Health Care Reform Articles - November 28, 2003

 

Maine Bureau of Insurance warns of ACA scams, substandard plans

by Joe Lawlor - Portland Press Herald - November 28, 2023

To find an Affordable Care Act plan, visit www.CoverME.gov. 

As open enrollment for Affordable Care Act plans continues, the Maine Bureau of Insurance is warning consumers to be cautious of scams, limited-benefit plans and misleading information when searching for a health care plan.

The website to find ACA plans in Maine is www.CoverME.gov. Open enrollment for 2024 plans started on Nov. 1 and continues through Jan. 16. About 63,000 Maine people have individual plans through the ACA.

The insurance companies licensed to sell individual ACA plans in Maine include Community Health Options, Anthem, Harvard Pilgrim/Point32, United Healthcare and Taro Health. Other products resembling major medical health insurance are sold, but are either not insurance or offer limited benefits.

“If you purchase a non-regulated plan, the Bureau of Insurance may not be able to assist you if the company later does not pay claims as promised,” said Timothy Schott, the bureau’s acting superintendent.  “It is worthwhile to spend a little time and make sure that you are purchasing an authorized insurance plan from a Maine licensed company.”

Aside from the official website and working directly with the five ACA insurers in Maine, purchasing plans from other entities may result in getting a substandard health insurance plan, or a plan that is not actually health insurance.

For instance, consumers who use “lead generating websites” are “often sold limited-benefit insurance plans instead of major medical health insurance plans,” the bureau said. The websites often show up when putting in a simple online search for Maine ACA health plans.

“There are crucial differences between these types of plans – major medical plans are traditional health insurance that covers preventive services, office visits, inpatient and outpatient services, and emergencies, while limited-benefit plans only cover specific medial issues (such as cancer) up to a certain dollar amount,” the bureau said.

Another common problem is that there are products that look like health insurance, but are not insurance, such as “health care sharing ministries.”

“Health care sharing ministries are not insurance plans and do not guarantee that all your claims for medical services will be covered. If your medical claim does not meet the sharing criteria for any reason, you will be responsible for the entire medical bill. If the ministry has spent what they collected, they may not be able to pay your claims,” the bureau said.

In addition to plans that offer few benefits, there are also numerous scams, where consumers will think they are purchasing insurance, but instead pay money for a plan that doesn’t exist.

ACA rates for Maine’s health insurers increased by 14.6% for 2024, although about 80% of consumers are shielded from rate increases because they are low- or middle-income and qualify for subsidies.

The Maine Bureau of Insurance listed the following “red flags” to help determine if you are being sold a scam or a substandard plan:

• The person on the phone won’t identify the name of their company.

• The person on the phone won’t provide you with their Maine license number.

• You are not given the chance to review documents prior to purchasing the plan.

• The person on the phone insists that you must make your purchase “right away” or you’ll lose the deal.

• You are told you need to pay a fee in order to purchase the plan.

• You are told you must join an association in order to purchase the plan.

https://www.pressherald.com/2023/11/27/maine-bureau-of-insurance-warns-of-aca-scams-substandard-plans/

Penobscot voters pass referendumon on Publicly Funded Health Care / 

by Chris McKinnon

The question of which Maine town would be the first to pass a referendum supporting publicly funded universal health care was decided on November 7th, when voters in Penobscot went to the polls to decide the question: “Shall the citizens of Penobscot call on the Maine Legislature to create a publicly funded health-care plan that provides every Maine resident with comprehensive medical care?” And by an impressive 2-1 margin the people of Penobscot, in Hancock County, gave their approval.

Penobscot voters delivered a resounding victory, raising expectations for future victories. More voters will address the same question in 2024 in town meetings across the state. Penobscot went first, in no small measure, because of the diligent and effective advocacy of Hancock County resident, David Jolly, who serves on the Board of Maine ALLCare, the group behind the referendum question.

It might also be noted that Maine people have passed comparable resolutions through representative meetings, boards, and councils in municipalities across the state. “[C]hange is possible at the state level,” David Jolly, Maine ALLCare Board Member, believes. And “Maine AllCare wants our state legislators to make that happen here.” That’s “why we ask all Maine residents to work with us for high-quality, affordable health care for all,” he adds.

The referendum was promoted by Maine ALLCare, an organization singularly devoted to securing universal health care for all Maine residents. Founded in 2010, with an all volunteer staff, the organization was quick to advance the cause of publicly funded health care for all Mainers. A central premise of Maine ALLCare’s project is “that health care, a basic necessity, be treated as a public good, since it is fundamental to our well-being as individuals and as a democratic nation.”

By 2014, with an increasing base of support, Maine ALLCare successfully championed a universal, single-payer health care bill, LD-1345, through the Maine Legislature. The bill passed both House and Senate by a sizable margin, 91-52 and 20-14, in turn. Regrettably, the bill was vetoed by the extreme right-wing Republican governor, Paul LePage. An attempt to override the unpopular veto fell short by four votes and the bill died.

But today, the cause has a renewed impetus thanks to the ongoing leadership of Maine ALLCare, its staff and volunteers, and to Maine people who once again demonstrated their support for publicly funded universal health care. As the fight continues, the challenges of confronting the existing for profit system will intensify.

Health care is central to the life of everyone. But capitalism is averse to ensuring health care as a human right. Taking private profit out of the health industry will provoke stiff resistance from the capitalist class. It will take a broad and inclusive working-class movement to prevail and to win for all Maine residents what the voters of Penobscot, Maine demanded of our state legislators on Election Day 2023.

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_{Chris McKinnon is a grassroots activist and retired librarian living in central Maine.}

Fights between U.S. States and the National Government Are Endangering Public Health

by Wendy E. Parmet - Scientific American - October 19, 2022

Americans have long been proud of our federalism, the way that we divide governmental power between the states and national government. As former Supreme Court Justice Anthony Kennedy famously explained, the framers of the U.S. Constitution “split the atom of sovereignty” creating “two political capacities, one state and one federal, each protected from incursion by the other.” In theory, this political invention serves to preserve liberty while bringing the government closer to the people. It allows red states to enact laws to their pleasing, and blue states to do the same. But in today’s public health, political and legal environment, our federalism has become deadly. Rather than permitting the governmental units that can best tackle health problems to do so, federalism invites partisan litigation and thwarts interstate cooperation. As a result, both the states and the federal government are increasingly unable to meet the nation’s health threats, even as those threats become ever more complex and dangerous.

This is not the first time our federalism has harmed health. Despite its many benefits, from the Constitution’s founding until the Civil War, federalism served to support slavery. Even after the Civil War and abolition, it perpetuated racial oppression, providing a rationale and legal defense for state laws that enforced segregation and imposed racial discrimination. By so doing, federalism helped to sow and maintain the racial inequities in health that continue to this day.

Despite that sordid background, for most of U.S. history, federalism also ensured that the units of government that were most capable of solving health problems—the states—had the legal authority to do so. When few people traveled and most goods were locally produced, the states (and their cities and towns) were in the best position to respond to disease outbreaks. States and localities could and did impose quarantines, license physicians and institute a range of other measures designed to protect the public’s health. All of these actions were grounded in the states’ so-called police powers, the sovereign powers that the states retained when they joined the federal union. For the most part, courts deferred to such powers, leaving states with broad authority over public health. Indeed, courts have repeatedly emphasized the centrality of public health to the states’ police powers.

The federal government, in contrast, lacks a police power. Its authority is limited to the areas specifically enumerated in the Constitution. Health is not one of those areas. Nevertheless, the federal government has long used its might to regulate international and interstate commerce, and to tax and spend for the general welfare, for the protection of health. For example, in 1798 Congress enacted a law providing Relief of Sick and Disabled Seaman, which led to the establishment of marine hospitals along navigable waters. In 1848 Congress passed the Drug Importation Act, which required the U.S. Customs Service inspection to block the importation of adulterated drugs.

As the economy became more integrated and travel became faster and more frequent, health threats were increasingly recognized as nationwide in scope. In turn, the federal government’s involvement with health expanded. In 1889, Congress established the United States Public Health Service. In 1906 it passed the Pure Food and Drug Act, leading to the establishment of the Food and Drug Administration. In 1965 Congress created Medicare and Medicaid. The Environmental Protection Agency was established in 1970. One year later, the Occupational Safety and Health Administration was born. Today the federal government’s role in health policy is pervasive.

Many federal health programs rely on what is commonly known as “cooperative federalism.” The federal government sets minimum standards and pays much of the costs. In exchange, the states, federal territories and tribal jurisdictions follow federal guidelines, do much of the on-the-ground work and, at times, set standards that are even more protective of health than those set by the federal government.

Still, many Americans cling to the nostalgic notion that the protection of health belongs primarily to the states, territories and tribal jurisdictions. In the early months of the COVID pandemic, then-President Trump expressed that view, telling governors that they were going to call their “own shots.” That’s a sentiment that the conservative justices of the Supreme Court seemed to share last June when they limited EPA’s ability to address climate change and overturned Roe v. Wade.

There are times when it makes sense to leave health policy to the states. Some health threats are truly local. Consider an unsanitary restaurant. It probably doesn’t require a nationwide solution. By leaving restaurant inspections to states and local governments, the public is more likely to be protected against unsafe meals. Likewise, states and local governments are in a far better position than the federal government to provide many on-the-ground health services, from sexually transmitted disease clinics to tuberculosis screenings. The day-to-day work of public health departments depends in large measure on their placement in and relationships with local communities.

States, territories, and tribal government can also serve as “laboratories of democracy,” to borrow Justice Louis Brandeis’ term. They can develop innovative health policies that other governments and even the federal government can copy. For example, Massachusetts 2006 health care reform law served as the model for the federal Affordable Care Act. States and cities have also led the way in tobacco control, banning youth access and indoor smoking years before the federal government made a serious effort to reduce cigarette consumption.

Policy differences between jurisdictions can also serve as a type of a natural experiment, from which policy makers can learn which laws work and which don’t. Researchers can look at how varying motor vehicle safety laws in different states or different childhood vaccine laws correlate with motor vehicular accidents and vaccination respectively. Much of what we know about the efficacy of health policies comes precisely from such studies.

Unfortunately, the cry for “states’ rights” today often ends up endangering health, just as it did by perpetuating the systematic racial oppression that underlies so many of today’s health inequities. To see how federalism threatens health, consider the early days of the COVID pandemic. Although states could and did implement many measures that slowed the coronavirus in 2020, they could not prevent the transmission of the microbe across state lines. One state’s lax policies invariably led to increases in cases in other states. The divergent approaches by different state governments in 2020 and 2021 also muddied the public health message. (To be fair, the poor messaging from the federal government did not help.) For example, it was hard to know in the summer and fall of 2020 if masking was beneficial when only some states required it. Worse, the variation in policies among states created a type of race to the bottom in which the economic competition from states with looser regulations pushed other states to rescind their own health orders. (Interestingly, states that kept restrictions in place longer had better health outcomes, but faced worse economic conditions).

The need for a national response has also been evident during the monkeypox outbreak. One of the major stumbling blocks to containing the disease last summer was a shortfall of reliable data. But due to constitutional limitations and the norms that have grown up around them, the federal government  depends on the states, territories and tribal authorities to gather and share data about disease outbreaks, as well as for much of the frontline response, as Secretary of Health and Human Services Xavier Becerra noted in excusing the federal government’s inability to get on top of the escalating outbreak. While Becerra’s statement was largely self-serving, he was correct in stating that the federal government’s capacity to respond to a pandemic depends, in large measure, on the cooperation of the states, territories, and tribal authorities.

These inefficiencies have been amplified by more than two decades of Supreme Court decisions that, in the name of states’ rights, have handcuffed the federal government’s ability to protect the public’s health. For example, in 1997, the Supreme Court ruled that the federal government could not command state officials to conduct background checks before gun sales. That decision explains why the federal government could not require the states to open or close schools during the pandemic, or require states to impose vaccination requirements. While the federal government can use its spending powers to induce states to comply with its policy goals, states can reject the money and refuse to cooperate.

The Supreme Court underscored that point, while emphasizing states’ rights in its 2012 decision in NFIB v. Sebelius, which blocked the federal government’s efforts through the Affordable Care Act to expand Medicaid. The result: more than two million more Americans were left uninsured. The goal of preserving the states’ primary role over health also played a crucial rule in the Supreme Court’s 2021 ruling striking CDC’s eviction moratorium, a policy the agency had intended to prevent people from losing their homes during the pandemic. The Supreme Court later relied on that case to block the Occupational Safety and Health Administration’s rule mandating that large employers require their employees to be vaccinated or wear a mask and be tested. A few months later, the Court cited those decisions to strike down EPA’s Clean Power Plan rule. Lower courts have relied on these cases to enjoin federal COVID vaccine mandates for federal contractors, federal employees and even Head Start childcare programs.

The impact of the Court’s decisions is magnified in our current polarized and often dysfunctional political landscape in which Congress and the states often choose not to cooperate with the federal government, or even sister states, regardless of the health consequences. Indeed, the various structural limits that the Court has erected to protect states’ rights have come to serve as a tool that partisans use to attack the policies of federal leaders from the opposing party. Hence, we have the increasingly frequent practice of red states rushing to court to challenge the policies of Democratic presidents, and blue states bringing lawsuits against Republican presidents. How else to explain the fact that 22 states brought lawsuits challenging a vaccine mandate for federal contractors?  With the courts’ assent, if not invitation, federalism has become but another weapon for partisan warriors. With that, health policies languish and public well-being declines.

The deleterious impact of our polarized environment has also spurred battles among the states. During the early days of the pandemic, several states threatened to block travel from residents of other states. States also engaged in a bidding war for the procurement of critical supplies in spring 2020. Such intrastate strife has only escalated since the Supreme Court issued its decision in Dobbs v. Jackson Women’s Health Center, overturning Roe v. Wade. In theory, the Supreme Court’s decision should allow each state to go its own way. But this live-and-let-live attitude may not be viable with an issue as deeply contentious as abortion (as it was not with slavery or Jim Crow). Predictably, in the months since Dobbs was decided, we have seen the type of interstate battles that we have not seen since the Civil War, as states banning abortion have threatened to block interstate travel and criminalize procedures done in other states, while states permitting abortion rushed to pass laws protecting their clinicians from out-of-state prosecution. Meanwhile, the federal government and the states are also engaged in litigation about whether federal protections for patients in emergency departments supersedes state bans on abortion. And advocates on both sides of the issue seek a federal law codifying their position. In short, despite frequent paeans to federalism, neither side is willing to accept the diversity of approaches that federalism should entail.

For more than a century, our federalism enabled the governmental units that were then best equipped to respond to health threats to do so. Even today, federalism need not be fatal, as the experience of other federal nations, such Germany and Canada, show. Both countries grant their states or provinces significant authority over health. But both nations were able to weather the COVID pandemic far more successfully than the U.S. And the citizens of both countries enjoy significantly longer life expectancies than Americans.

Federalism is not, of course, the only reason why the U.S. fares so poorly as compared to other wealthy nations on a wide range of health measures. But in today’s increasingly polarized political environment, legal doctrines that once supported the states’ ability to protect the health of their residents are diminishing the capacity of both our national and local governments to do so. Unless the courts stop enabling this political weaponization of federalism, our federalism will remain uncooperative. And deadly.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

https://www.scientificamerican.com/article/fights-between-u-s-states-and-the-national-government-are-endangering-public-health/ 

 

Opinion | Congress Must Act to Eliminate Hepatitis C

by Francis Collins - NYT - November 28, 2023

Dr. Collins served as the director of the National Institutes of Health from 2009 to 2021. He leads the White House initiative to eliminate hepatitis C.

A little over a decade ago, I watched my brother in-law Rick Boterf die of complications from infection with the hepatitis C virus that took his health, his vibrant energy and ultimately his life.

A husband, father and practical joker, Rick designed and built intricate boat interiors in Florida. But then he experienced the slow onset of signs of liver failure, followed by an excruciating five years on the liver transplant list. At the time of his transplant surgery, an unrecognized liver cancer was discovered. Ultimately, Rick died in his sleep, a heartbreaking ending for a fine man who had suffered terribly at the hands of this destructive virus.

It was only two years later, in October 2014, that medical science provided a cure for hepatitis C infection. Based on groundbreaking research that later was recognized by a Nobel Prize, the treatment is simple — one pill a day for eight to 12 weeks, with essentially no side effects, and a 95 percent cure rate.

When the cure became available, I was serving as director of the National Institutes of Health. I was overjoyed that a cure had been approved, but the news was bittersweet. What gave me hope was thinking of the many other individuals and their families who would be spared from the misery that Rick and our family experienced. And to a significant extent, that hope was justified: These medications have cured about a million people in the United States.

But nearly a decade later, at least 2.4 million Americans remain infected with hepatitis C. About two in five people with hepatitis C don’t even know that they have the virus. Of those who do, many do not have access to the cure. Congress has an opportunity to turn this ongoing human tragedy into a public health advancement, by providing support for a five-year project to eliminate hepatitis C in the United States. But the time available for approval is growing short.

Hepatitis C progresses slowly. Over years, the virus causes fibrosis of the liver that can result in cirrhosis, esophageal bleeding and liver failure requiring transplantation. Hepatitis C is also the leading cause of liver cancer, responsible for half of the 40,000 annual liver cancer cases in the United States. Each year, about 15,000 Americans die from hepatitis C, many in their 40s and 50s. Given the safe and effective cure available for the last nine years, the correct number of deaths in 2023 should be zero.

Put simply, we are squandering one of the most important medical advances of the 21st century. It’s time to eliminate this threat to the health of Americans.

It’s no secret what has gone wrong. The cost of curative medications remains stubbornly high, so many insurance companies and Medicaid programs have erected barriers to coverage, requiring, for instance, abstinence from drugs and alcohol before people can receive treatment, referral to a specialist, or that the patient already shows liver scarring. Relatively few doctors offer treatment, and many sites where people at risk come for care do not even offer testing, let alone the cure. The result is that fewer than one in three people diagnosed with active infection get timely treatment.

After stepping down as N.I.H. director in 2021, I was asked to serve as the acting science adviser to President Biden. I learned that many other countries — including the United Kingdom and Australia — have taken great strides toward hepatitis C elimination. Egypt is essentially there. Will the United States be last? That can’t be the right answer. So I was delighted when in March, President Biden came out in favor of a five-year program to put the United States on track to eliminate hepatitis C.

The plan includes an innovative approach to provide broad access to curative medications, modeled on a successful effort in Louisiana. Under this approach, sometimes known as the “Netflix model,” a drug company or companies agree to provide full access to medications for a population in need in exchange for a set lump sum payment. In the current proposal, the populations who would have access to free hepatitis C drugs are Medicaid enrollees, the uninsured, Native Americans, and those in the prison and jail systems. If structured correctly, many more people can get lifesaving care and the cost per cure drops significantly.

Greater access to medications is necessary for a successful hepatitis C elimination program, but it is not sufficient. That’s why the plan also includes training, technical support and resources for primary care offices, federally qualified health centers, drug treatment centers, and jails and prisons, where rates of infection can reach 40 percent or more. To help more people find out whether they are infected, the effort will also help make available point-of-care tests that diagnose hepatitis C infection in less than an hour, allowing treatment to start in a single visit. That would be a major advance over the current tests, which require multiple clinic visits over weeks to return results and start treatment.

I’m not the only one inspired by the opportunity to end this devastating disease. I’m finding a lot of support among both Republicans and Democrats in Congress, from all parts of the country. But a key question is whether the effort can gain the full bipartisan support it needs to move in this Congress.

I believe it can. People treated for hepatitis C will avoid very expensive downstream medical needs for transplantation and cancer treatment. Furthermore, a cured person cannot pass it on to others; as a result, every case treated today means multiple cases averted in the future. An expert group has estimated that a national initiative to end hepatitis would save society more than $18 billion in health care costs over the next decade, with $13.3 billion of that savings accruing to the federal government.

Eliminating hepatitis C is the compassionate response for a nation that cares about all of its people — but it is also deficit reduction. It’s costing us taxpayers much more to live with hepatitis C than to cure it. Without action, we will continue to doom many more families to go through the same pain that mine did with Rick’s suffering and death. Inaction is indefensible.

Francis Collins served as the director of the National Institutes of Health from 2009 to 2021. He leads the White House initiative to eliminate hepatitis C.

https://www.nytimes.com/2023/11/28/opinion/hepatitis-c-eliminate.html 

 

Opinion

Efforts to kill Obamacare made it popular. Trump says he’ll try again.

By Catherine Rampell - The Washington Post - November 28, 2023

Unable to come up with new policy ideas, former president Donald Trump has returned to playing the greatest hits. A case in point: He is once again threatening to repeal Obamacare.

It’s hard to think of a more wrongheaded campaign promise than this, on both political and policy grounds.

To be sure, there was once a time when destroying Obamacare, a.k.a. the Affordable Care Act, was a winning issue for Republicans. For the first few years after the marquee health-care law passed in 2010, many voters despised it. The law’s favorability was underwater in almost every poll for the first six years of its existence.

Such disdain had relatively little to do with what the law actually did. Yes, there was a small slice of the population angered by the loss of cheap, threadbare health coverage that was being phased out. A few other critics had philosophical objections to the law’s objectives — i.e., whether the government should even try to guarantee universal access to insurance, or to specific kinds of health-care services.

But for the most part, it was the GOP’s fearmongering campaigns that gave the law a black eye. Obamacare was a technical and complicated suite of programs, and government complexity is generally an opportunity for demagogues. So demagogue Republicans did, convincing Americans that this scary new statute would kill not only jobs and federal budgets, but somehow even your beloved grandma, too. (Remember “death panels”?)

None of these things came to pass. And while the Obamacare brand might have been unpopular, most of Obamacare’s actual provisions were well-liked. Nearly every major plank of the Affordable Care Act (ACA) — such as guaranteeing coverage to people with preexisting conditions, expanding Medicaid, and allowing children to stay on their parents’ insurance plans for longer — was and continues to be favored by the public.

It took a while for Americans to connect the dots between the law’s name and its popular provisions. Specifically, it took a potent threat of repeal, when Republicans gained control of the presidency in 2017 to go along with majorities in both chambers of Congress. The GOP repeatedly tried to “repeal and replace” the law, but could not come up with anything that would prevent millions of Americans from losing care.

Ultimately, Republicans were unable to muster the votes to dislodge the ACA. What they did do was scare voters straight about what losing it would mean. Ever since these failed efforts, Obamacare has consistently garnered more favorable than unfavorable views from the public (59 percent to 40 percent in the most recent KFF poll, from May).

This has been an unequivocal boon to Democrats, who regained control of the House after the 2018 midterms largely by promising to safeguard health coverage. Red states have also increasingly been hopping on the ACA bandwagon, often as a result of popular-ballot measures to expand Medicaid.

Most Republican politicians have now figured out that talking about health care is a political liability, so they’ve shut up about it. In the 2022 midterms, for instance, health care was the second-most-frequently featured topic in Democrats’ campaign ads (behind abortion); in Republicans’ ads, health care did not even crack the top 20 issues, according to data from AdImpact.

Trump hasn’t gotten the message, though. Over the weekend, he declared on social media that the failure to terminate Obamacare during his presidency “was a low point for the Republican Party, but we should never give up!”

Trump is right about one thing: Voters remain unhappy about the health-care status quo. A majority of Americans from both parties say health costs are a major problem for the country.

Not everyone who wants insurance is able to purchase it, and many who have insurance are still struggling with out-of-pocket costs. Some of these challenges are because of shortcomings in the drafting of the ACA; others are a consequence of the GOP’s relentless sabotage efforts.

If you’re wondering who is actually trying to fix such problems, though, don’t look to Republican politicians, who remain reluctant to talk about health care even when directly asked. Definitely don’t look to Trump, whose secret plan to replace Obamacare with “something terrific,” remains, alas, perpetually two weeks away.

Instead, look to President Biden, who’s implemented a bunch of little-noticed, technical measures to improve Americans’ access to care and lower their costs.

Biden has patched the “family glitch,” a long-standing affordability problem with employer-sponsored health plans. He has reversed some of Trump’s efforts to undermine individual-market plans. Under the president’s leadership, Congress has also expanded premium tax credits available for individual health plans. This means many more Americans do not have to pay anything for their health insurance, at least through 2025.

What’s more, stymied only by a couple of uncooperative Democratic senators, Biden brought Congress tantalizingly close last year to concluding the unfinished business of Obamacare: making eligibility for health coverage virtually universal, as is already the case in all other rich countries.

If Trump wants to make yet another election about health care, well, have at it. But if voters who appreciate the Affordable Care Act evaluate the candidates’ actual records, Biden deserves to win by a landslide.

https://www.washingtonpost.com/opinions/2023/11/28/trump-threatens-obamacare-popularity-repeal-aca/

 

Why Puerto Rico had an unexpectedly high rate of deaths last year

by Omaya Sosa Pascual, Jeniffer Wiscovitch, Arelis R. Hernández, Andrew Tran, Dylan Moriarty - The Washington Post - November 28, 2023

AGUAS BUENAS, Puerto Rico — In a purple house along a narrow road in Puerto Rico’s Central Mountain Range, Margarita Gómez Falcón’s breathing suddenly grew labored one March evening. She called an ambulance and began a grim two-hour wait for paramedics to arrive.

Health services across this self-governing island have been deteriorating for years, contributing to a surge in deaths that reached historic proportions in 2022, an investigation by The Washington Post and Puerto Rico’s Center for Investigative Journalism has found.

The case of Gómez Falcón, 67, underscores the many ways a faltering medical system has contributed to elevated death rates. She had struggled with kidney disease, covid-19, and breathing problems requiring the use of oxygen. But access to dialysis and other specialized medical care had dwindled, especially since Hurricane Maria devastated the island in 2017.

Aguas Buenas, a small, working-class town in the central highlands, had one working ambulance for its 25,000 people when Gómez Falcón called for help, so dispatchers sent a private one that had trouble finding her home in the town’s winding back roads. As her breathing slowed, her family members said, they gathered around her and prayed for paramedics to arrive in time. When they finally pulled up, she was already dead.

“At one point, she just leaned back, closed her eyes and she was gone,” said her sister, Carmen Gómez, 62.

This “excess mortality” — a term scientists use to describe unusually high death counts from natural disasters, disease outbreaks or other factors — resulted in part from a covid spike early last year that killed more than 2,300 people, health data shows.

A chart showing the excess deaths in Puerto Rico over the past year, and what number of those are associated with COVID-19.

But elevated death rates continued in the months after covid subsided, indicating a broader breakdown as the island lost medical staff and services and younger Puerto Ricans moved away, leaving behind a population that is increasingly elderly and facing age-related health complications.

Héctor Montañez

Monte Santo funeral director

In 2022, we exceeded 200 for the first time in the history of this funeral home,

The recent jump in mortality is the latest warning sign that years of natural disasters and financial crises have taken a deadly toll. Last year’s spike was concentrated among Puerto Ricans over age 65, with other age groups dying at more typical rates, the analysis found. If Puerto Rico had a more typical population of younger people, the death rate in 2022 would have been the same or potentially even lower than in the rest of the United States, the statistical analysis showed.

“These types of events, both hurricanes and earthquakes, as well as pandemics, have made evident the vulnerability of many older adults who live alone, many of whom live below the poverty line, who do not have the most basic resources to face that type of adversity,” said José Carrión-Baralt, a professor in the gerontology program at the Recinto de Ciencias Médicas Graduate School of Public Health in San Juan, Puerto Rico’s capital and biggest city.

Last year, 110 Puerto Ricans died per 1,000 residents, a rate that is nearly 11 percent higher than in the United States overall. That marks a reversal from years past, when the island had lower or similar death rates compared with the United States as a whole. Even the wealthiest Puerto Ricans experienced death rates last year similar to those long suffered by poorer communities.

A map showing how nearly half of Puerto Rico's municipalities have no hospitals, and have seen higher death rates.

Puerto Rico’s death rate in 2022 surpassed that of any other year in the past two decades, including 2017, when Hurricane Maria devastated large swaths of the island, according to the analysis. The increase in deaths appears to have continued into 2023, with preliminary data for the first quarter showing that the death rate remained elevated.

“It’s been nearly six years since Maria, and nothing has been resolved,” said Nereida Meléndez‚ a community activist in Aguas Buenas. “Here there are bridges that no one has done anything for. There are damaged highways no one has done anything to fix. Here one says, ‘What about that money they sent us? Where is it? What are they doing with it?’”

Puerto Rico’s Health Department has acknowledged that the island’s mortality rate rose to unusual heights in 2022, although its statistics are slightly different from the ones found in this analysis because researchers used different estimates for each municipality’s population. Officials have said they believe covid played a role in the surge of deaths, as did the shortage of doctors on the island, but health officials did not investigate the causes in their analysis.

“Right now, the conversation has focused on the cause of greatest impact, covid-19, which triggered the highest number of hospitalizations and deaths,” said Melissa Marzán Rodríguez, chief epidemiologist for Puerto Rico’s Health Department.

The analysis by The Post and the Center for Investigative Journalism, which is the first to comprehensively examine the reasons for the surge in mortality, confirms the role of covid and the shortage of doctors, but also points to other problems.

Puerto Rico’s leading killers last year were covid, cardiovascular disease, Alzheimer’s disease, drug overdoses, kidney disease and dementia — most of which are potentially less lethal with routine medical care.

Health data shows that in 2022, compared with the historical average from 2015 to 2021, deaths from Alzheimer’s increased by 26 percent, heart disease by 11 percent and mental health causes by 53 percent, with most of those deaths from substance abuse or dementia. Alcoholism also was listed as a leading cause of death.

Reversing Puerto Rico’s surge in death rates, experts said, would require addressing social, economic and political problems that have undermined medical services for those who need them most.

The death rate in Aguas Buenas increased by nearly 50 percent in 2022 compared with the town’s historical average — the largest increase of any community in Puerto Rico.

Gómez Falcón’s death certificate said that she died of a heart attack and that she also suffered from respiratory and kidney failure. But her family is haunted by the thought that she might have survived.

The state agency that dispatched the private ambulance said the problem was poor communication, not a systemic decline of medical systems. “The delay was not due to a lack of resources,” said Javier Rodríguez, commissioner of the state Emergency Medical Corps, in a statement. “Paramedics tried but failed to reach the caller for directions or a point of reference to get to the right location.”

The family of Gómez Falcón, however, sees a cascading series of failures, with the delayed ambulance just one problem among many undermining the health of Puerto Ricans — especially older ones.

“I know my sister wasn’t the only person who experienced this,” Carmen Gómez said.

As Puerto Ricans strove to rebuild in the months after Maria struck, an estimated 120,000 people — most of them of working age — moved away, according to the U.S. census. Accelerated migration continued through the end of the decade, and birthrates also fell. Puerto Rico’s overall population fell by nearly 12 percent from 2010 to 2020.

Sicker and older adults were left behind, making Puerto Rico one of the most rapidly aging societies on the planet. More than 1 in 5 residents are now over 65, which is higher than the U.S. average, according to an analysis by Hunter College’s Center for Puerto Rican Studies.

The population of Aguas Buenas, a city founded in the 19th century and named in honor of the crystal-clear water that flowed through its springs, shrank by nearly 4,500 residents after Maria, a drop of nearly 16 percent from a decade earlier.

But the population of those over 65 grew by about 9 percent, a shift that by itself can increase death rates because elderly people are more likely to die in any given year than younger ones.

On the streets of Aguas Buenas, the graying of its residents is as vivid as the ruby blossoms of its flamboyán trees. Elders stroll through the plaza clutching word-puzzle books while matriarchs sit perched on balconies watching comings and goings. The waiting rooms of local clinics run three rows deep with seniors. And the neighborhood bakeries are havens for old friends comparing notes on blood pressure medications.

It’s not just Puerto Rico’s young who have left. Doctors, including some who saw their clinics damaged by hurricanes and earthquakes, increasingly are in short supply, with about half of the town’s 15 physicians having moved away, people here said.

In Puerto Rico overall, government data shows there are more than 400 fewer doctors than in 2019. Less than a third of the island’s municipalities have hospitals with accessible beds, with some Puerto Ricans living up to 20 miles away from the nearest facility, according to data from Puerto Rico’s Heath Department. In 2022, municipalities with no hospitals saw greater death rates than their historical averages.

Aguas Buenas itself has only ever had one small emergency room, leaving residents to rely on a few small clinics. Mariemma Jiménez works for one of the newer ones, NeoMed, helping to identify and eliminate barriers to care. She roams the remote barrios, setting up preventive-health fairs, arranging transportation for patients and educating poor farmworkers.

She estimated that most of the clinic’s patients are over age 60 and managing serious chronic disease. Bus service also has been cut, making it harder for those without cars to seek care amid a general deterioration of public services and political turmoil.

“It’s a demoralized population with many transportation needs living in far-flung barrios. These are people who are used to going to the doctor only when they are sick or in pain,” Jiménez said. “That’s where I see the breakdown.”

To whom does it belong? It is not mine. It is the government's. 

Puerto Rico’s public health system was once the envy of the Caribbean. Then-Gov. Pedro Rosselló privatized it in the 1990s, in what became known as “La Reforma.” Most government-owned hospitals were sold in an effort to control costs and streamline operations. But the opposite took place: By 2006, Puerto Rico’s economy tanked and public debt ballooned — in part, because of government borrowing to cover skyrocketing health costs.

The massive flight of doctors began then. In 2010, there were approximately 19,000 physicians on the island. As of 2022, there were 10,846, of whom 3,000 have active medical licenses but also practice in the mainland United States, according to data from the Colegio de Médicos Cirujanos of Puerto Rico.

Heart disease is a leading cause of death in Puerto Rico, with rates increasing 11 percent in 2022. But there are only 95 cardiologists — or one for every 17,500 adults between ages 18 and 64 — to treat them. It’s the lowest ratio among all U.S. jurisdictions, according to the American College of Cardiology. The national average is one per every 7,000 adults.

Table showing the top five increased causes of death since 2015-2021

Many of Puerto Rico’s cardiologists are themselves older than 65 but continue practicing because there are no younger physicians to take over their growing patient loads. Medical professionals leave the island largely because of low pay and poor working conditions, physicians and experts said.

It can take six to eight months, residents and physicians said, for patients to be seen. Urgent cases are managed as they come but interventions are sometimes too late, after more serious problems develop.

“All of that pressure weighs on you,” said cardiologist Luis Rosado Carrillo, who has 17,000 patients on his roster. He sees about half of them on a regular basis. “We are overwhelmed.”

During the pandemic, the terror of contracting covid kept geriatric patients away from the practice of family physician Belinda Rodríguez, who is based in Bayamón, a suburb of San Juan. Many opted for telehealth as their primary means of care, but when they returned for in-person visits as the pandemic waned, there was a “total decline” in their overall health, she said.

Their underlying conditions had worsened and many had developed insomnia, depression and anxiety, she said.

“It accumulates,” said cardiologist Luis Molinary Fernández. “And then you have a catastrophe.”

Patient advocates said the hardships of staying healthy in Puerto Rico push many to resign themselves to declining health.

We know that here in Puerto Rico that there is an emotional crisis

“We all have to die of something,” said Wilfredo Ramos, 61, a stroke survivor who lives deep in the remote peaks of the Central Mountain Range, one of the most challenging topographies on the island.

In 2020, Ramos fell unconscious, and three days passed before someone found him bleeding near his bed after a massive brain hemorrhage inside his rural home, where he lived alone. He lost the use of one side of his body, can’t drive and has frequent fainting spells.

Karina Quiñones, who works with a community clinic, asked Ramos during a recent visit, “When was the last time you saw a doctor?” as she rummaged through a tub of seven prescription bottles.

“Maybe more than 18 months,” he replied. “Who’s going to take me?”

Quiñones, also a nurse, swallowed hard: “These scripts tell me you have high cholesterol.”

“And a heart condition,” Ramos added.

He said he was lonely and ashamed of his inability to fix anything in his life. His old house leaked after earthquakes left cracks in the kitchen. He had trouble being understood well enough on the phone with his insurer to schedule appointments. So he stopped trying to remedy his own health, apart from taking pills and some exercises to regain leg movement. Instead, he tinkered with what he could manage, repairing broken speakers and radios with his collection of old electronic parts.

“Sometimes I just sit in bed waiting for the hours to go by,” he confessed.

Some Puerto Ricans fashion workarounds and call in favors to coordinate health care, score lifesaving pills or get elusive cardiologist referrals. Families pay out of pocket for private ambulances or taxis because there are few public means to transport incapacitated loved ones to medical facilities. Some put fragile relatives into the back seat of whatever car is available for journeys to other cities for care.

“If we don’t do it, it doesn’t happen. It’s one problem after another that complicates health,” said Roberto Colón, 56, who lives in a city near Aguas Buenas and recently paid a private ambulance driver to bring his elderly mother home from surgery. “The Puerto Rican who loves this place will stay, but it will come with sacrifice.”

At the Cementerio Municipal 1 in Aguas Buenas, workers installed a new aboveground tomb on a recent afternoon.

The graveyard, like most in Puerto Rico, is at capacity, in part because of poor planning and limited resources, but also because too many people are dying. A patch of dirt the length of about two parking spaces is all that’s left for the municipality to construct additional plots.

Buenaventura Dávila Roldán

Former Aguas Buenas mayor

That is why the cemeteries of people. Sad to say, but it is a truth. It is a truth.

Across the street from the cemetery is the Monte Santo funeral home, one of two in Aguas Buenas. The local Facebook page, “What’s happening in Aguas Buenas,” is maintained by the other funeral home director, Carlitos Román, who posts a seemingly endless stream of funeral notices.

“We normally do about 140 to 150 services a year,” said Monte Santo director Héctor Montañez, looking at his 2022 records. “We are at 201. That’s the highest number in the 40-year history of this business.”

Meléndez, the community activist, said she grows depressed thinking about how her mostly elderly neighbors and relatives fight to stay healthy amid mounting pressures.

“Everything here is just hard,” Meléndez, 66, said while wiping sweat from her forehead. “Don’t tell me that I need to go to the United States because here I don’t have what I need. We deserve better services and a higher quality of life here.”

Gómez Falcón once presided over a large extended family living on a sloping mountainside with panoramic views. As health services deteriorated, she battled an inherited kidney disease that required regular dialysis, with the catheter often getting misplaced or stuck. Bacteria sometimes found its way inside the artificial blood vessel under her skin. It was a lot to manage, family members said, but Gómez Falcón did it alone so as not to burden anyone else.

The strain grew far more severe when Hurricane Maria swept her wooden home off the face of the mountain in 2017. The Category 4 storm with winds of up to 175 mph flattened 1 in every 10 homes in Aguas Buenas, according to local estimates.

Gómez Falcón was hospitalized in the nearby town of Cayey, where she underwent dialysis — with generators powering her treatment — three times a week. She came home to nothing but debris.

The Federal Emergency Management Agency helped Gómez Falcón rebuild the family home. But she caught covid and was hospitalized with breathing difficulties during a trip to Ohio the following year to visit three of her children for Christmas. She was never the same after that, reliant on oxygen 24 hours a day, family members said.

By February 2022, she suffered a new setback when her oxygen levels dipped dangerously low. Gómez Falcón survived because she reached the hospital in time.

She was not as lucky the next time she called for the ambulance, just three weeks later.

Gómez Falcón was cremated. Her family said she was ready to be reunited with her late husband of nearly 50 years.

Her daughter Catherine Meléndez spent her grieving months rearranging her mother’s house and discarded the chair where she took her last breath. One day her grandmother — Gómez Falcón’s 88-year-old mother — handed Meléndez her mother’s wedding ring.

Meléndez slid it through a silver necklace, where it sits close to her heart.

This report is the result of a joint investigation by The Washington Post and the Center for Investigative Journalism, a nonprofit news organization in Puerto Rico.

https://www.washingtonpost.com/nation/interactive/2023/puerto-rico-deaths/?itid=hp-top-table-main_p001_f001