On the Outskirts of National Health Reform: A Comparative Assessment of Health Insurance and Access to Care in Puerto Rico and the United States

Abstract

Context: Puerto Rico is the U.S.’s largest territory, home to nearly 4 million American citizens. Yet it has remained largely on the outskirts of U.S. health policy, including the Affordable Care Act (ACA). This paper presents an overview of Puerto Rico’s health care system and a comparative analysis of coverage and access to care in Puerto Rico versus the mainland U.S. Methods: We analyzed 2011-2012 data from the Behavioral Risk Factor and Surveillance System, and 2012 data from the American Community Survey and its counterpart the Puerto Rican Community Survey. Among adults 18 and over, we examined the following outcomes: health insurance coverage; access measures such as having a usual source of care and cost-related delays in care; self-reported health; and the receipt of recommended preventive services such as cancer screening and glucose testing. We used multivariate regression models to compare Puerto Rico and the U.S., adjusted for age, income, race/ethnicity, and other demographic variables. Findings: Uninsured rates were significantly lower in Puerto Rico (unadjusted 7.4% vs. 15%, adjusted difference -12.0%, p<0.001). Medicaid was far more common in Puerto Rico. Puerto Rican residents were more likely than those in the mainland U.S. to have a usual source of care and a check-up within the past year, and fewer experienced costrelated delays in care. Screening rates for diabetes, mammograms, and Pap smears were comparable or better in Puerto Rico, while colonoscopy rates were lower. Self-reported health was slightly worse, while obesity and smoking rates were lower. Conclusions: Despite its far poorer population, Puerto Rico outperforms the mainland U.S. on several measures of coverage and access. However, Congressional policies capping federal Medicaid funds to the territory have contributed to budgetary challenges. While the ACA significantly increases federal resources in Puerto Rico, ongoing restrictions on Medicaid funding and premium tax credits pose substantial health policy challenges in the territory.