The scourge of Zika is also a major burden on the island, especially for the pregnant mothers and young children that are major beneficiary groups under Medicaid. Zika is a major stress on the health-care infrastructure, even as more and more physicians leave, uncompensated care rises, and the budget crisis leaves Puerto Rico struggling to keep the lights on at major hospitals.
The seeds for that disaster were sown into the very fabric of the American safety net. After decades of naked colonial and racist policy following the acquisition of Puerto Rico and the Virgin Islands, the territories were not included in the social-insurance provisions of the Social Security Act of 1935. Their inclusion would not come until 1950, when legislators wrote them into the law, with support from politicians from districts with strong Puerto Rican constituencies like Rep. Vito Marcantonio from East Harlem. “I hope the House will insist on the position of having Puerto Rico included in our social security system,” Marcantonio argued on the House floor. “Not to do so will only mean an intensification of the discrimination that exists against Puerto Rico under the present colonial system.”
Still, the inclusion of the territories came as a second-class package, reducing the disability and dependent insurance to much lower levels than those for the states and establishing hard annual caps for them. When the Social Security Act of 1965 created Medicaid and Medicare, the Medicaid provisions for the territories simply updated the older law’s limits. Even so, while territorial citizens don’t pay federal personal income taxes, they were obligated to pay the major Social Security and Medicare taxes required by the law to fund its major programs.
There’s simply no reason other than that history of exclusion for the serious health-care spending shortfalls that Puerto Rico faces every year. Obamacare was the first major missed opportunity to fix this policy flaw: Although its major one-time funding package was a boon to the territories, it still put them in a position to have to continuously lobby for Medicaid funding, now with a much less friendly Congress.
Also, since Obamacare’s insurance subsidies for purchasing private coverage are provided as refundable tax credits, Puerto Rican residents who might be in a position to purchase private insurance can’t apply for them since they don’t pay income taxes. Medicare advantage payments and the Medicare system in general have invested less for seniors on the island with lower effectiveness, problems that could have been fixed with the last round of health reform.
President Trump definitely doesn’t seem to be the ear the territory seeks in the White House—on Twitter he characterized budgetary funds for Puerto Rico’s Medicaid program as a “bailout,” and seemed to imply that Puerto Ricans were neither his constituents or taxpayers.
But for a president bereft of early policy accomplishments who seems to crave them, there’s a chance now to begin to reverse centuries of exclusionary policy by simply endorsing a plan to treat the people of the territories like the American citizens they are.
For now, if the proposed budget does pass Congress, Puerto Ricans will be granted some relief. But there are no guarantees for the next time, or the next crisis.