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U.S. Territory Hospitals Have Higher Death Rates, Less Federal Funding

The views expressed are those of the author and are not necessarily those of Scientific American.


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us territory hospital death rate worse than statesIt’s no secret that health care in the U.S. is not as good as that in many other developed countries. And a new report finds that hospitals in U.S. territories—including Puerto Rico, Guam, the U.S. Virgin Islands and the Northern Mariana Islands—are even further behind. "Virtually all of the territorial hospitals performed below the U.S. national averages," noted the authors of the study.

To assess the quality of hospital care in U.S. territories, a team of researchers tabulated patients’ risk of dying or being readmitted a month after being hospitalized for cardiac arrest, heart failure or pneumonia between 2005 and 2008. All rates were "significantly higher" (except for readmission proceeding heart failure) in territories versus in states, according to the report.

"Despite a national commitment to eliminate health disparities, the territories are largely absent in national reports of health care equity and quality," pointed out the authors of the new report, which was published online June 27 in Archives of Internal Medicine and was led by Marcella Nunez-Smith, an assistant professor of general medicine at Yale School of Medicine.

Previously, territory-wide health statistics have been difficult to come by. "I applaud Nunez-Smith and colleagues for embarking on an effort to assess the quality of care in the U.S. territories despite limited data," Nilsa Gutierrez, of the Centers for Medicare & Medicaid in New York City, wrote in an essay also published online by Archives of Internal Medicine.

For the study, the Nunez-Smith and her colleagues compared the records of Medicare patients visiting 57 hospitals in various U.S. territories with those from 4,799 hospitals in the 50 states and District of Columbia. They found, for example, that patients admitted to a territory hospital for pneumonia had a 14.9 percent chance of dying within a month, whereas in the states, that chance was 11.4 percent. And for every 100 heart attack hospital admissions, two more people die in the territories than in the states (18.8 percent risk of dying within a month in the territories versus 16 percent stateside).

"Eliminating the substantial quality gap in the U.S. territories should be a national priority," the researchers asserted in their report. But improving care for the nearly 5 million people who live in the territories likely means adjustment of the way federal funds are distributed.

U.S. states receive federal Medicare and Medicaid funds to help them cover residents who need it. Territories get this government aid, too, but policy has limited it to 50 percent of territory contribution—and places a cap on the overall dollar amount given to each territory. For territories, this "makes it unfeasible to cover all eligibility groups and Medicaid services as required of states," said Gutierrez, who calls the impact of these caps "considerable."

For example: Of Puerto Rico‘s four million residents, Medicaid programs cover about 900,000—about the same number as in New Jersey. In 2008 the federal government gave New Jersey about $4.5 billion to cover its Medicaid recipients; Puerto Rico got $26 million, Gutierrez noted. And across all of the territories, in 2003 the federal government chipped in 44 percent of an average stateside Medicare enrollee’s benefits for each enrollee in the territories ($6,300 versus $2,800, respectively)—even though shipping costs there often make medical treatments pricey for the providers.

There is some hope for improvement, however. The American Recovery and Reinvestment Act boosted funding of U.S. territorial Medicaid, and starting July 1, federal Medicaid contributions will increase from 50 to 55 percent, courtesy of the Affordable Care Act.

But the medical systems in U.S. territories will likely need more than just financial assistance. American Samoa, for example, has just four registered doctors who qualify as physicians able to bill independently for Medicare services—and they also have to sign off on all Medicare work done by the territory’s other docs.

Going forward, the report authors concluded, "the nation has a great responsibility to guarantee that residents on these islands have access to care that is at least of the same quality as care in the U.S. states"

Image courtesy of iStockphoto/plherrera





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  1. 1. ScienceisNotOpinion 3:18 pm 06/28/2011

    People that don’t pay Federal Taxes are receiving less Federal Funding?! How appalling! But seriously, with only a couple of percentage points off for all the conditions, perhaps we should determine the ROI on the Billions of dollars spent to save 2% more people, it would seem a strong majority of it is being wasted.

    Link to this
  2. 2. courtburg1 6:38 pm 06/28/2011

    True, it should not surprise anyone that the U.S. Citizens in the territories, who are not permitted to contribute equally, have to be subjected to less and lower quality health care benefits. It is a question of distribution of limited resources and it would just be plain unfair if they shared equally in funding, if they do not contribute in proportion, the thinking goes. In Puerto Rico US Citizens don’t pay taxes in revenue generated locally, they DO pay federal taxes on revenue generated in the states, even if they live in the Island. However, uncle Sam should not turn a blind eye to the Thousands of vets that made the Island their home after serving in our wars, uncle Sam should not turn a blind eye on those Millions (not thousands, Millions) of Puerto Ricans who if the government provided a federally sponsored plebiscite would vote for statehood today, with all its benefits and RESPONSIBILITIES. Members of Congress do not want to fund or engage in a serious consultation process, (federally funded periodic plebiscites, not the local every decade or so unofficial circus)for fear of receiving a formal request for Statehood. It is a reality that members of Congress approaches all issues that concern the territories with a "reservation" mentality. The problem is not scientific, it’s political. The Island happens to be a pharmaceutical manufacturing paradise. (because of sect. 901 of the Internal Revenue code, profits earned by controlled foreign corporations — essentially, subsidiaries of U.S. companies operating outside the U.S. — are exempt from federal income tax until they are repatriated to the U.S.) CHA CHING!
    The pharma industry would have to pay billions in federal taxes (equal footing doctrine would prohibit favorite treatment of corporations in the Island by the fed, if it were a State) if the Island were to petition for Statehood and if Congress approved the petition. All federal special treatment of the pharma industry in PR and federal excemptions would eventually end. Anyone willing to take on the most powerfull lobby in existence in Washington today and try to fight for equality for Puerto Ricans! Anyone want to take on the pharma industry establishment and take PR away from them? No champions? No takers? I did not think so! It is just easier to keep promoting all sorts of stereotypes and just kick the can down the road. The title of the article should be: "Puerto Rico and the Pharma Plutocracy" Ay Bendito!

    Link to this
  3. 3. courtburg1 6:42 pm 06/28/2011

    True, it should not surprise anyone that the U.S. Citizens in the territories, who are not permitted to contribute equally, have to be subjected to less and lower quality health care benefits. It is a question of distribution of limited resources and it would just be plain unfair if they shared equally in funding, if they do not contribute in proportion, the thinking goes. In Puerto Rico US Citizens don’t pay taxes in revenue generated locally, they DO pay federal taxes on revenue generated in the states, even if they live in the Island. However, uncle Sam should not turn a blind eye to the Thousands of vets that made the Island their home after serving in our wars, uncle Sam should not turn a blind eye on those Millions (not thousands, Millions) of Puerto Ricans who if the government provided a federally sponsored plebiscite would vote for statehood today, with all its benefits and RESPONSIBILITIES. Members of Congress do not want to fund or engage in a serious consultation process, (federally funded periodic plebiscites, not the local every decade or so unofficial circus)for fear of receiving a formal request for Statehood. It is a reality that members of Congress approaches all issues that concern the territories with a "reservation" mentality. The problem is not scientific, it’s political. The Island happens to be a pharmaceutical manufacturing paradise. (because of sect. 901 of the Internal Revenue code, profits earned by controlled foreign corporations — essentially, subsidiaries of U.S. companies operating outside the U.S. — are exempt from federal income tax until they are repatriated to the U.S.) CHA CHING!
    The pharma industry would have to pay billions in federal taxes (equal footing doctrine would prohibit favorite treatment of corporations in the Island by the fed, if it were a State) if the Island were to petition for Statehood and if Congress approved the petition. All federal special treatment of the pharma industry in PR and federal excemptions would eventually end. Anyone willing to take on the most powerfull lobby in existence in Washington today and try to fight for equality for Puerto Ricans! Anyone want to take on the pharma industry establishment and take PR away from them? No champions? No takers? I did not think so! It is just easier to keep promoting all sorts of stereotypes and just kick the can down the road. The title of the article should be: "Puerto Rico and the Pharma Plutocracy" Ay Bendito!

    Link to this

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