Puerto Rico’s push for more federal Medicaid funding and its success in vaccinating residents were among the topics its governor discussed in a recent interview with CQ Roll Call. 

Unlike states, Puerto Rico receives capped Medicaid funding and is reimbursed at 76 percent of the health care program’s costs for the island territory’s residents. The continuing resolution would keep that rate, but without government action it would fall to 55 percent. A state in a similar situation would receive 83 cents on each dollar spent.

Gov. Pedro R. Pierluisi, a Democrat and former resident commissioner of Puerto Rico in the House, said 76 percent is a “reasonable rate” but a short-term fix. He said he also plans to continue to lobby for long-term equal treatment.

“As a matter of federal policy, mistreating American citizens in Puerto Rico, it doesn’t make any sense. You are basically encouraging them to hop on a plane and move to the states to get better health care,” he said.

Pierluisi said Medicaid in Puerto Rico isn’t comparable to Medicaid programs in the states. The territory covers individuals up to 85 percent of the federal poverty level, he said, compared with 138 percent of the federal poverty level in a state that has expanded Medicaid. About 44 percent of Puerto Rican residents qualify for Medicaid.

The program also does not cover certain programs that states do, such as home health care and nonemergency medical transport. This has put a strain on older adults and those with chronic conditions.

“We shouldn’t be shortchanging any U.S. jurisdiction’s federal health funding when we’re still in the midst of this pandemic. It is just not right,” he said.

The continuing resolution, if passed, would provide funding until Dec. 3. Pierluisi said he has talked with Senate Majority Leader Charles E. Schumer, as well as Speaker Nancy Pelosi and House Majority Leader Steny H. Hoyer, D-Md. He’s also met with House Energy and Commerce Chairman Frank Pallone Jr., D-N.J., and Senate Finance Chair Ron Wyden, D-Ore., whose committees have jurisdiction over Medicaid.

Resident Commissioner Jenniffer González-Colón, R-P.R., has also fought for the issue in Congress.

“The committees of jurisdiction in the House and in the Senate have shown us that they are committed to continue working in this direction, including provisions in the continuing resolution to make sure we don’t revert back to a 55 percent federal match,” she told CQ Roll Call. She said their work was not yet done.

Some support from GOP

Pierluisi said he has received some Republican support.

“The only thing is that [Republican] leadership tends to give us either a four-year deal or a five-year deal, as opposed to any kind of permanent financing. And that’s detrimental, I have to say,” he said. “We cannot continue going from one year to the next because you cannot budget appropriately for your health program along those lines.”

Pierluisi also said he was concerned by a provision in the CR pushed by Republicans that would call for the Government Accountability Office to review the funding statute for the territory by Nov. 15. 

The 2010 health care law provided the territories with additional Medicaid money. Puerto Rico has used its funding faster than other territories, which raised questions among Republicans. 

Some Republicans have pushed for additional program integrity measures for Puerto Rico that they say are necessary to prevent fraud and provide oversight. 

The Biden administration said this month that its interpretation of the fiscal 2020 spending law, which included the most recent funding reauthorization, would be used as the basis for future funding. Using that as a baseline, the administration wants about $3 billion for Medicaid in Puerto Rico.

The GAO review of the statute and future funding would be nonbinding, per a House Democratic aide.

“HHS has the legal authority to interpret its own statute, so I don’t anticipate HHS reversing course,” said Pierluisi. “They’re the agency with the expertise to review Medicaid law and determine its coverage.”

COVID-19 protocols

The island’s record of curbing COVID-19 transmission outshines the results in many states. 

Puerto Rico saw a surge of COVID-19 cases and hospitalizations in the spring but made significant progress in reducing reported transmission.

At the peak, Centers for Disease Control and Prevention data for April 13 documented 1,550 new cases. But recent data available for Sept. 21 shows a drop to 361 cases among the island’s 3.2 million residents.

The shift, Pierluisi said, can be attributed to Puerto Rico’s mitigation approach and mandates, which are not seen locally as political.

Puerto Rico boasts some of the best COVID-19 vaccination rates in the country. In Puerto Rico, he said, the full vaccination rate for individuals 12 or older is about 76 percent. For one dose, it’s about 85 percent. 

Pierluisi says initially lower rates of vaccination can be attributed to data entry issues, with many providers unable to submit updated electronic data. Those numbers were underreported, he said, leading to a later jump in numbers.

Puerto Rico now consistently ranks among the top 10 in vaccination among states and territories. This is in part due to a number of modified vaccine requirements.

First-responders, teachers and school personnel, health care workers and, most recently, government workers all must either be vaccinated or submit to weekly COVID-19 testing.

As of last week, 90 percent of teachers in Puerto Rico were fully vaccinated, he said, as well as 85 percent of students who are eligible for the vaccine. Ninety percent of state government employees also are vaccinated.

Employees in industries that interact with the public at large, such as hospitality and entertainment, are subject to the requirements as well.

Pierluisi says the key to his strategy is providing an option. It requires businesses to ask for proof of vaccination or a negative COVID-19 test if they want to operate at 100 percent capacity; if they do not, they can operate at 50 percent capacity.

“What I’ve been doing is giving options, but obviously, I am encouraging vaccination,” he said.

Advice from scientific coalition

Pierluisi said a scientific coalition advises him on COVID-19 policies, such as a change he put in place to close businesses at midnight and, more recently, prevent alcohol consumption in public areas between midnight and 5 a.m. The second executive order will be extended into October.

“I want to be very careful because I don’t want to revert. The schools are open, and we don’t have transmission. We haven’t identified any case, any virus transmission within the schools themselves,” he said.

Pierluisi said there is still vaccine resistance among some individuals with strong religious convictions, those opposed to vaccines and some older adults in remote areas who may have less information about the vaccine.

Puerto Rico saw hesitancy among younger populations that dropped when the requirements for in-person learning changed.

“I believe the mandates work. I do give options, like I have said but it’s not convenient,” he said. “It’s quite inconvenient, I would say, to start testing yourself once a week to go to work. Who wants to go through that?”