♪♪ >>> AND NOW, TO A GROWING PROBLEM IN AMERICA'S BACKYARD.

PUERTO RICO IS IN THE MIDST OF A HEALTH CARE CRISIS, AFTER A SERIES OF NATCH RAM DISASTERS HIT ITS RAPIDLY AGING POPULATION.

"THE WASHINGTON POST" WRITES, MORE PEOPLE ARE DYING IN PUERTO RICO AS ITS HEALTH CARE SYSTEM CRUMBLES.

AND SHE'S TELLING HARI SREENIVASAN HOW WHAT'S HAPPENING THERE COULD BE A SIGNAL OF WHAT'S TO COME IN THE U.S. >> CHRISTIANE, THANK YOU.

THANK YOU FOR JOINING US, ARELIS.

YOU AND A GROUP OF FOLKS AT "THE WASHINGTON POST" LOOKED AT THE RATE OF DEATH IN PUERTO RICO OVER THE LAST YEAR.

WHAT DID YOU FIND?

>> WE FOUND THERE WAS AN EXCESS IN MORTALITY, NOT DISSIMILAR TO WHAT WE SAW AFTER HURRICANE MARIA IN 2017.

BUT IN THIS CASE, THERE WASN'T A HURRICANE TO EXPLAIN WHAT WAS GOING ON.

WE FIGURED THAT ABOUT 3,300 PEOPLE, MORE THAN IS EXPECTED, BASED ON AVERAGE RATES, ANNUAL RATES, DIED IN 2022.

PART OF IT WAS COVID, BUT THERE WERE A LOT -- IT WENT BEYOND THAT.

THERE WERE A LOT OF REASONS FOR WHY PEOPLE WERE DYING ON THE ISLAND.

>> LET'S START TO UNPACK THAT.

3,300 PEOPLE IS A LOT, ABOVE THE AVERAGE YOU WOULD EXPECT.

WAS IT ANY SPECIFIC GROUP OF PEOPLE THAT WERE IMPACTED MORE, THE YOUNG OR THE OLD OR THE MALE OR THE FEMALE?

>> YES, PUERTO RICO ACTUALLY HAS BEEN AGING QUITE RAPIDLY IN RECENT YEARS, AND THAT'S AGING BY COMPRESSION, AS SOCIAL SCIENTISTS WILL TELL YOU, MEANING THAT THERE'S BEEN A MIGRATION OF YOUNG WORKING-AGE PEOPLE FROM THE ISLAND, SO, WHAT YOU HAVE IS A POPULATION THAT'S SIGNIFICANTLY OLDER, THAT IS MORE PRONE TO CHRONIC ILLNESS, AND WHO HAVE, IN SOME CASES, A LOT MORE DIFFICULTY REACHING THE HEALTH CARE RESOURCES THAT MIGHT HELP THEM TO MANAGE THOSE DISEASES.

>> OKAY, SO, DOES THAT EXPLAIN IT ALL?

IF YOUNG PEOPLE LEAVE, THE OLD PEOPLE ARE LEFT BEHIND, THEY CAN'T GET TO THE AMBULANCES OR THE HOSPITALS FAST ENOUGH, IS -- WHAT ELSE IS HAPPENING?

>> NO, NO, THE CHRONIC ILLNESS, THEY ARE LARGELY PREVENTABLE DISEASES, THESE ARE THINGS THAT POINT TO AN OVERALL COLLAPSE OR COLLAPSING WITHIN THE HEALTH CARE SYSTEM AND UNABLE TO DELIVER CARE TO PATIENTS IN A WAY THAT IS ADEQUATE THAT HELPS THEM MANAGE THEIR CHRONIC ILLNESSES.

I MEAN, WE LOOK AT THE OVER 65 POPULATION, BUT WE ARE ALSO TALKING ABOUT FOLKS THAT ARE 50 AND OLDER THAT ARE HAVING A LOT OF DIFFICULTY.

THE OTHER REASON THAT THIS IS HAPPENING IN PUERTO RICO IS, YOU HAVE MANY, MANY DOCTORS THAT ARE FLEEING PUERTO RICO, GOING TO THE MAINLAND UNITED STATES IN SEARCH OF OTHER OPPORTUNITIES.

>> WHY ARE HEALTH CARE PROFESSIONALS LEAVING PUERTO RICO?

>> THEY CAN'T AFFORD TO STAY.

THE -- THE SCHEME OF INSURANCE AND THE REIMBURSEMENTS THAT THEY GET FROM GOVERNMENT HEALTH CARE JUST SIMPLY DOESN'T PAY THE BILLS.

FOR DOCTORS.

AND THEY ARE ALSO OVERWORKED.

THERE ARE FEW NUMBER OF SPECIALISTS THAT ARE THERE TO TREAT THOUSANDS OF PEOPLE AND THEY ARE UNABLE TO KEEP UP WITH.

AND THERE ARE SOME DOCTORS WHO TOLD ME DURING THE SERIES OF REPORTING THAT, YOU KNOW, IT JUST DIDN'T FEEL -- IT GOT THEM DEPRESSED TO KNOW THAT THERE WERE THOUSANDS OF PEOPLE THAT THEY COULDN'T REACH WHO NEEDED THEM AND THEY WERE UNABLE TO DELIVER CARE, BECAUSE THEY HAVE TO ROLL THROUGH LARGE NUMBERS OF PEOPLE.

IT'S JUST NOT A SITUATION THAT'S SUSTAINABLE FOR MEDICAL DOCTORS.

>> SO, YOU'RE TALKING ABOUT THESE BIG SHIFTS HERE.

IF YOU LOSE THE YOUNGER POPULATION AND YOU START TO LOSE DOCTORS, WHAT'S LEFT?

I MEAN, DESCRIBE THE KIND OF HEALTH CARE INFRASTRUCTURE, YOU HAVE THESE SAD SORT OF STORIES.

TELL ME ABOUT THE PEOPLE YOU SPOKE TO AND HOW THEY ARE EMBLEMATIC OF THE PROBLEM.

>> ABSOLUTELY.

WHAT YOU HAVE LEFT IS A CONSIDERABLY YOUNG AND OLD POPULATION, BOTH OF WHOM ARE SEVERELY VULNERABLE TO SOME OF THE ISSUES THAT PUERTO RICO FACES WITH CLIMATE CHANGE, FOR EXAMPLE.

YOU HAVE A TRAUMATIZED POPULATION, FOR EXAMPLE, A MAN I MET IN A CENTRAL MOUNTAIN TOWN, PRETTY REMOTE, THIS IS A GUY WHO HAD A -- A STROKE AND NO ONE FOUND HIM, HE LIVED ALONE IN THIS REMOTE HOME IN THE MOUNTAINS, NOT SUPER FAR FROM HIS FAMILY, BUT FAR ENOUGH WHERE NO ONE FOUND HIM FOR THREE, FOUR DAYS AND HE WAS BLEEDING OUT OF HIS HEAD FOR AWHILE.

I WENT TO VISIT HIM WITH WHAT THEY CALL A HEALTH PROMOTER, SOMEONE IN THE COMMUNITY WHO GOES FROM HOUSE TO HOUSE, TRYING TO FIND OUT WHAT THE PARTICULAR HEALTH NEEDS ARE, AND THIS IS AN INDIVIDUAL WHO HADN'T HAD HIS PRESCRIPTIONS RENEWED, WHO WAS STRUGGLING WITH ANXIETY AND DEPRESSION AND SLEEPLESSNESS, THIS IS -- THIS IS A STATE OF SO MANY OF THE PEOPLE THAT I MET IN PUERTO RICO THIS LAST TRIP.

>> AND THEN, YOU ALSO TALK ABOUT JUST, YOU KNOW, CALLING 911 ISN'T REALLY A SUREFIRE WAY TO GET CARE.

>> NO, THE MAIN CHARACTER IN OUR STORY IS A WOMAN AND HER FAMILY WHO ALSO LIVE IN A FAIRLY REMOTE AREA OF PUERTO RICO.

THE TOPOGRAPHY IS CHALLENGING.

PUERTO RICO IS NOT EASY.

BUT WHEN YOU CALL 911, YOU EXPECT A CERTAIN LEVEL OF SERVICE, AND IN THIS CASE, THE AMBULANCE THAT WAS DISPATCHED, A PRIVATE AMBULANCE, DID NOT GET THERE IN TIME.

THEY GOT LOST, ASKED FOR DIRECTIONS, BUT COULDN'T REACH HER, WHO, HERSELF, WAS SUFFERING FROM BREATHING, SHE WAS STRUGGLING TO BREATHE AND HAVING ALL KINDS OF ISSUES AND SHE PASSED AWAY WITH HER FAMILY.

>> SO, WHAT IS THE HEALTH DPT DEPARTMENT, OR THE HEALTH SYSTEM IN PUERTO RICO TRYING TO DO TO DEAL WITH SOME OF THESE CHALLENGES?

PUERTO RICO'S HEALTH CARE SYSTEM IS PRETTY COMPLICATED.

>> IT DEPENDS A LOT ON THE FEDERAL GOVERNMENT, AND THAT'S WHERE, IF YOU ASK, YOU KNOW, STATE OFFICIALS, PEOPLE WITH THE GOVERNMENT, THEY'LL IMMEDIATELY SORT OF ORIENT THEIR ANSWER TO WHY THESE THINGS ARE HAPPENING TO, YOU KNOW, THE COLONIAL STATUS OF PUERTO RICO.

BUT WE KNOW THAT'S ONLY PART OF THE STORY.

SOME OF IT HAS TO DO WITH MEDICAID REIMBURSEMENTS TO WHAT DOCTORS IN THE UNITED STATES RECEIVE FOR SIMILAR LAIR, IF NOT THE SAME CARE.

YOU HAVE A SITUATION WHERE THE GOVERNMENT IS RIGHT NOW NOT DOING MUCH TO STOP THE LEADING OF YOUNG DOCTORS, PEOPLE THAT ARE STUDYING IN THE UNIVERSITIES THERE IN PUERTO RICO WHO ARE EAGER TO WORK ON THE ISLAND AND SERVE THEIR PEOPLE, BUT ARE UNABLE TO, BECAUSE THEY HAVE STUDENT LOANS AND, YOU KNOW, SIMPLY CANNOT MAKE IT HAPPEN.

THEN YOU HAVE THE COMPLICATED SORT OF INTERCHANGE OF INSURANCE COMPANIES IN PUERTO RICO AND JUST VERY BASICALLY AT A GROUND LEVEL, IF YOU ARE SOMEONE WHO IS LOOKING FOR A SPECIFIC SPECIALIST, DERMATOLOGIST, A RULE TOLL GIST, A NEUROLOGIST, YOU ARE LOOKING AT FOUR TO SIX MONTHS TO SCHEDULE AN APPOINTMENT.

AND IF YOU HAVE A CONDITION THAT IS EXACERBATED BY THE WAIT, YOU HAVE IN BIG TROUBLE.

>> YOU HAVE SPEND YEARS REPORTING FROM PUERTO RICO, AND I WONDER HOW MUCH OF AN IMPACT WAS HURRICANE MARIA?

I MEAN, TO ME, SOME OF THIS, CERTAINLY THE OUTMIGRATION, SEEMS TO HAVE ACCELERATED AFTER HURRICANE MARIA.

>> I THINK AT THE BEGINNING, WE SORT OF EXPECTED TO SOME DEGREE THAT THE TRAUMA AND THE -- THE AFTERSHOCKS, IF YOU WILL, OF HURRICANE MARIA WERE GOING TO BE SEVERE, BUT WE ARE SEEING THE MANIFESTATION NOW.

IT WASN'T JUST HURRICANE MARIA.

SHE WAS A BIG HIT FOR PUERTO RICO, BUT YOU ALSO HAD A SERIES OF EARTHQUAKES THAT HAPPENED, HURRICANE FIONA, YOU HAD THE OUSTER OF THE GOVER NOR IN, I THINK, 2019, IF I RECALL CORRECTLY, THROUGH PROTESTS.

SO, IT'S JUST BEEN ONE THING AFTER ANOTHER.

YOU HAVE AN EXHAUSTED POPULATION.

>> SO, IS THIS A LONGER TALE OF WHAT HAPPENS WHEN THE DEMOGRAPHY SHIFTS SO MUCH?

WOULD THOSE 3,300 EXCESS DEATHS NOT HAVE HAPPENED IF, FOR EXAMPLE, 120,000 YOUNG PEOPLE STAYED IN PUERTO RICO INSTEAD OF LEFT?

>> THAT'S POSSIBLE.

BUT I ALSO THINK THERE'S DEFICIENCIES IN MENTAL HEALTH TREATMENT, THERE ARE DEFICIENCIES IN THE SYSTEM OVERALL.

YES, IT WOULD HAVE HELPED IF THOSE FOLKS WOULD HAVE STAYED, IF THOSE ELDERLY FOLKS WHO CONSISTENTLY APPEAR ON THE NEWS OF HAVING DIED BY THEMSELVES INSIDE THEIR HOMES, IF THERE WERE PEOPLE THERE NEARBY TO BE, YOU KNOW, WATCHING OR TAKING CARE OF THESE FOLKS, MAYBE THAT WOULDN'T HAVE HAPPENED, BUT THIS IS A LONGER TALE AND I THINK THIS IS SOMETHING AS AMERICANS, ON THIS RESIDENCE ON THE MAINLAND, IS SOMETHING WE NEED TO PAY ATTENTION TO.

THESE ARE FRIENDS THAT ARE ALSO APPEARING IN OTHER PARTS OF THE MAINLAND U.S. WITH THE SORT OF FLIGHT OF DOCTORS, INCREASING NUMBER OF DOCTORS WITH THE ISSUES WITH INSURANCE COMPANIES WHO MAKE IT DIFFICULT TO ACCESS CARE IN SOME CASES, SO IN MANY CASES, I THINK PUERTO RICO IS A CANARY IN A COAL MINE, IF YOU WILL, OF WHAT COULD HAPPEN WHEN WE'RE NOT WATCHING AND ALLOW THE HEALTH CARE SYSTEM TO DETERIORATE IN FRONT OF US.

>> YOU'VE GOT SO MANY DIFFERENT LEVELS OF DEFICIENCY, WHETHER IT'S HUMAN BEINGS THAT ARE THERE TO BE DOCTORS AND NURSES AND FILL THE INFRASTRUCTURE THAT WAY, OR, YOU KNOW, TOPOGRAPHY THAT YOU CAN'T EASILY CHANGE, I MEAN, WHAT CAN YOU DO?

>> WELL, I'M NOT A POLICYMAKER, SO, I DON'T PRETEND TO HAVE ALL OF THE SOLUTIONS, BUT I DO THINK THERE ARE CERTAIN PRINCIPLES THAT ARE AT PLAY HERE.

ONE, BUILDING SINNIVES FOR PEOPLE TO STAY.

IF YOU ARE STUDYING AT GRUFRT OF PUERTO RICO, A PREMIER INSTITUTION FOR MEDICAL SCIENCE, THERE SHOULD BE PERHAPS INCENTIVES TO KEEP THOSE FOLKS ON THE ISLAND AND TO HAVE THEM PARTICIPATE IN THE SYSTEM FOR A CERTAIN AMOUNT OF TIME, IF THEY ARE, YOU KNOW, EDUCATIONS ARE SUBSIDIZED.

OR MAYBE IT'S CHANGING THE DELIVERY SYSTEM.

RIGHT NOW, BECAUSE SO MANY PEOPLE LIVE IN, YOU KNOW, THEIR OWN COMMUNITIES, MAYBE THE HEALTH CARE SYSTEM NEEDS TO GO TO THEM INSTEAD OF EXPECTING PEOPLE TO COME TO, YOU KNOW, URBAN CENTERS THAT ARE SOMETIMES DIFFICULT FOR THEM, ESPECIALLY IF YOU ARE ELDERLY, TO RECEIVE CARE.

THERE ARE A BUNCH OF DIFFERENT THINGS THAT WE THINK.

MENTAL HEALTH CARE, YOU KNOW, MAYBE THE FEDERAL GOVERNMENT NEEDS TO LOOK A LITTLE BIT MORE CLOSELY IN WHAT WAYS IT CAN HELP SUPPORT FEDERALLY QUALIFIED HEALTH CLINICS THAT ARE IN SOME OF THESE COMMUNITIES TO BE ABLE TO REACH THOSE.

OVERALL, I THINK THERE IS A LACK OF UNDERSTANDING, BOTH AT THE STATE AND FEDERAL LEVEL OF WHAT INDIVIDUAL COMMUNITIES ACTUALLY NEED, AND THAT WAS CLEAR FROM THE VERY BEGINNING THAT WE DON'T -- THEY DON'T KNOW THESE COMMUNITIES.

THEY DON'T KNOW WHERE THE NEEDS ARE, AND ARE ABLE -- UNABLE TO DELIVERER IN THAT WAY.

>> YOU SAID THAT THERE WAS ON AVERAGE ONE CARDIOLOGIST FOR EVERY 17,500 PEOPLE, BECAUSE THERE'S ONLY SOME 95 CARDIOLOGISTS ON THE ISLAND.

ARE THESE PREVENTABLE DEATHS THEN, IF WE BASICALLY HAD MORE CARDIOLOGISTS THAT COULD PROVIDE CARE?

>> WELL, AGAIN, I'M NOT A MEDICAL DOCTOR, BUT I THINK SOME OF THE EVIDENCE THAT WE'VE SEEN, THAT POINTS TO THAT SOME OF THESE DEATHS ABSOLUTELY COULD HAVE BEEN PREVENTED WITH MORE PREVENTATIVE CARE AND CONSISTENT FOLLOWUP CARE.

>> YOU ALSO SPENT SOME TIME IN A SMALL TOWN IN THE KIND OF RURAL HIGHLANDS -- CENTRAL HIGHLANDS, AND I WONDER -- THEY HAD A 50% INCREASE IN DEATH COMPARED TO THE YEARS PRIOR.

SO, IS THERE SOMETHING SPECIFIC ABOUT THIS TOWN, THIS LOCATION, IS IT A RURAL PROBLEM?

WHAT HAPPENED?

>> IT'S A RURAL PROBLEM, IT'S A PLACE THAT'S LOST A LOT OF POPULATION, AND SO, WHO ARE LEFT ARE RETIRED AND OLDER INDIVIDUALS WHO ARE LIVING ALONE.

IT'S ALSO A PLACE WITH A REALLY CHALLENGING SORT OF FAR-FLUNG BARIO.

THE NEIGHBORHOODS ARE AT THE TOPS OF MOUNTAINS THAT SURROUND THE VALLEY WHERE THE CENTRAL SQUARE IS.

THEY ALSO LOST ABOUT HALF OF THEIR DOCTORS, SO, PRIMARY CARE PHYSICIANS THAT WERE IN TOWN.

AND WHILE THIS TOWN IS NOT SUPER FAR FROM SAN JUAN, URBAN CENTERS IN PUERTO RICO, IT'S FAR ENOUGH WHERE FOLKS WHO DEPENDED ON BUS SERVICE THAT IS NO LONGER AVAILABLE CAN'T GET TO THESE PLACES UNLESS A FAMILY MEMBER TAKES THEM OR THEY FIND A RIDE FOR SOME OTHER MEANS, AND IN PUERTO RICO, CULTURALLY, TO BURDEN SOMEONE ELSE WITH, YOU KNOW, GIVING THIS FAVOR OF GIVING YOU A RIDE, THAT IS SOMETHING THAT'S FROWNED UPON, PARTICULARLY FROM AN OLDER GENERATION.

>> YOU ALSO SPENT SOME TIME WITH THESE HEALTH BRIGADES THAT WERE OUT THERE TRYING TO GET TO THESE PLACES.

WHAT WAS THAT LIKE?

ARE THEY FRUSTRATED WITH WHAT THEY'RE SEEING?

>> THEY'RE ABSOLUTELY FRUSTRATED.

AND THEY'RE HEARTBROKEN BY SOME OF THE THINGS THAT THEY SEE.

THERE'S A LOT OF POCKETS OF COMMUNITIES ALL ACROSS PUERTO RICO, AND WHEN THE HEALTH PROMOTERS, THESE BRIGADES GO INTO THE COMMUNITIES, THEY FIND ALL KINDS OF PROBLEMS.

THEY'RE HAVING TO, IN THAT MOMENT, PROVIDE DENTAL CARE, PROVIDE, YOU KNOW, TAKE THEIR BLOOD PRESSURE.

AND ONE OF THESE SITUATIONS, WE WERE IN THE CENTRAL MOUNTAINS, WHERE A WOMAN, THEY TOOK HER BLOOD PRESSURE, THE DOCTOR WHO WAS WITH US, AND HER BLOOD PRESSURE WAS ENOUGH TO HAVE PUT HER IN A COMA AND SHE HAD NO IDEA.

SHE WAS JUST SO STRESSED.

THIS IS ALSO A PLACE THAT HAD BEEN HIT HARD BY MARIA.

DIDN'T HAVE ADEQUATE ACCESS TO WATER AND WHERE THE ELECTRICITY WENT OUT CONSISTENTLY.

>> GIVEN THE STATUS OF WHERE HEALTH CARE IS IN PUERTO RICO TODAY, ARE WE LIKELY TO SEE AN EXCESS NUMBER OF DEATHS AGAIN AND AGAIN AND AGAIN?

>> IT'S HARD FOR ME TO PREDICT THE FUTURE, BUT THE TRENDS THAT WE SEE IN THE DATA SUGGEST THAT 2023 WILL ALSO BE A RECORD YEAR OF DEATHS IN PUERTO RICO, AND IT'S UNCLEAR TO ME DEMOGRAPHICALLY WHERE THAT WILL TAKE US IN 2024 OR 2025.

BUT CERTAINLY ISN'T STOPPING NOW, AND, YOU KNOW, MAYBE -- THE GOVERNMENT AUTHORITIES ON THE ISLAND, HEALTH OFFICIALS ARE LOOKING AT COVID AND TRYING TO MITIGATE THE DESTRUCTIVE FORCE THAT COVID HAS BEEN IN PUERTO RICO, 2021 FORWARD, PRETTY MUCH, SO, MAYBE WITH COVID WE'LL SEE THESE NUMBERS NORMALIZE, BUT KEEP IN MIND THAT BEFORE, YOU KNOW, HURRICANE MARIA, THESE NUMBERS WERE PRETTY MUCH ON PAR OR LOWER THAN THE UNITED STATES.

>> SO, IS THERE ANYTHING THAT'S WORKING?

>> THERE ARE SOME MODELS THAT ARE IN PLACE THAT ARE SPECIFIC TO REMOTE COMMUNITIES.

>> THERE'S A GROUP, THEY'RE A BRIGADE, AGAIN, OF HEALTH PROMOTERS, MOSTLY FROM THE COMMUNITIES THAT THEY SERVE, THAT HAVE KEPT, YOU KNOW, GOING CENSUSES AND THEY KNOW WHERE PEOPLE LIVE AND THEY ARE ABLE TO BRING THAT.

BUT THEY DEPEND ON GENEROSITY TO BE ABLE TO SERVE THESE COMMUNITIES, AND THAT ISN'T EXACTLY CONSISTENT.

THERE ARE MODELS, QUALIFIED HEALTH CLINICS HELP WITH BRIDGING SOME OF THOSE GAPS.

BUT WHEN IT COMES TO MAJOR HEALTH ISSUES WHERE YOU NEED HOSPITALIZATION, THAT'S WHERE THE CHALLENGE IS, AND YOU HAVE HOSPITALS THAT ARE RUNNING INTO BANKRUPTCY AND ALL KINDS OF ISSUES IN PUERTO RICO, CLOSING IN COMMUNITIES THAT DESPERATELY NEED THEM.

>> SO, HOW DOES ALL THIS FACTOR INTO KIND OF THE SOVEREIGNTY VERSUS STATEHOOD PERPETUAL CONVERSATION THAT SURROUNDS PUERTO RICO?

>> WELL, IT'S A DIFFICULT QUESTION.

AS I MENTIONED BEFORE, WHEN YOU ASK THE STATE, WHEN YOU ASK PUERTO RICO GOVERNMENT OFFICIALS, THEY'LL TELL YOU, THIS IS ALL A PROBLEM THAT IS COMING FROM ITS POLITICAL STATUS.

THEY BLAME IT ON THE JONES ACT, WHICH IS, YOU KNOW, THIS PROHIBITION, ESSENTIALLY, OF SHIPS WITH GOODS COMING DIRECTLY TO PUERTO RICO.

THEY HAVE TO STOP IN JACKSONVILLE, UNLOAD, PUT THE PER MERCHANDISE ON A SHIP WITH A U.S.

FLAG ON IT.

PUERTO RICO IMPORTS A HUGE AMOUNT OF ITS FOOD, GROCERY FOOD, INCLUDING FRUITS AND INDIVIDUAL TABLES, THAT ARE PRETTY EXPENSIVE WHEN THEY REACH PUERTO RICO.

THEY WOULD TELL YOU THAT THE JONES ACT HAS EVERYTHING TO DO WITH IT.

MEDICAID REIMBURSEMENT INEQUALITY, THE BULK SUM THAT THE FEDERAL GOVERNMENT GIVES TO PUERTO RICO.

A DOCTOR PRACTICING IN PUERTO RICO GETS ABOUT HALF OF THE REIMBURSEMENT, SAY, FOR READING AN X-RAY OR, WHATEVER TREATMENT, GIFTS ABOUT HALF THE REIMBURSEMENT FROM MEDICAID AND MEDICARE THAT A DOCTOR IN THE VIRGIN ISLANDS OR THE UNITED STATES WOULD.

AND THAT IS EXTREMELY FRUSTRATING TO FOLKS ON THE ISLAND.

SO, THERE ARE ASPECTS THAT ARE DIRECTLY TYPED TO POLITICAL STATUS, BUT IT IS DEFINITELY NOT THE WHOLE STORY.

>> WHAT CAN WE TAKE FROM WHAT'S HAPPENING IN PUERTO RICO AND APPLY IT TO WHAT COULD HAPPEN IN THE MAINLAND?

>> PUERTO RICO ONCE HAD A HOSPITAL AND HEALTH CARE SYSTEM THAT WAS THE ENVY OF THE CARIBBEAN.

IT WAS A PUBLIC SYSTEM, AND THE 1990s, THE GOVERNOR MOVED TO PRIVATIZE THAT SYSTEM AND SELL OFF SOME OF THOSE ASSETS, IN AN ATTEMPT TO SORT OF REIN IN SOME OF THE BALLOONING COSTS.

INSTEAD OF IT BEING A COST-SAVING MEASURE, IT TURNED INTO A HUGE ISSUE AND PLUMMETED THE -- THE GOVERNMENT INTO DEBT, IN THE DEBT THEY'RE STILL TRYING TO GET OUT FROM UNDER.

I'VE SEEN REPORTS OUT OF CALIFORNIA THAT SOUND REALLY SIMILAR TO WHAT'S HAPPENING IN PUERTO RICO, THE DECREASING NUMBERS OF SPECIALISTS AND DOCTORS WHO ARE AVAILABLE TO PROVIDE APPOINTMENTS IN A TIMELY MANNER, TO BE ABLE TO CATCH THINGS BEFORE THEY BECOME VERY SERIOUS PROBLEMS.

THERE ARE ISSUES WITH PRIVATE INSURERS THAT ARE, AGAIN, MAKING IT VERY DIFFICULT IN THE RELATIONSHIP BETWEEN DOCTOR AND PATIENT.

THEY'RE MUCH MORE SEVERE IN PUERTO RICO THAN WHAT I'VE SEEN IN THE UNITED STATES.

BUT ALSO JUST THE MODEL TOWARDS HAVING PEOPLE COME TO HEALTH CARE INSTEAD OF HEALTH CARE GOING TO THEM, I THINK, IS SOMETHING THAT IS A MAJOR ISSUE IN PUERTO RICO.

IT MIGHT BE UNIQUE TO PUERTO RICO, BUT I DO THINK THERE ARE PARTS OF THIS COUNTRY WHICH ARE CHALLENGING TOP GRAPHICALLY, WHERE THE POPULATION IS WHERE WE NEED TO THINK ABOUT ALTERNATIVE MODELS FOR HOW WE DELIVER CARE.

>> THANK YOU SO MUCH FOR JOINING US.

>> THANK YOU.