In 1917, the Jones Act granted US citizenship to natives of Puerto Rico, the first among the 5 territories acquired by the United States since 1898.1 A dilemma in that early period—“Does the Constitution follow the flag?”—was addressed in several cases considered by the Supreme Court between 1901 and 1932, known as the “Insular Cases.”2 These decisions ultimately set the legal basis to limit the constitutional rights of US citizens who reside in the territories. Law scholars have recently argued the need to “Reconsider the Insular Cases” and their sociopolitical consequences in light of their inconsistencies with contemporary constitutional and international law, and human rights principles.3
Disparities in Federal Healthcare Funding
The doctrine of the Insular Cases may have influenced the Social Security Act in 1935 and Medicare and Medicaid in 1965, because these programs are applied differently to the approximately 4 million US citizens who reside in the territories compared with those residing in the 50 states and the District of Columbia. These differences were examined in a 2005 Government Accountability Office (GAO) report to Congress.4 The GAO found uniform and profound differences in the implementation of the Medicaid program across all 5 territories, with a Medicaid per capita funding of only one tenth of that in the states. For the Medicare program, spending per beneficiary in the territories was consistently less than half of that in the average state. Since then, these disparities remain and new ones have emerged (Table).
Disparities in Quality of Care and Outcomes
Healthcare funding disparities may have contributed to observed gaps in key hospital performance measures and outcomes for Medicare beneficiaries in the territories. In one study, Puerto Rico ranked last among all states and the District of Columbia on average performance across 22 Medicare quality indicators.5 Another study found that Fee-for-Service Medicare beneficiaries in the US territories admitted with acute myocardial infarction, pneumonia, or heart failure had higher 30-day mortality and lower performance on core process measures.6 Likewise, Medicare Advantage enrollees in Puerto Rico fared worse in 15 of 17 performance measures recently evaluated.7In the treatment of acute myocardial infarction, US territories also lagged during a period of rapid improvement of the door-to-balloon time metric in the states.8 However, several Puerto Rico hospitals now match the states’ performance, thus supporting the potential to reduce quality gaps.9 The root causes of quality gaps between the US territories and the states are likely complex and need continued exploration and scrutiny.
Disparities in Healthcare Infrastructure
The results of a national survey that included Puerto Rico and the US Virgin Islands showed fewer registered nurses, emergency medicine specialists, and intensive care unit beds, as well as longer emergency department wait times.10 Moreover, the GAO reported significantly fewer skilled nursing facilities in all US territories compared with the states, which may increase hospital length of stay and costs.4 Compared with the states, where most hospitals had electronic health record technologies by 2014, their adoption in Puerto Rico hospitals lagged as a result of being excluded from the incentives provided by the Health Information Technology for Economic and Clinical Health Act of 2009.11 Compounding this, the exodus of physicians and allied healthcare professionals from Puerto Rico as a result of the combined healthcare and financial crisis further threatens access to care.12
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-Orlando Rodríguez-Vilá, MD, MMS, Sudhakar V. Nuti, BA, Harlan M. Krumholz, MD, SM
This article originally appeared in the February 2017 issue of The American Journal of Medicine.
