“If we are American citizens,” asked Keishla Rodríguez, “Why don’t we have equal rights?” It’s a good question with a sobering answer: Congress is allowed by U.S. federal law to treat territories differently from states.
Keishla’s mother had to leave Puerto Rico to get the health care she needed because healthcare benefits in Puerto Rio are not equal to those in the states. Keishla lives in Puerto Rico and her mother is far from her, in Florida. The inequality of healthcare in Puerto Rico is built into the system. It’s not an oversight — it’s a choice.
One example of the effects of this inequality is coming up yet again: the Medicaid cliff.
What’s a Medicaid cliff?
Medicaid works differently in Puerto Rico from the way it works in the states. Nearly half the residents of Puerto Rico qualify for Medicaid, so it is one of the foundations of the healthcare system. Yet the Medicaid program in Puerto Rico spends just $2,841 per person served in Puerto Rico and $9,090 per person in the states.
What makes the difference?
In a state, the local government pays for the needs of Medicaid recipients as they come up, and the federal government reimburses a percentage of those costs. In Puerto Rico, there is a single block grant. For 2026, it’s $3.645 billion. Iowa, a state with about the same population as Puerto Rico, received about $5 billion last year. Since about 20% of Iowans receive Medicaid, Iowa received more funds for fewer people. And since Iowa’s Medicaid funding is needs-based, not a block grant, the amount they receive can expand when needs are greater.
In Puerto Rico, needs are greater than in Iowa. More Puerto Ricans rely on Medicaid, o Puerto Rico usually runs out of money before the end of the year. The territory government offers fewer services under Medicaid, pays less to doctors, and generally pinches its pennies as much as possible. Yet in most years, there just isn’t enough funding. That’s when the Medicaid cliff comes up.
If Congress won’t provide more funding, Puerto Rico must cut off Medicaid payments or come up with the money locally. This was one of the primary reasons for the crushing debt the Island has been facing. If Congress does provide additional funding, Puerto Rico cannot predict the amount or how quickly it will be available. This makes it impossible to manage efficient long-range planning.
The next Medicaid cliff
Puerto Rico faces another Medicaid cliff in 2027. The current Medicaid block grant and the one allocated for next year are larger than these grants have been in the past. But in September 2027, this funding runs out. If Congress doesn’t take action to provide a solution, Puerto Rico’s block grants could go back to less than $500,000 a year. After many years grappling with an underfunded healthcare system, Puerto Rico could be in desperate straits — with more Puerto Ricans forced to leave the Island in order to receive the healthcare they need.
Currently, Governor Jenniffer Gonzalez-Colon of Puerto Rico and Rep. Pablo Hernandez, the resident commissioner of the Island, are working together to demand changes to the Medicaid program that will end the specter of Medicaid cliffs.
These are the changes they have called for:
- Congress must eliminate the cap on funding
- Puerto Rico should use the same formula as the states to determine the reimbursement percentage
- They should eliminate the exclusion of programs that expand healthcare coverage
- Given the aging population, Congress should also extend long-term care services and support
El Nuevo Dia reports that Congress is unlikely to resolve the upcoming Medicaid cliff this year, leaving it in the lap of the new Congress being elected in this year’s midterm elections. They are also unlikely to pass laws making Puerto Rico equal to the states in the Medicaid program before they close up shop for the year.
In fact, even if they did, the next Congress could change the laws they passed. States have rights and responsibilities under the U.S. Constitution, but Puerto Rico is dependent on Congress. The real solution to the problems that divide families like Keishla’s: statehood.
What can you do?
If you live in a state, you have some power that your friends and family on the Island don’t have. You have senators and congressional representatives you can reach out to. You can vote in the midterm elections and make your voice heard. You can bring a friend with you when you vote, or gather friends to call or write to your legislators.
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