“Un buen comienzo es la mitad del trabajo realizado”

I witnessed a crisis like none other seen in the United States. Destruction of houses, loss of electricity, closure of schools and government facilities. Hospitals flooded, inability to perform emergent surgeries, and a collapse of the primary care system. These events started not with local mismanagement or weather events, but poorly crafted policy decisions that allowed public and medical infrastructure to decay.

Puerto Rico lives in a political gray-zone, where un-enfranchised citizens pay federal taxes and yet do not benefit from the federal investment in health care and infrastructure provided to others in the United States. Puerto Ricans have long accepted a clear agreement with the U.S. federal government. In exchange for partial citizenship, Puerto Ricans historically enjoyed ease of migration to the mainland U.S. and a tax-haven status that stimulated development of technology and pharmaceutical industries. This arrangement – outlined within the Treaty of Paris in 1898, the Jones-Shafroth Act of 1917, and the Insular Cases heard by the federal Supreme Court – was not renewed by the U.S. Congress. Since then Puerto Ricans have been subjected to federal taxes without the inherent rights provided states incorporated within the U.S. This has led to diminishing industrial investment, which in turn allowed stagnation of regional Gross Domestic Product and a loss of municipal funds to support infrastructure investment in health care, roads, and schools.

Additional policy decisions have crippled the health care system. For example, federal Medicaid payments to states are directly linked to per-capita health care spending, allowing safety net hospitals to cover uncompensated care and maintain financial stability irrespective of how many patients they see. However, in Puerto Rico, federal Medicaid spending is capped at 55% of costs, a significantly lower rate than what is found in poor states like Mississippi or even in the District of Columbia. In the face of a growing elderly population and a migration of healthy, working-aged individuals to the mainland U.S., the municipal government has struggled to fill the gap in federal support, leading to low reimbursement for Medicaid services and a migration of talented medical staff from the island.

The Merchant Marine Act, colloquially known as the Jones Act of 1920, was passed to protect the U.S. maritime industry, created additional regulatory barriers to addressing the acute and chronic crises in Puerto Rico. When disaster in Haiti, a deluge of disaster relief followed from all sources, transported by whichever shipping was willing and best positioned to help. However, in Puerto Rico, supplies by law must be transported using American shipping only, debilitating any disaster response that can be garnered by philanthropic parties. Though Trump waived the Jones Act for a short period of time, Puerto Ricans continue to suffer from empty shelves in supermarkets and pharmacies as the shipping industry struggles to meet the demand for basic supplies. Anecdotally, many crisis responders have commented on the relative surplus of supplies seen in the response to crises in Haiti as compared to the current crises in the U.S. territories. These economic barriers will become even stronger, as Republicans in Congress and President Trump have celebrated tax reform policies that will levy additional federal taxes on Puerto Ricans.

Before Hurricane Maria struck, Puerto Rico was in many senses teetering on the brink. A population suffering from elevated rates of diabetes, asthma, high blood pressure, and the associated comorbidities of heart and kidney disease as seen in underserved communities across the United States, but without a federally funded health care safety net for support.

Economic migration to the mainland of young and talented individuals. Infrastructure suffering from lack of investment. Add to this one of the strongest hurricanes seen in a decade passing directly over the island, devastating roads, destroying houses, and removing access to potable drinking water and electricity.

People continue to ask how this can happen. How can an island that has contributed more soldiers per capita to every American war than any state and pays federal taxes without political representation continue to suffer needlessly? All due to political decisions made over 100 years ago and a lack of political will to make reforms today.

Solutions will require significant involvement from federal institutions with an eye not on 1-year or 3-year goals, but on the long-term stability and prosperity of Puerto Rico. Restructuring debt and balancing the budget will only provide short-term relief. Regulatory solutions that stimulate business investment, strengthen the primary care network, and create a positive environment for people to live and thrive are necessary. With these reforms and assistance from municipal leadership Puerto Rico can thrive. It can return to its place as both a tourist attraction and economic stronghold of the Americas.