Dr. Kevin Most: Health care in Puerto Rico

Steve Cochran

Dr. Kevin Most (photo taken prior to the pandemic)

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We have heard almost daily the dire straights that the people of Puerto Rico are going thru. The devastation to their homes is crushing, the lack of electricity and safe water is heart breaking. Many have stepped up with financial donations with the hope of accelerating the repair and infrastructure, and the people of Puerto Rico are grateful. Federal aid although it appeared slow and late,  is at least present now. However the correction is slow.

The health impact of this is starting to be felt and is only thought to increase as families go longer without homes, water, power and adequate food. The case of bacterial infections continues to rise and the sites of care are limited as many hospitals and clinics have limited power.  Many hospitals are working on generator power which is not ideal. The health system in Puerto Rico was already strained, they have had a doctor’s shortage, the lack of electricity in offices limits the ability to give even simple vaccines. Without clinics open the ER’s have been overrun with patients needing care or medication. The USS Comfort is helping with some of the demand. This is a large hospital disguised as a ship and is able to care for the most severely ill individuals.

It is an embarrassing response to the needs and the healthcare needs of Puerto Rico. Little do we know that the impact of our slowness will personally impact many of us here. Why do I say that? Well, 12 of the top 20 global pharmaceutical and bio tech companies have manufacturing facilities on the island. They make seven of the top ten drugs sold worldwide.  They also make chemotherapy and drugs for transplant patients and although they are not in the top 10 drugs used they are life  saving for thousands. To put it in total perspective, 72% of Puerto Rico’s exports are based on healthcare products.

The bigger impact will be felt on a simple product that we use everyday, 100’s of time at every hospital. You all have heard of saline, we use it to deliver drugs, to give fluid to dehydrated patients, to help control blood pressure…… the list goes on. There are two major manufacturers and when one is knocked out the other cannot pick up the production demand. So, as we work thru the current supply you have many hospitals scrambling for ways to cover this need. Baxter saw the storm coming and moved some product early, to help soften the impact, but the issue now is not only the plant but the workforce to get the production back to the volume needed. They can get the plant back to working status but will the workforce be present and ready to work, or will they, work with less people or need to hire and train new workforce. Either of these scenarios are concerning from a quality control view.

The company is trying to prevent hoarding so it is limiting distribution to control the impact. Remember the island itself has need for these medications for their people, especially if a viral or bacterial stomach illness arises. The impact of this should be felt here in the upcoming weeks.

Trump’s recent executive order- understanding it now before it goes into effect

Wow what a crazy time in healthcare right now, the President continues to act on his own making decisions that may topple the ACA as we know it. If that is the desire, there is a much better way than impacting millions of individuals personally. So what did he do? The original premise for the ACA realized that insurance companies would need some relief on the cost of premiums, without some financial support the premiums from these companies would have been well outside the reach of many individuals. The ACA had wording built into it for CSR’s, cost saving reduction, dollars that would be shared with the insurance companies taking new risk as they entered the market. This allowed for insurers to enter the market and provide coverage that was affordable when coupled with individual premium subsidizes based on income of the individual. 4/5ths of the 10 million patients on the ACA receive some percentage of individual subsidy relief. He also took action that may allow for lower cost insurance products to be offered, that would not be required to contain the benefits outlined in the ACA.

Some felt the CSR would continue to grow from several billion towards a 100 billion dollars over the next decade. Others felt that as a country it was time for us to begin to manage our health not just treat illness. Promoting a healthy US and putting incentives in to encourage health and early screening was thought to perhaps final bend the cost curve we had noticed for many years. If this were to occur we would see the cost of care start to stabilize and the need for a subsidy program to slow. It would also begin to promote the need to eliminate waste or non value added care, which also would slow the cost curve.

Unfortunately the dollars used for the CSR were not legally appropriated by Congress, there was no approval of these federal dollars to be delivered to these for profit insurance companies. A lawsuit was filed and a decision was made that in fact they were not legal as they had not been approved, this decision is currently under appeal. The President’s actions may make this a moot point, as his executive order would end the plan.

So what might happen? This change actually allows insurance companies the right to drop out of the plans for next year, fortunately in Illinois, Blue Cross has stood up and stated they will continue next year. Other states may not be so lucky, we currently have some states where it is down to a single insurer in the state and the loss of this subsidy may make them exit, leaving some areas with no marketplace options. Premiums have been set and approved prior to this action so it is unclear if they will be allowed to adjust premiums based on this loss of the federal subsidy. We do know however that it also allows a large loophole, which would allow for the expansion of short term plans. These plans are exempt from the ACA and historically were allowed for a few months to bridge coverage for individuals between jobs or for those who no longer were covered by their parents policies. In the ACA they were essentially 90 day plans, Trump however wants to see these extended to a year. As these plans are not covered by the ACA, they are not required to contain the basic services that plans in the ACA were required to cover (Mental illness, preventative screening, etc.)

Another move made hours before makes it easier for individuals and small businesses to buy alternative types of insurance with much lower prices as many of the benefits and federal protections would be allowed to be removed. It allows for association health plans to be sold across state lines, these are plans where a similar group bands together to form an association in order to negotiate health benefits. It is appearing likely that these plans would also request for the ability to sell lower priced, less benefit programs. This is one of the tipping points as the young healthy may flock to these plans while leaving the sick and elderly in the marketplace plans. It does not take a math major that would result in a collapse of the program as well as an increase in all premiums.

It is unfortunate that the health and lives of millions in the US will again be at risk and uncertainty.

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