Policy options to cover the uninsured population in Puerto Rico

Background: The goal of this project was to acquire the information needed to shape state policies that will assure access to health insurance for all residents of Puerto Rico (PR). Although PR does not have a large number of people without health insurance (7-9%), the uninsured present serious healthcare and social justice issues. The PR Health Reform Program (“Reforma”), created in 1993, is a government sponsored health insurance program for the medically indigent. Approximately 1.6 million persons or 40% of the population are enrolled in Reforma. A growing concern is that accesses to services, regulations and service structure of the Reforma program, and affordable private coverage for the employed, are major factors influencing lack of coverage, particularly for documented/non documented immigrants from the Caribbean countries. The University of PR School of Medicine conducted the study under contract with the PR Department of Health and with technical support from the University of Minnesota. HRSA State Planning Grants (SPG) funded the study.

Methods: We used a three phase strategy to estimate the characteristics of the uninsured population and delineate policy proposals. First, we reviewed the existing data related to health insurance coverage on the island and analyzed areas of agreement and disagreement. Next, we extracted data from the US Census, CDC-BRFSS and the Puerto Rican Household Survey for an analysis of employment status, income, demographics, and health insurance coverage. Finally, we conducted 13 focus group discussions with providers, administrators and key informants. During the study process we shared findings with the appointed SPG Advisory Committee gathering their recommendations for the final report.

Results: We proposed five policy options summarized as follows: (1) Re-engineer Reforma; (2) Create incentives for employers with over ten employees; (3) Allow employers with less than ten employees to enroll their employees in Reforma; (4) Create an individual tax credit for health insurance; (5) Create a State funded small grants program for Community Based Organization willing to provide primary care for immigrants and homeless persons. Re-engineer Reforma was the most viable option.

Conclusions: We explored and then discarded several alternatives for the provision of health care coverage for the uninsured because they placed these populations in a second class status. Issues to consider in designing health coverage for the uninsured include: group diversity, reasons for being uninsured, health insurance market, method/amount of payment to providers, financial feasibility, and support from individuals/families, providers, employers and legislators.