and internet networks, leaving millions with no means of communication. As the weeks have passed, power lines remain downed, and it could take months before electricity is permanently restored.4 The lack of electricity in Puerto Rico has also severely limited the availability of potable water, since the filtration systems that create clean running drinking water rely on electricity to treat sewage.5 Clean water is critical to public health; without it, health care providers are already seeing a Source: Kaiser Family Foundation. (2017). Puerto Rico: Fast Facts. https:// www.kff.org/disparities-policy/fact-sheet/puerto-rico-fast-facts/ surge in the number of patients needing treatment for 3 Kaiser Family Foundation. (2017). Puerto Rico: Medicaid, Fiscal Issues and the Zika Challenge. http://files.kff.org/attachment/Fact-Sheet-Puerto-Rico-Medicaid-Fiscal-Issues-and -the-Zika-Challenge 4 Webber, T. (2017, October 20). “Why It’s So Hard to Turn the Lights Back on in Puerto Rico.” NPR. http://www.npr.org/2017/10/11/557051712/repairing-puerto-ricos-power-grid- could-top-5-billion 5 Dreazen, Y. (2017, October 23). “Darkenss: Life in Puerto Rico without Electricity.” Vox. https://www.vox.com/platform/amp/2017/10/23/16501164/puerto-rico-hurricane-maria- power-water-sewage-trump Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 communicable diseases such as conjunctivitis, gastritis, providers lack access to what they need; as of mid-October, and scabies. 6,7 Furthermore, the combination of high downed trees and standing water mean that less than ten temperatures, standing water from flooding, and percent of roads are open;11 as a result, access to diesel contaminated water sources considerably increases the risk fuel and supplies is compromised. The consequences for of mosquito-borne and water-borne diseases that could patients with chronic conditions who need dependable affect residents in the coming weeks and months, including access to health care are severe. chikungunya, Zika, and dengue.8 Leptospirosis, a bacterial disease that can be fatal without timely treatment, is also on the rise as a result of unsanitary living conditions; state Puerto Rico’s Health Centers epidemiologists report more suspected cases in the wake In 2016, the island’s 20 federally funded health centers of Hurricane Maria than they normally see in a year.9 Mental operated in 86 urban and rural locations (Table 2). Health health is a matter of great concern, given the effects of centers provided comprehensive primary health care to trauma and its aftermath, including the loss of homes and 352,172 residents, serving as medical homes for more than livelihood. Shelters report heightened need for mental one in ten residents that year.12 Beyond providing health health care. 10 care, health centers are a major source of employment and The post-hurricane conditions have and will continue to serve as economic engines in rural and urban communities create heightened demand for health care. But the health across the island, including those most isolated and care system, including the island’s twenty federally funded underserved. In 2016, Puerto Rico’s health centers health centers, are under enormous stress. Without regular employed over 3,200 staff including physicians, nurses, power, clinics and hospitals depend on diesel-run advanced practice health providers, dental staff, emergency generators for basic operations such as community outreach workers and administrative and laboratory services, x-ray equipment, refrigerators for facilities personnel. medication storage, hemodialysis machines, ventilators, and a host of other diagnostic and treatment services that require electricity. Even with extraordinary efforts, 6 Roig-Franzia, M. and Hernández, A.R. (2017, October 11). “Three Weeks Since Hurricane Maria, Much of Puerto Rico Still Dark, Thirsty and Frustrated”. The Washington Post. https://www.washingtonpost.com/national/three-weeks-since-hurricane-maria-much-of-puerto-rico-still-dark-dry-frustrated/2017/10/11/3a263b22-ade7-11e7-9e58- e6288544af98_story.html 7 Bendery, J. (2017, October 16). “These Volunteer Nurses in Puerto Rico Fear FEMA is Failing.” Huffington Post. https://www.huffingtonpost.com/entry/puerto-rico-hurricane-maria -fema-trump_us_59df75d5e4b00abf3646c751 8 McKay, B., Evans, M., Hernandez, D., and de Cordoba, J. (2017, September 27). “Puerto Rico Rushes to Patch Up Health-Care System Ravaged by Hurricane Maria.” Wall Street Journal. https://www.wsj.com/articles/puerto-rico-rushes-to-patch-up-health-care-system-ravaged-by-hurricane-maria-1506480187 9 Moreno, C. (2017, October 20). “Doctors Fear a Potentially Deadly Disease Outbreak in Puerto Rico.” Huffington Post. https://www.huffingtonpost.com/entry/leptospirosis- outbreak-puerto-rico-hurrincane_us_59e905aae4b0f9d35bc969ac Melia, M. and Coto, D. (2017, October 5). “Mental Health Concerns Arise in Puerto Rico Aftermath of Hurricane Maria.” Pittsburgh Post-Gazette. http://www.post-gazette.com/ 10 news/health/2017/10/05/Mental-health-concerns-arise-in-Puerto-Rico-aftermath-of-Hurricane-Maria/stories/201710050224 11 Federal Emergency Management Agency. (2017). Hurricane Maria. https://www.fema.gov/hurricane-maria (Accessed October 23, 2017) 12 US Census Bureau. Quick Facts: Puerto Rico. Population estimates, July 1, 2016. https://www.census.gov/quickfacts/PR Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 Source: GW analysis of 2016 Uniform Data System (UDS) data Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 As shown in Figure 1, in 2016, health centers provided over 1.53 million visits for medical, dental, mental health and substance abuse services, as well as services that enable patients to secure access to necessary care such as case management and home visiting.13 Most patient visits are for medical care, but oral health and behavioral health also figure prominently. Two-thirds of health center sites serve the island’s many rural communities. Demographically, Puerto Rico health center patients resemble other U.S. health center patients (Figure 2). But there are also key differences. In 2016, 86% of health center patients in Puerto Rico had below-poverty income, compared to 70% of patients served by health centers in the 50 states and DC.14 As might be expected given the size of Puerto Rico’s Medicaid program, health center patients in Puerto Rico are also far more dependent on Medicaid and CHIP. In 2016, 68% of health center patients were insured through Medicaid or CHIP, compared to 50% of health center patients served by health centers in the 50 13 Bureau of Primary Health Care. (2017). 2016 Health Center Data: Puerto Rico Data. SOURCE: Bureau of Primary Health Care. (2017). 2016 Health Center Data: Puerto Rico Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ datacenter.aspx?q=tall&year=2016&state=PR datacenter.aspx?q=tall&year=2016&state=PR; GW analysis of 2016 Uniform Data 14 GW analysis of 2016 Uniform Data System (UDS) data System (UDS) data Notes: Income distribution reflects 270,139 patients with known income. SOURCE: Bureau of Primary Health Care. (2017). 2016 Health Center Data: Puerto Rico Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ datacenter.aspx?q=tall&year=2016&state=PR Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7 NOTE: The percentages for the 50 states and DC do not sum to 100% because non-CHIP other public insurance (0.5%) is not shown. SOURCE: GW analysis of 2016 UDS data states and DC (Figure 3). Conversely, 10% of health center prevention and as first emergency response in the face of patients in Puerto Rico have private health insurance, public health threats. During the Zika outbreak, for compared to 17% of patients receiving care at health example, health centers served as a central part of the centers in the 50 states and DC. effort to control its spread, receiving, along with health centers in other U.S. territories, nearly $40 million to Figure 4 shows that, like other health center patients, those undertake expanded primary and preventive care served by Puerto Rico health centers experience a range of activities. 16 health conditions that can be well managed in primary health care settings. Compared to health center patients in Given the extent of Puerto Rico’s poverty and reliance on the 50 states and DC, higher percentages of Puerto Rico Medicaid, health centers disproportionately depend on patients are diagnosed with hypertension and asthma, but Medicaid and federal grant funds for their operating lower percentages with depression and anxiety. Health revenue. As Figure 5 shows, in 2016, 30% of health center centers also provide essential primary and preventive revenue in Puerto Rico came from Bureau of Primary Health health care, furnishing routine and influenza vaccines to Care (BPHC) grants, compared to 18% for health centers in over 78,500 patients, preventive cervical cancer screenings the 50 states and DC; similarly, Medicaid accounted for (including Pap tests) to nearly 25,000 patients, and 53% of Puerto Rico health center revenue in 2016, prenatal care services to 3,350 patients in 2016. Because 15 compared to 43% in the 50 states and DC. of where they are located, whom they serve, and their mission, health centers play a vital role in public health Bureau of Primary Health Care. (2017). 2016 Health Center Data: Puerto Rico Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx? 15 q=tall&year=2016&state=PR 16 HHS News Release. (October 31, 2016). “HRSA announces $39 million to fight Zika in U.S. territories.” http://news.aha.org/article/161031-hrsa-announces-39-million-to-fight- zika-in-us-territories Geiger Gibson / RCHN Community Health Foundation Research Collaborative 8 NOTE: Percentages determined by dividing the number of patients with a primary diagnosis for each condition by the total number of patients. SOURCE: GW analysis of 2016 UDS data NOTE: The percentages for the 50 states and DC do not sum to 100% due to rounding. Other public insurance revenue is not shown (accounted for 0.001% of revenue for Puerto Rico and 1% for the 50 states and DC) SOURCE: GW analysis of 2016 UDS data Geiger Gibson / RCHN Community Health Foundation Research Collaborative 9 Recovering from Hurricane Maria ASPPR reports that given the severe damage to the structural facilities, health centers have employed Because of health centers’ role in the Puerto Rico health alternative methods to continue providing needed health care system and the extent to which communities rely on care for their communities. Health centers are furnishing them for care and as sources of employment and services from tents outside their clinics and in mobile units community economic well-being, their recovery becomes a in the community. Virtually all assessed health centers matter of vital concern. According to information provided reported one or more employees having lost homes by the Health Resources and Services Administration themselves, yet these staff have continued to provide (HRSA),17 83 out of 93 (89%) community health center sites services at their centers. Health centers also report that in Puerto Rico were open as of October 20, 2017 (the staff have been conducting outreach visits to resident number of sites is higher than the 86 sites reported in the homes, emergency shelters, and elderly living facilities. 2016 UDS because new sites have opened since 2016, Health centers are reporting an urgent need for a wide including one look-alike health center site).18 The ten closed range of vaccines and drugs, including antibiotics, eye sites include nine permanent service sites and one mobile drops, insulin, anti-inflammatory drugs, gastrointestinal van, while the 83 open sites include nine mobile vans and drugs, serums, and respiratory therapy. Two-thirds of health 74 permanent service sites. It should be noted that “open” centers report a need for tetanus vaccines, while one third does not mean that sites are operating as they were before need influenza vaccines. Because of the severe community the hurricane hit, and many sites are without power, relying needs after the hurricane, many of the clinics are on generators, and offering limited services or hours of supplementing their staff with volunteers to be able to operation. extend their reach still further. Two in five sites are seeking Asociación de Salud Primaria de Puerto Rico, Inc. (ASPPR), volunteer nurses, physicians, dentists, and pharmacists. the health centers’ primary care association, is undertaking ASPPR also has collected information on the range of extensive efforts, along with the health centers themselves, health conditions Puerto Rico health centers are treating in to restore health centers to full operation as rapidly as the aftermath of Hurricane Maria. Health centers report possible. Evidence to date suggests that while health treating conditions closely aligned with catastrophic public centers have been extraordinarily responsive to local need, health events that elevate the risk for infectious disease: there is far to go, and a significant level of aid will be acute infections, conjunctivitis, scabies, leptospirosis, needed. Based on their needs assessment of 70 health gastroenteritis, asthma, dermatitis, and viral infections center sites, ASPPR reports that as of mid-October, only (including influenza and suspected dengue and Zika). 13% of assessed health center sites had power restored, while another 4% had intermittent power; the rest appear Health centers also are reporting on the state of the to be running on generators. Approximately 40% of communities they serve. As of mid-October, slightly more assessed sites have an internet connection and access to than half of all assessed health centers report that their electronic health records, while many remain without stable communities had only intermittent access to drinking water internet or telephone services. and virtually all assessed health centers reported a need 17 Personal communication, HRSA 18 The term “look’-alike” refers to health centers that meet all program requirements but do not receive federal grant support. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 10 for water filters. Seven in 10 health centers report that their Addressing this long-standing inequity in federal Medicaid communities need food, 85% report that community financing, continuing the Health Center Fund, and including residents need personal hygiene products, and all targeted relief to Puerto Rico’s health centers in federal aid assessed health centers report a need for vector control to packages emerge as crucial steps to preserving population prevent mosquito bites and other insect infestations. health and promoting a more rapid recovery by health centers and other parts of the health care system. Indeed, a The health of the communities served by Puerto Rico’s direct investment into Puerto Rico’s health care system has health centers depends on sustained economic investment emerged as among the island’s most critical needs, a cutting across all social sectors. Where health care is reality reflected in the formal declaration of a public health concerned, like Puerto Rico’s hospitals, health centers’ emergency that has been in place for over a month and ability to make a full recovery hinges heavily on an infusion that, in all likelihood, will not end any time soon.21 of financial resources. In the case of health centers, the two most important sources of funding are federal BPHC grants and Medicaid. While all health centers rely predominantly on these two funding sources, the level of reliance is particularly great in the case of Puerto Rico health centers; these two financial sources alone represent 83% of all health center operating revenue. The Health Center Fund, established in 2010 as part of the Affordable Care Act, represents 70% of all federal health center grant funding; legislation to extend the Fund, whose spending authority expired on September 30th, is now pending in Congress.19 In addition, Congress is considering additional investment in Puerto Rico’s Medicaid program, long a victim of federal under-investment. Following an additional infusion of federal Medicaid funding under the ACA, this more generous funding period has ended, leaving the Commonwealth – nearly 50% of whose residents are impoverished – responsible for 80% of the cost of its Medicaid program; in comparison, Mississippi, the poorest state, is expected to fund only 25% of its program.20 19 George Washington University. (September 14, 2017). “With Community Health Center Fund Expiration Looming, Health Center Services at Risk Nationwide.” https:// publichealth.gwu.edu/content/community-health-center-fund-expiration-looming-health-center-services-risk-nationwide; see also, Shin et al., (2017). What are the Possible Effects of Failing to Extend the Community Health Center Fund? http://www.rchnfoundation.org/?p=6112 20 Miller, J. (October 13, 2017). “Puerto Rico’s Economic Recovery Requires a Sustained Federal Investment.” Brookings Institution. https://www.brookings.edu/blog/the- avenue/2017/10/13/puerto-ricos-recovery-requires-a-sustained-federal-commitment/ United States Department of Health and Human Services. (September 19, 2017). “Secretary Price declares public health emergency in Puerto Rico and US Virgin Islands due to 21 Hurricane Maria.” https://www.hhs.gov/about/news/2017/09/19/secretary-price-declares-public-health-emergency-puerto-rico-and-usvi-due-hurricane-maria.html Geiger Gibson / RCHN Community Health Foundation Research Collaborative 11