Although President Joe Biden included it in his budget bill and Democrats control both houses, the road is not clear.
Having learned of the Joe Biden administration's intention to grant parity to Puerto Rico and the other territories in Medicaid funding, the island's healthcare industry is preparing to ensure that the intention is realized through one of the possible congressional vehicles and recognizing the obstacles that may arise between now and October 1, when fiscal year 2022 begins.
The most realistic path, agreed several of the people consulted by Metro, would be through the budget reconciliation process, which, although it has certain limitations, allows passing measures with a simple majority in both chambers, instead of requiring 60 votes in the Senate, where both Republicans and Democrats have 50 legislators.
"There are different ways, such as through a law (that eliminates the caps to which the territories are subject), but the law has the problem that it needs 60 votes in the Senate, and that is practically impossible," said Jaime Plá, executive president of the Hospital Association and part of the Multisectoral Health Group formed by Governor Pedro Pierluisi to promote the issue in Washington D.C.
Puerto Rico, by law, receives a maximum allocation of $390 million from Medicaid, as well as a federal match (FMAP) of 55% on services provided under the coverage. However, since the passage of Obamacare, and later emergency allocations for Hurricane Maria and the COVID-19 pandemic, federal funds have covered much of the services under the government health plan, currently known as Vital.
The last block allocation, approved in 2019, granted some $5.7 billion for the past two years, but those funds expire at the end of the current fiscal year, so Puerto Rico would face the so-called "cliff" in which it would revert to funding similar to what it received in the 2000s.
A Department of Health report submitted last April 30 to Congress estimates that, if action is not taken between now and October, as many as 600,000 people could lose Vital Plan coverage, including 200,000 who received it for the first time this fiscal year through funds included in the appropriation that was approved in 2019.
The report details that, as of fiscal year 2018, 1,505,610 people relied on government health coverage.
The resident commissioner Jenniffer Gonzalez recalled that Biden's proposal does not specify language for full access to Medicaid for the territories, but noted that she, along with other congressmen, has already introduced bills with specific language to close disparities.
Federal affairs consultant Federico de Jesus believes that Democrats, with weak majorities in both congressional bodies, will not present, in principle, major objections to pushing President Biden's parity proposal. However, if the budget reconciliation route is chosen, such parity will have to compete with other initiatives that also require important investments from the federal government.
"Reconciliation has more of an infrastructure focus, and although it has the American Families Plan component, several tax credit initiatives for families and children, there are a lot of initiatives and that is going to cost a lot and there will be a lot of pressure for several senators and congressmen who want to include initiatives like these and others that are praiseworthy. There is going to be competition for that," said the analyst, who pointed out that this is the first time that a president has included among his budget priorities full access for Puerto Rico to Medicaid benefits.
De Jesús suggested that, through reconciliation, the permanent laws that establish the appropriations and FMAP caps could be amended. However, this would require finding a way to offset the additional cost it represents, since congressional rules do not allow approval of expenditures that would increase the fiscal deficit beyond a 10-year period.
"The biggest challenge is time. We have until September. In the two previous years we had to extend the current budget and that delayed everything. In this case, they (the Democrats) have the House and Senate and the White House, so there should be no problem to pass these measures in the House and Senate before August. That is why these months of June and July are vital for the approval of these measures," said the resident commissioner.
In Plá's opinion, even obtaining parity for a 10-year period would provide the healthcare industry with a stability that it has historically lacked.
"It gives us the opportunity to cement our processes. After 10 years, it's very difficult for that to go backwards," said the Hospital Association leader.
The Pierluisi administration estimates that, if parity is achieved for the next fiscal year, which would imply a federal match of 83% in services, Puerto Rico could have access to between $5 billion and $5.2 billion, depending on the eligibility requirements established by federal authorities.
Under current appropriations of approximately $2.85 billion, the federal government bears 76% of the cost.
"There are services that (could) be offered that are not offered now. Pay part D of Medicare (medications), for example. Plus increasing the payment of providers," said the president of the College of Physicians, Victor Ramos, who also belongs to the Multisectoral Group.
Plá, for his part, indicated that already in the next few weeks the Multisectoral Group, which is co-chaired by Health Secretary Carlos Mellado and Federal Affairs Administration Director Carmen Feliciano, could intensify its efforts before Congress. "They are working on a document that everyone is going to use to speak in the same language," Plá stressed.