Dr Rafael Rodríguez Mercado, Secretary of Health for Puerto Rico, explains the priorities his administration has put in place, the impact of Hurricane Maria on the Puerto Rican healthcare system, and the next crucial rebuilding steps.


What were your initial priorities when you first took office?

The main priority was to find funding for Medicaid and instil credibility at the Senate. Back in 2009, an anti-corruption mechanism was supposed to be implemented within the Medicaid program. However, this mechanism did not see the light of day until the Promesa Bill was passed in 2016 and the Financial Oversight and Management Board was created. The lack of anti-fraud mechanisms severely damaged our credibility and our ability to raise funds for the continuation of the program, which is vital for Puerto Rico. Hence the priorities were to garner support from senators in Washington D.C. under the condition that we implement two programs: the Medicaid Management Information System and the Medicaid Fraud Control Unit. The first phase of the Medicaid Management Information System (MMIS) is finished and the second one started, which will end in June of 2020. The Medicaid Fraud Control Unit has been established so there is now an alignment in terms of compliance. After Hurricane Maria, we received USD 4.8 billion in funding which provides 100 per cent coverage for the Medicare program. Within that sum, USD 1.2 billion were under the care of the Secretary of Health of the United States, to be granted only if we complied with the measures implemented. The funding was received in full, and currently, Puerto Rico is ranked sixth in the nation in terms of compliance.

However, the arrest of the Secretary of Education and the executive director of the Health Insurance Administration on fraud charges earlier this year damaged the credibility of the government of Puerto Rico. Swift action had to be taken, and through lobbying and personal discussions with Democratic and Republican representatives in Washington D.C, credibility was restored. We are slowly making headway, but we are on the right path to having a program that can last and help the people of Puerto Rico.

The next challenge that we have will be regarding accountability, in other words, how the money will be spent, on what medications, and how many patients will be able to benefit from it. This will require more visits to the United States and produce a yearly estimate of funds for the number of patients enrolled in the program. Additionally, in the context of free medication for hepatitis C, we should detail the amount of the funding that will be directed to this and how many participants would benefit.


What has been the impact of Hurricane Maria on the healthcare system?

Hurricane Maria weakened an already frail system. Before it hit, we had waves of emigration as economic prospects were not as promising as abroad. This weakened the government’s ability to fund itself as more working and tax-paying professionals went out to seek employment elsewhere. The government was in a state of bankruptcy and was not able to set up programs for the benefit of the people. Hence, when the Hurricane hit, not only was the healthcare system devasted but the country as well.

The aim to bring the government and the healthcare system back afloat was to look for different opportunities and migrate towards a more self-sustainable model. In such situation, you must change the way you do things, and that meant applying for federal grants and projects to compensate for the loss of taxes that we incurred, even to ones we were not benefitting from. However, Maria brought about a state of emergency, rendering Puerto Rico eligible for waivers are still in place to this day. This created new opportunities in the health field and was a positive outcome for the country. Thanks to the initiatives of the private sector, NGOs, and governmental agencies such as the Federal Emergency Management Agency (FEMA) and the Center for Disease Control (CDC), we managed to heal from this incident.

The focus at this stage is to implement further reforms and take advantage of the grants to implement prevention, chronic disease, and children health programs. We have been quite successful as we are getting USD 42 million in supplemental funds aimed at these efforts and strengthening the Medicaid program. We can increase the area of the full coverage reimbursement list of providers. HIV patients, for instance, have better coverage now compared to what they had for decades.


What is the administration doing to prevent further upward migration of healthcare professionals?

Since so many professionals emigrated from the country, this left certain sectors short-staffed, notably the healthcare one. Hence, to mitigate the lack of physicians in general, and in specialized fields in particular, an incentive act has been implemented. The incentive act covers more than 3,000 physicians, which has helped to curb the migration by four per cent. It is not only specialized physicians that are leaving but healthcare professionals as a whole since 14 states have a reciprocity agreement with Puerto Rico that was implemented in case of emergencies. As a result, healthcare professionals can practice in those states with a Puerto Rican license and assume a better paying job, sometimes earning double or triple what they do here.

Another factor to consider is that the Latin population is rising year by year in the United States, which increases the demand for Puerto Rican healthcare professionals since they are bilingual. That is why the current incentive program is not enough but hopefully, in time we can broaden its scope so that it incorporates nurses, paramedics, anaesthetists, and general practitioners.


What recommendations do you propose to better the ecosystem? 

There is a moral responsibility to help our people that is deeply embedded in our culture. Even the people who have left return regularly and lend their services to help the best way they can. The poverty level in Puerto Rico is much lower than other US jurisdictions at USD 10,260 compared to the poorest state, Mississippi, which is at USD 33,000. There is an unfair trade-off between a yearly cost of living allowance or insurance and food stamps. This creates a big problem, as Puerto Rico has now 400,000 uninsured patients. The aim of this new bill, besides reimbursement, buying medicine for hepatitis C, and pay Part B of Medicare, is to increase the poverty level to USD 16,000 and add the yearly cost of living allowance. That way, the government can protect the people who want to work and not penalize them.


What are some of the prevention policies that you have put into place? 

Five years ago, there was an influenza outbreak, but only 10,000 people were vaccinated. Once Hurricane Maria hit, the refrigeration systems for medication were damaged. A campaign was launched and with the help of Direct Relief, CDC, and other foundation programs, the necessary shots, in addition to other medication, were brought to the island. Educational and vaccination programs were launched thereafter, and I am happy to say this is the second year in a row that we do not have an epidemic outbreak. The same strategy was used with the human papillomavirus (HPV), as the cancer rates related to the disease rose from 7.3 percent to 13 percent in seven years. Additionally, children in schools from age 11 to 14 are obligated to receive their shorts, and currently, we have an 85 percent vaccination rate. The same can be said for measles, which we do not have on the island.

The rise of chronic diseases is noticeable here as well as in other countries, and those are linked to social determinants: health and wealth. Hence, to curb this, the federal government funded the diabetes centres, the health reform covered insulin pumps and the supply of insulin and strengthened to cooperation with the private sector. There are programs in 330 primary health centres that benefit the uninsured population, in addition to fair and school visits. However, this is not enough as we need to aim at creating a better environment to improve the health of the people. Social determinants incorporate broader social markers like justice, civil rights, food, housing, and education, which all need to be improved to holistically better the health of the population.

The grants that we receive are going to prevention as this is the strategy that we think is the best way forward. If actions are made today, it will have an impact in the next 5-10 years, which will have an impact on the quality of life of the people. Additionally, we have partnerships in projects where we offer dialysis, renal care, and are engaged in research to further push that agenda.


What can be done to promote clinical trials in Puerto Rico?

Puerto Rico received a USD 13 million for cancer research which was allocated to the alliance that our university has with M.D. Anderson. The funds were aimed at finding new ways of treating cancer, and two students conducted clinical trials. However, we have to create an environment and motivate people to go into research, since this a field that needs to be developed, as not everyone can be a physician. Additionally, if more relationships and partnerships are created with world-class health institutions, this would attract more medical clinical research. As many pharmaceutical companies are present in Puerto Rico, engaging them would also be an added benefit.


How can Puerto Rico be more competitive in the medical tourism sector?

In my opinion, in order to be attractive as a medical tourism destination, we first need to establish a strong telemedicine program to serve as an introduction to the capabilities that we offer. Additionally, a good marketing strategy is required and , more importantly, professionals that have publicized credentials and exposure nationally and internationally in their specialized field. Specialized professionals that have national and international exposure are ultimately the people who will advertise this domain. These areas require more investments, and there needs to be a detailed strategy in place before we can consider launching Puerto Rico as a medical tourism destination. In its development phase, the target market would strategically be 9.6 million Puerto Ricans living in the U.S. who have friends and family here and can do the recovery on their home island. If we follow this roadmap, medical tourism could be successful and could create new opportunities.


What is your final message? 

Despite the economic downside and issues that arose from Hurricane Maria, Puerto Ricans are hardworking people who committed to make the island a better place than it was. Even though the hurricane was a tragedy, it has allowed us to access recovery funds to rebuild the country better than it was, and not only in the healthcare sector. Recovery will take time, between 10 to 15 years according to FEMA, but we are hopeful that the governments that follow this administration will continue the path that we are on now. This will ensure a better healthcare system and more health professionals who want to stay in the country. Nevertheless, this will mean continuously improving the surrounding conditions in which they live and work: offering better salaries, modernizing hospitals with newer technologies, and increasing accessibility.