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Updated: 21 hours 13 min ago

The Storm Has Passed, But Puerto Rico’s Health Faces Prolonged Recovery

October 16, 2017

As President Donald Trump signals impatience to wind down emergency aid to Puerto Rico, the challenges wrought by Hurricane Maria to the health of Puerto Ricans and the island’s fragile health system are in many ways just beginning.

Three weeks after that direct hit, nearly four dozen deaths are associated with the storm. But the true toll on Puerto Rico’s 3.4 million residents is likely to involve sickness and loss of life that will only become apparent in the coming months and in indirect ways.

As victims continue to be found and stranded people reached, it will take time to assess the consequences of their missed care or undertreatment.

The situation in Puerto Rico’s health system is far more vulnerable than those in Texas or Florida, which also weathered hurricanes this fall — medically, economically and politically. A month after Hurricane Katrina in 2005, only about half of the final official fatalities had been tallied.

This KHN story also ran in Stat. It can be republished for free (details).

Puerto Rico has a higher rate of diabetes than any state, according to 2015 data from the U.S. Centers for Disease Control and Prevention. About half of the island’s population depends on Medicaid. And, unlike in the States, Puerto Rico’s Medicaid system receives a fixed amount to meet residents’ needs, a pot of money that could run dry next month, said Jenniffer González-Colón, Puerto Rico’s delegate to Congress.

“We’ve had a fiscal crisis, a Medicaid funding cliff, Hurricane Irma and Hurricane Maria —we are being hit from every angle,” she said.

Orlando Gutiérrez, an associate professor of nephrology at the University of Alabama-Birmingham and a board member of the American Kidney Fund, said Puerto Rico is the “perfect storm” for a disaster.

The Federal Emergency Management Agency has distributed food and water to help stave off disease or dehydration, relief workers have prioritized efforts to get hospitals and other health facilities operating again, and the Navy dispatched the hospital ship USNS Comfort, which has 250 beds.

Coordinated efforts to deliver fuel, water and medications to health facilities have allowed some to reopen. As of Oct. 12, federal emergency officials said nearly all Puerto Rican hospitals were open, although some are still dependent on generators. The Puerto Rican government said electricity has been restored to more than half of the hospitals. Nearly all of the dialysis centers are operating now, though many patients have missed treatments.

But Katia León, deputy director of primary care for the Association of Primary Care in Puerto Rico, said she believes the population’s health has worsened since the storm hit. Cases of diarrhea, pink eye and skin rashes are appearing in larger numbers, she said, and health officials are concerned about infections from contaminated water.

The potential for outbreaks means it is now more important than ever to keep clinics open, León said, even though the operating costs are likely to be high.

“We are talking about a situation that is going to continue in the long term … because this is a crisis without precedent,” she said.

Many residents are still unable to get to clinics or health centers for their chronic health conditions, such as diabetes or heart disease. Diabetes test strips and dialysis equipment have been in short supply since the storm. Patients went days or weeks without medication and treatment. Nutritious food and working refrigerators to store it in are scarce.

Some medicines are in tight supply or require arduous travel to secure.

Slow gains to provide electricity threaten patients on dialysis, who rely on power to filter their blood and survive. And mental trauma caused by the storm will linger long after buildings are reconstructed.

In addition, Puerto Rico was already facing a significant “brain drain,” as many young professionals, including doctors, moved to the U.S. mainland, said Andrew Schroeder, who works for DirectRelief, a private charity that has been coordinating shipments of medical supplies to the island. It will be an uphill battle to persuade these doctors and other health specialists to stay on the island now.

Hospitals and health clinics are working hard to get back to speed. Eddie Perez-Caban, the executive director of the Camuy Health Services clinic on the western side of Puerto Rico, said he was astonished after making the 25-minute commute through downed wires and fallen electric poles the day after Maria hit. He found a damaged roof, a broken air conditioning system and no electricity or running water — and about 75 of his employees ready to work. Five days later, the clinic opened with running water and AC and light powered by a generator.

“For so many people to show up — truthfully, it filled me with a lot of satisfaction to work with a group of people that have that commitment to the community and the patients we serve,” he said.

Republican leaders in the House of Representatives have proposed allotting an additional $1 billion for Puerto Rico’s Medicaid program to resupply its coffers as part of a bill that would extend the Children’s Health Insurance Program. But the legislation has been stalled in committee.

Puerto Rico’s program is different than those in the States. While states receive open-ended federal funding, Puerto Rico’s annual funding amount is capped — typically at more than $300 million. Nearly half of the island’s residents rely on the program for coverage. If the money runs out, as many as 900,000 beneficiaries could lose their health coverage, according to estimates from the Department of Health and Human Services under the Obama administration.

Another bill under consideration in Congress could offer Puerto Rico millions of dollars in disaster relief, an effort that has broad support. More than 6 in 10 Americans said Puerto Rico isn’t getting all the help it needs yet, and more than half said the emergency response has been too slow, with the federal government not doing enough to restore electricity and access to food and water, according to a poll released Thursday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

In Puerto Rico, most of the roughly four dozen dialysis centers are now seeing patients, though that service is dependent on getting shipments of fuel to power generators and water and dialysis solution for the treatments. Some clinics are shortening their hours and the time of treatment. Instead of four-hour treatments, patients are receiving only three hours of dialysis, which saves on staffing time, supplies and use of generators.

Mike Spigler, an official with the American Kidney Fund, who is handling some of the emergency response for kidney patients on the island, describes the situation as “tenuous.”

In the short term, patients can function without dialysis, or with limited treatments. But as time goes on, the risk of heart failure and stroke begins to climb.

Schroeder also said he is worried about mental health services, which often get lower priority than food and shelter after a storm. He said people are traumatized and, without counseling, anxiety and depression could become major public problems. Multiple news outlets report that two of the island’s 34 total deaths attributed to the hurricane were suicides.

Older residents of the island are particularly vulnerable to mental trauma in the aftermath of the storm, said José Acarón, the director of the Puerto Rican branch of AARP. Approximately 1.2 million people in Puerto Rico are 50 or older, Acarón said. Many of them live outside of traditional nursing homes or independent living facilities, making them harder to reach.

“We still have a lot of challenges to overcome before things can go back to normal,” said Acarón. “But a return to normal is not going back to where we were before the hurricane. It’s a new normal.”

Staff writer Phil Galewitz contributed to this article.

10 Ways Medicaid Affects Us All

October 05, 2017

Medicaid was created in 1965 as a program for the poor. Today, it helps 74 million people — more than 1 of every 5 people in the U.S. You or someone you know likely benefits.

Big School Booster

Medicaid paid for nearly $4 billion in school-based health care services in 2015.

Dependent Children

Medicaid aimed, at its start, to insure healthy children and pregnant women. Children are still the largest demographic group served. How Medicaid coverage breaks down:

Where The Money Goes

But a look at who benefits from Medicaid spending shows a different story.

Sustaining Livelihoods

About 60 percent of non-disabled Medicaid adult enrollees have a job.

Balance For Mental Health

Medicaid is the single-largest payer for mental health services in the U.S. and increasingly picks up the bill for substance abuse treatment.

Academic Achievement

Many adults under age 65 receiving Medicaid are well-educated.

Coverage Forecast

Most Medicaid enrollees churn in and out of the program every few years, depending on their circumstances. Odds are 1 in 4 you might need this safety net one day.

Editor’s Note: If you would like to republish these graphics, please contact to discuss licensing details.

Hepatitis C Drug’s Lower Cost Paves Way For Medicaid, Prisons To Expand Treatment

October 03, 2017

Valerie Green is still waiting to be cured.

The Delaware resident was diagnosed with hepatitis C more than two years ago, but she doesn’t qualify yet for the Medicaid program’s criteria for treatment with a new class of highly effective but pricey drugs. The recent approval of a less expensive drug that generally cures hepatitis C in just eight weeks may make it easier for more insurers and correctional facilities to expand treatment.

The drug, Mavyret, is the first to be approved by the Food and Drug Administration that can cure all six genetic types of hepatitis C in about two months in patients who haven’t previously been treated. Other approved drugs generally require 12 weeks to treat the disease and often aren’t effective for all types of hepatitis C.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

To contact Michelle with a question or comment, click here.

This KHN story can be republished for free (details).

In addition, Mavyret’s price tag of $26,400 for a course of treatment is significantly below that of other hepatitis C drugs whose sticker price ranges from about $55,000 to $95,000 to beat the disease. Patients and insurers often pay less, however, through negotiated insurance discounts and rebates.

“It certainly stands to reason that the continual march downwards on cost would lead to continual opening up of criteria,” said Matt Salo, executive director of the National Association of Medicaid Directors.

Hepatitis C is a viral liver infection spread through blood that affects an estimated 3.5 million people in the United States. It can take years to cause problems. Many baby boomers who contracted it decades ago before blood was screened for the virus don’t realize they have it until they develop liver disease. In addition, the growing heroin epidemic is adding to the problem as people become infected by sharing contaminated needles.

“Direct acting antiviral” therapies like Harvoni, a once-a-day pill introduced in 2014 that generally cured hepatitis C in 12 weeks, are much more effective than earlier treatments that required weekly interferon injections and multiple daily pills for nearly a year. But the newer regimens came at a price: $94,500, in Harvoni’s case.

State Medicaid programs, which cover a high proportion of people with hepatitis C, balked at the high prices, even with the 23 percent drug discount the programs typically receive.  Many threw up roadblocks to limit drug approval until the disease was advanced. Some required people to be drug- and alcohol-free for six months or more before treatment would be approved.

Those moves prompted advocates to push for better access, in some cases filing suit to force the programs to cover more people.

Faced with a lawsuit in Delaware, the state Medicaid program began loosening up treatment criteria this year, and in January will begin approving enrollees regardless of the severity of their disease.

The state joins more than a dozen others that no longer (or never did) restrict hepatitis C treatment based on disease severity, said Kevin Costello, director of litigation at Harvard Law School’s Center for Health Law and Policy Innovation, which has been a key player in litigation in Delaware and other states.

It can’t happen soon enough, said Green, 58, who believes she contracted the disease 31 years ago when she suffered complications during childbirth and required a blood transfusion. Although her liver isn’t damaged, Green said, she’s suffered with abdominal and joint pain, weight loss and fatigue for decades, symptoms that doctors attribute to the hepatitis C virus.

“It’s been a difficult fight for us Medicaid patients,” she said.

People who are incarcerated face an even tougher battle to get treatment for hepatitis C. Roughly 17 percent of prisoners are infected with hepatitis C, compared with about 1 percent of the general population.

Prisons have a duty not to be deliberately indifferent to the medical needs of incarcerated people. Prisons don’t get the price discounts that the Medicaid programs have, and their budgets are fixed.

“Administrators have to make do with what is there,” said Dr. Anne Spaulding, an associate professor at Emory University’s public health school who has worked as a medical director in corrections and published research on hepatitis C among prisoners.

Lawyers in a handful of states are pursuing class action lawsuits to force prisons to provide hepatitis C treatment. Mavyret may make a difference, said David Rudovsky, a civil rights lawyer who’s litigating a class action lawsuit against the Pennsylvania Department of Corrections.

“Everyone recognizes that it’s going to make it easier to cover people,” he said.

People with regular private insurance may face some obstacles to coverage of hepatitis C, but coverage is typically less problematic. For example, Mavyret is one of seven hepatitis C drugs that are included in the 2018 national preferred formulary by Express Scripts, which manages the pharmacy benefits for 83 million people.

“The benefit to patients and payers is the additional competition, which brings down costs across the class, thus resulting in greater access and affordability,” said Jennifer Luddy, director of corporate communications at Express Scripts.

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.