Alongside stigma, a historic lack of adequate funding has also impacted the quality of HIV care on the island.
The Medicaid and CHIP Payment and Access Commission said in a June 2019 report to Congress that a 55% federal medical assistance percentage, the percentage of Medicaid program expenses paid by the federal government, and a capped allotment of funds in Puerto Rico have created what the bloc called “chronic underfunding” of Medicaid on the island. According to the report, Medicaid covered roughly half of the island’s population in 2017.
And according to data provided by the Health Resources and Services Administration, which administers a federal program known as the Ryan White HIV/AIDS Program, the funding provided has stayed relatively consistent on the island.
That consistency, HRSA spokesperson Elizabeth Senerchia said, is partly due to certain Ryan White funding being awarded based on living HIV/AIDS cases and on the federal appropriation, which Senerchia noted doesn’t take healthcare coverage in any jurisdiction into account.
But in light of that “chronic underfunding” of Medicaid services on the island that the Commission described, consistent Ryan White money could still leave a funding gap.
The island has also recently been facing a mass exodus of medical professionals, which leaves Puerto Ricans on the island with fewer and fewer healthcare options. As a specialized population in the medical field, people living with HIV have been seriously impacted by that dwindling number of doctors, said Naiska Guzman, coordinator for San Juan–based HIV clinic Center for Life.
The Puerto Rico College of Physicians and Surgeons told the Congressional Task Force on Economic Growth in Puerto Rico in September 2016 that, at the time, more than 4,000 physicians had left the island in the decade prior, shrinking the number on the island from 14,000 to 10,000.
Of the doctors who haven’t left the island, Guzman also said many have switched to more lucrative specializations or retired.
But as was the case for Diaz León, medical providers can create hurdles of their own. Diaz León said that when his government insurance plan, which he uses to pay for his HIV treatment, had expired, his doctor’s office didn’t tell him that his accompanying private health insurance would not cover his HIV treatment.
He said he was able to use connections in the government to get an appointment to renew his government insurance the following day. Oftentimes, those appointments can take a month or two, he said.
“I have been lucky because I have connections, but then that makes me think about all those people who aren’t as lucky as me or who don’t have the means in terms of time or transportation or information or the connections to fast pace this type of procedure,” Diaz León said.
Natural and Unnatural Disasters
Roughly three years after hurricanes Maria and Irma hit the island, and months after massive earthquakes rocked the southern part of Puerto Rico, experts and the public have said the local government’s response to and readiness for natural disasters is still failing its people.
Helga Maldonado, a regional director of Escape, a nonprofit organization that works to prevent child abuse and domestic violence in Puerto Rico, told BuzzFeed LGBTQ in February that the government hadn’t learned from its mistakes and said the island’s health department was “invisible” in the areas impacted by the January earthquakes.
The response, Maldonado said, was particularly frustrating given the government’s heavily criticized actions following 2017’s deadly hurricanes. Many Puerto Ricans say that it was the community organizations and activists, not government officials, who have been the primary sources of help after the disasters.
“All they’ve done is throw paper towels at us,” Maldonado said, referring to President Donald Trump’s infamous visit to the island after the 2017 storms.
Elaine C. Duke, former acting Homeland Security secretary under Trump, told the New York Times in an interview published in early July that Trump had also brought up selling the colony after the catastrophic storms in 2017. Duke said in the interview that the idea was never seriously considered after Trump had raised it.