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The Health 202: Puerto Rico's problems include a Medicaid shortfall


with Paulina Firozi


Puerto Rico, despite President Trump's not-so-bleak assessment during his visit yesterday, was wrecked by Hurricane Maria. But there could be a silver lining for the U.S. territory as it seeks to emerge from the wreckage: a renewed focus from Congress on the health-care funding cliff it faces later this year.

Maria inflicted widespread devastation on Puerto Rico, resulting in billions of dollars of damage that will take years to clean up. The territory was struggling with a massive government debt crisis and a languishing economy even before it was hit by the 10th-most-intense Atlantic hurricane on record.

When Trump visited the island Tuesday, nearly two weeks after the storm, 93 percent of Puerto Ricans remained without power. More than 88 percent of the territory’s cellphone towers are out of service. A large part of the island is without clean drinking water. 

But there are a couple of numbers with which many lawmakers might not be familiar: Nearly half of all Puerto Ricans participate in Medicaid, the federal health-care program for low-income Americans — and the island doesn't receive the same amount of money as U.S. states to help keep it flush. Puerto Rico got some additional funding under the Affordable Care Act, but that is expected to run out by the end of this year or the start of 2018. If it's not replaced, the island could be forced to kick half a million people off Medicaid, officials there have said.

The White House will soon propose a $30 billion aid package, including $12.77 billion in disaster relief for Hurricanes Maria, Harvey and Irma (the latter two hit Texas and Florida).

“Building political support for such a plan may be tricky, given that both territories have only nonvoting House members — a Democrat from the Virgin Islands and a Republican from Puerto Rico. And yet, Puerto Rico especially has a network of lawmakers in both parties who either were born on the island, own property there, or represent districts or states with large Puerto Rican voting blocs,” my colleagues Damian Paletta, Mike DeBonis and Ed O'Keefe report.

Yesterday, No. 2 Senate Republican John Cornyn (R-Tex.) said he expects Congress to take up a hurricane recovery bill this month.

"I expect there will be one combination package that will involve Harvey, Irma and Maria,” Cornyn told reporters.

But some lawmakers are also pushing to assist Puerto Rico with its Medicaid cliff by sending more health-care dollars its way for the next two years. Rep. Greg Walden (R-Ore.), chairman of the Energy and Commerce Committee, wants to try tacking some Medicaid funding onto a must-pass bill funding the Children's Health Insurance Program.

Today Walden’s panel will mark up legislation to fund for five years the the federal program that covers about 9 million low-income kids, known as CHIP. Republicans on the panel want to include $1 billion more for Puerto Rico’s Medicaid program over a two-year span, a sum that would ramp up its future Medicaid funding by nearly 50 percent.

Another panel with a big say over health care, the Senate Finance Committee, also meets today to consider a similar measure to fund CHIP, but it doesn’t propose funding for Puerto Rico.

Yet the island's health-care funding shortage has serious consequences given the number of Medicaid enrollees and its financial instability. 

Under a long-standing policy, the territory gets far fewer federal dollars for the program compared with U.S. states. The federal government covers 57 percent of state Medicaid programs, on average. Were Puerto Rico treated the same way, it would get enough federal funding to cover 83 percent of costs, according to an estimate by the Center on Budget and Policy Priorities. Instead, the feds pay Puerto Rico only 15 to 20 percent because of a cap on total Medicaid funding for U.S. territories, whose residents don't pay federal income taxes.

“The question now is ... is it appropriate to be treating U.S. citizens in the territories in a different way than U.S. citizens are treated in the states?" Krista Perreira, a health economist at the University of North Carolina, told me.

The Affordable Care Act provides Puerto Rico with a significant infusion of money — about $1.2 billion a year. But officials say those funds will run out at the end of this year or the beginning of 2018, likely forcing big rollbacks in the program if replacement funds aren’t found.

Trump has continued to play down the damage in Puerto Rico while singing the praises of his administration’s response to it. Although the administration did earn kudos for its response efforts in Texas and Florida, critics have slammed it for a slower response to Puerto Rico’s crisis.

In his visit there yesterday, the president told Puerto Rico officials they should feel “very proud” they haven’t lost thousands of lives in “a catastrophe like Katrina” (a reference to the 2005 storm that blasted New Orleans), while adding that Puerto Rico's needs have thrown the federal budget “a little out of whack.”

“Every death is a horror, but if you look at a real catastrophe like Katrina, and you look at the tremendous — hundreds and hundreds and hundreds of people that died, and you look at what happened here, with really a storm that was just totally overpowering, nobody’s ever seen anything like this,” Trump said, before turning to a local official to ask how many people had died.

“What is your death count as of this moment?” Trump asked. “Seventeen? 16 people certified, 16 people versus in the thousands.”

Hear Trump’s comments:

President Trump praises Puerto Rico Gov. Ricardo Rosselló and Puerto Rico’s nonvoting representative Jenniffer González-Colón (R) for their hurricane response. (Video: Reuters)

Top Senate Democrat Chuck Schumer (N.Y.) jumped on Trump's remarks.

“Mr. President, enough,” Schumer told reporters yesterday. “Stop blaming Puerto Rico for the storm that devastated their shores, and roll up your sleeves and get the recovery on track. That’s your job as president.”

Senate Minority Leader Charles E. Schumer (D-N.Y.) blasts President Trump for saying that Puerto Rico has “thrown our budget a little out of whack.” (Video: The Washington Post)

Trump kept at it in a tweet this morning:

Several other Democrats took the chance to advocate for lifting Puerto Rico's Medicaid funding cap -- and noted that it's an illustration of how block-granting the program means states couldn't get extra Medicaid funding just when they most need it.

Sen. Chris Murphy (D-Conn.): 

Obama's former administrator for the Centers for Medicare and Medicaid Services:

Recently ousted CEO of Molina Healthcare, J. Mario Molina:

This video shot by a tourist in January 2016 apparently shows the inside of room 32-135 of the Mandalay Bay hotel in Las Vegas. (Video: Jeff Bridges/Facebook)

-- LAS VEGAS SHOOTING UPDATE: Investigators are still trying to determine a motive behind the deadliest mass shooting in modern United States history. But on Tuesday, new details emerged about the meticulous plan that 64-year-old Stephen Paddock created before killing at least 59 people at a country music festival in Las Vegas.

Paddock fired for 9 to 11 minutes from his suite on the 32nd floor of the Mandalay Bay Resort and Casino. He used video cameras around the room to keep an eye out for police. Authorities with the Bureau of Alcohol, Tobacco, Firearms and Explosives said Tuesday that 12 of the guns recovered from his room had “bump fire” stocks, which enable semi-automatic weapons to fire almost as fast as fully automatic weapons. Prior to the shooting, Paddock wired $100,000 to someone in the Philippines. Clark County Sheriff Joe Lombardo said the shooting was “preplanned, extensively, and I’m pretty sure that he evaluated everything that he did in his actions, which is troublesome.”

The Post’s Matt Zapotosky, Devlin Barett and Mark Berman note that while some public officials have suggested that Paddock was likely troubled, there were no immediate indications that he suffered from a mental illness or that he was not aware of his actions. The shooter’s girlfriend Marilou Danley arrived in the United States from the Philippines late Tuesday and was met at the airport by FBI agents. Investigators consider her a “person of interest” and hope, at the very least, she can shed light on Paddock's life.

As of Tuesday afternoon, authorities were able to identify all but three of the victims of the shooting. And here’s an updated look at what we know about the lives lost in Las Vegas.


AHH: People who don’t get vaccinated are the most likely reason for the steady increase in the rate of measles and major outbreaks in the United States, a new study in JAMA finds.

The findings "add to the body of evidence linking failure to vaccinate with the spread of the highly infectious and potentially fatal disease," The Post's Lena Sun reports. "Once common in the United States, measles was eliminated nationally in 2000 but has made a return in recent years largely because of people who reject vaccinating their children...Most of those cases occur when the disease is brought into the country by unvaccinated people who get infected in other countries, where measles may remain endemic."

Researchers from the CDC analyzed 1,789 measles cases from January 2001 through December 2015. They found that nearly 70 percent, or 1,243 individuals, were unvaccinated. Babies and toddlers had the least protection. Of 163 infants ages 6 to 11 months who became sick, only two had been vaccinated. Among 106 toddlers ages 12 to 15 months, 95 were unvaccinated.

OOF: More testimony emerged yesterday about how Sen. Bob Menendez (D-N.J.) allegedly fought for the business and personal interests of his friend and supporter, Florida ophthalmologist Salomon Melgen. Appearing at his ongoing corruption trial in New York, former HHS Secetary Kathleen Sebelius said Menendez asked her for help in changing a Medicare billing policy that cost Melgen millions of dollars.

Sebelius recounted the events leading up to an August 2012 meeting with Menendez and then-Senate Majority Leader Harry Reid (D-Nev.) at Reid’s office, saying she didn't know exactly what he wanted. After meeting for about 30 minutes, Sebelius declined to take action, explaining that she thought the policy was consistent and clear and in keeping with safety protocols.

"Menendez’s intervention in the Medicare issue is a key prong in the government’s case," The Post's Alan Maimon writes. "The senator is accused of fighting for Melgen’s business and personal interests in exchange for political donations, trips on Melgen’s private plane and other gifts. Sebelius testified that she turned down an earlier request from Menendez to meet about the issue and didn’t agree to talk to him until Melgen’s appeal of the case was no longer before her agency."

OUCH: We already knew that Rep. Tim Murphy of Pennsylvania, who touts himself as a conservative Republican, had engaged in an extramarital affair. But it gets worse. The Pittsburgh Post-Gazette is reporting that text messages sent to Murphy indicate he told his mistress to get an abortion when they had a pregnancy scare.

"That's especially problematic because Murphy is supposed to be an antiabortion congressman," The Post's Aaron Blake writes. "He's got nearly a flawless voting record, as far as groups like the Family Research Council are concerned. And in fact, it was his promotion of that position that led to the fateful exchange with his mistress, Shannon Edwards."

In a January text to Murphy, Edwards took him to task for an antiabortion statement posted on Facebook from his office's public account. “And you have zero issue posting your pro-life stance all over the place when you had no issue asking me to abort our unborn child just last week when we thought that was one of the options,” she wrote.

A text from Murphy’s cellphone number the same day says: “I get what you say about my March for life messages. I've never written them. Staff does them. I read them and winced. I told staff don't write any more. I will.”


--As investigators fill in the details of Paddock’s Sunday rampage, doctors, nurses and paramedics are recounting injuries they say are rarely seen in this country. And even the hardiest medical professionals acknowledged being rattled, The Post's Tim Craig, Felicia Mello and Lena H. Sun report.

"With Paddock perched on the 32nd floor of the Mandalay Bay Resort and Casino and firing military-style rifles onto the crowd of concertgoers below, the scale and degree of physical damage were extreme," they write. "So many patients poured into the city’s hospitals that pediatric surgeons were operating on adults and obstetricians were attending to trauma patients."

--Many of the most critically wounded patients arrived at the 541-bed University Medical Center of Southern Nevada, the state’s only Level One trauma center. Over about four hours, it received 104 patients. More than 80 percent were gunshot victims. Douglas Fraser, the hospital’s chief of trauma surgery, struggled with other doctors there to deal with bullet wounds in torsos and limbs that had shredded human flesh into “unusual patterns,” caused “extreme fractures” and bounced through bodies with horrific force.

“These were quite large wounds that we saw,” he said Tuesday. “The fractured shrapnel created a different pattern and really injured bone and soft tissue very readily. This was not a normal pattern of injuries.” 

--Long after the dead have been buried and the wounded have returned home, psychological distress from the shooting will linger. The question is whether Las Vegas specifically, and Nevada generally, will be able to meet the need in the weeks, months and even years to come, The Post's Amy Ellis Nutt writes.

Consider this: Nevada ranks 51st among all states and the District of Columbia in mental-health resources and access to treatment; 90 percent of severely depressed youths in the state received no treatment or inadequate treatment last year; 16 of Nevada's 17 counties were listed by the federal government as mental-health-professional-shortage areas.

Watch doctors and nurses describe what they saw after the shooting: 

Doctors and nurses describe the chaos on the night of the shooting as casualties were brought into Sunrise Hospital in Las Vegas (Video: Jorge Ribas, Dalton Bennett/The Washington Post, Photo: Salwan Georges/The Washington Post)

--Yesterday the GOP-led House approved a bill banning most abortions after 20 weeks of pregnancy, advancing a key Republican priority for the third time in the past four years -- but now with a supportive Republican in the White House. Known as the "Pain-Capable Unborn Child Protection Act," it provides for abortions after 20 weeks gestation only when they are necessary to save the life of the mother or in cases of rape or incest.

It's not expected to emerge from the Senate, where most Democrats and a handful of moderate Republicans can block the measure. But abortion opponents still cheered on the vote, which they view as incremental progress toward eventually making such a ban law.

“It’s past time for Congress to pass a nationwide law protecting unborn children from the unspeakable cruelty of late-term abortion,” said Marjorie Dannenfelser, president of the antiabortion Susan B. Anthony List, who'd extracted a written promise from Trump during the campaign to sign such a law should he get the opportunity.

Some more reads from The Post and beyond:

Veterans Affairs inspector general is reviewing David Shulkin's Europe trip (CBS News)


Why Price’s conservative imprint on HHS is likely to endure (Politico)

Ryan asked White House to reconsider ousting Price (Politico)

Ron Johnson, John Barrasso say they're not in the running for Tom Price's job (Washington Examiner)


Medicare officially kills controversial drug payment model (Axios)


States Gird for Worst as Congress Wrestles with Children’s Insurance Program (New York Times)



  • The S&P Global Ratings’ Health Care Conference.

  • The Brookings Institution holds an event on 21st century medicine.

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the federal response to the opioid crisis on Thursday.


President Trump’s visit to Puerto Rico, in two minutes:

President Trump tells Puerto Rican officials they should be “very proud” that hundreds didn’t die from Hurricane Maria as in a “real catastrophe like Katrina.” (Video: Bastien Inzaurralde/The Washington Post)

Trump says Puerto Rican leaders are ’totally unable’ to handle disaster:

On Sept. 29, President Trump said that "the government of Puerto Rico will have to work with us to determine how this massive rebuilding effort…will be funded." (Video: The Washington Post)

The United States will expel 15 Cuban diplomats amid concerns over mystery illnesses:

U.S. to slash embassy staff in Cuba, warns not to travel there (Video: The Washington Post)

Las Vegas police say gunman fired for 9 to 11 minutes:

Authorities tell reporters that the gunman who killed at least 58 people in Las Vegas fired for around nine to 11 minutes. (Video: Reuters)

Food truck cooks free meals for hospital staff in Las Vegas:

Las Vegas-based food truck Dragon Grille parked outside Desert Spring Hospital on Oct. 2, cooking free meals for medical staff. (Video: Dragon Grille/Facebook)

Watch Stephen Colbert's take on Trump's visit to Puerto Rico: 

Jimmy Kimmel says it's not too soon to talk about gun violence: