It’s been less than a year since the first reported case of Zika in Puerto Rico, but doctors in the territory are already at their breaking points. Zika infections themselves are not terribly taxing to health-care systems—symptoms usually resemble those of a cold or flu, if patients exhibit them at all—but the potential complications can stagger even well-funded health systems. Treatment for microcephalic infants and adults that develop neurological complications can cost millions per patient. Evidence from Brazil presented in an upcoming Centers for Disease Control and Prevention study indicates that the true burden of neurological disorders from Zika is underreported, and that in addition to a well-reported link to Guillain-Barré, the disease is associated with a rise in expensive hospitalizations from other neurological conditions, including encephalitis, myelitis, and encephalomyelitis. Additional services for child and maternal health—including screening and access to abortions—and contraceptive services simply add to the price tag. And with so little information available about Zika’s long-term effects, it’s impossible to know if hidden symptoms and costs don’t lurk down the road.
That’s all bad news, and especially bad news for Puerto Rico, which simply doesn’t have the resources to fight even the immediate effects of Zika. Since the decade-long economic crisis began, the commonwealth has hemorrhaged hundreds of thousands of people—usually healthy, younger people seeking work—in a steady mass migration to the mainland. In that flood of people were hundreds of Puerto Rico’s doctors, and perhaps over a thousand physicians have moved away since 2014. The result back on the island is devastating. Not only are the remaining people more likely to be those most vulnerable to Zika—children, elderly people, and poorer families and women—many would-be primary-care providers are gone.
Most of Puerto Rico’s residents are covered by public insurance, either Medicare for elderly individuals or Puerto Rico’s Medicaid program for low-income families. In theory, these insurance programs should help defray the costs of Zika for patients themselves and should also help keep the lights on in hospitals and doctor’s offices—which is still a real challenge in some places. Medicaid, especially, is a vital part of the public-health safety net for the most vulnerable people. As evidenced by federal policy in Flint and other public-health responses, Medicaid is a first line of defense for women and children against diseases that uniquely affect women and children.
Puerto Rico’s Medicaid program doesn’t fill that role well, however, because its federal funding is capped at levels that are much lower than the rates provided to states. The federal government provides a federal medical assistance percentage (FMAP) to states and territories for each Medicaid enrollee based on the average income in that area; and the federal minimum is 50 percent, meaning that the federal government will pay for at least half of all Medicaid patients’ costs. Puerto Rico is entitled to a 55 percent rate by those calculations, but federal spending there is currently statutorily capped at only 19 percent. That means that the struggling Puerto Rican government has to foot 81 percent of the medical bills for a huge chunk of people on the island—including the low-income women and families who face the most risk from Zika complications. Even before Zika became the burden that it is today, that completely arbitrary underfunding led to hospital blackouts and drug shortages across the island. Those conditions contributed to poor health that has been exacerbated by the advancing outbreak.