Health care in the US’ biggest colony

Healthcare in the US, Midwifery students, Reflections on racism and oppression in midwifery

By Tamara Trinidad-Gonzalez, Student Midwife

First, I must confess that making this post has taken longer in time and energy than I had anticipated. Writing about this subject and all its layers is a huge trigger of all the frustrations that living in a colony entails.  Pointing out one preexisting factor of why the care system in Puerto Rico has been so inefficient is not that easy as there is no such thing as one factor. This is more a cascade of effects, in fact, a very complex one than an isolated situation. I will try my best to explain it.

All this inefficiency goes back to the origins of our colonial politic situation (starting in 1898), which opens the biggest gate for Puerto Rico to not being treated equal as the other US territories and jurisdictions. In addition to this, the predominant political corruption for decades, have been a fertile ground to make this a major disaster. You may have heard already through the media that there is a huge, and unfair $73 billion debt that Puerto Ricans are being blamed for. Economists keep studying this socio-economic issue and it is evident that the colonial control over the economy of Puerto Rico has contributed to create this crisis. This crisis is affecting the daily quality of lives of Puerto Rican’s especially when it comes to educations and health. Alvarez and Goodnough (2015) emphasize that the disparity of federal fund is responsible for $25 billion of the total debt because the government of Puerto Rico was forced to borrow money to be able to keep the Medicaid program running. They also explain in this article that the misery of Puerto Rico’s health care began in the late 60’s with the initiation of the Managed Care health system and the Medicaid Cap placed by the U.S. Congress for all of its territories. The managed care health system in Puerto Rico has proven to be very ineffective for decades. This type of health care plan only works in favor of the insurance companies and not to benefit the people nor the health care providers.

There is a huge disparity of federal funding available for Puerto Rico in comparison to what is available to the rest of the US jurisdictions and territories.  The federal funding and commonwealth funding need to be equally paired, but the Commonwealth pocket does not have the capacity to pair sufficient amounts so, substantially less amounts of funding are given to Puerto Rico. The problem is that in Puerto Rico, more than 60% of its residents (which used to be 3.5 million people before Hurricane Maria), receive Medicare or Medicaid. Thus, the funding allocated is just not enough to properly care for the health of people. Alvarez and Goodnoug (2015) make a comparison of how much funding is given to two other states equal in population, but wealthier than Puerto Rico, and I created this table to see it better.

State/ Jurisdiction Population Medicaid funding/year
Puerto Rico 3.5 million $373 million
Oklahoma 3.49 million $3 billion
Mississippi 3 million $3.6 billion

Because of this situation, we (Puerto Ricans) grow accustomed to hearing of doctors leaving the island motivated for better income and work conditions. There are great physicians in Puerto Rico (PR), so they are being offered an income that is 3 or 4 times what they are earning, with moving expenses covered, health insurance, vacations and even with their liability insurance paid. To have a clearer idea of the magnitude of this problem, an article from 2016, a year before hurricane Maria, was already revealing the dangerous migration of Puerto Rican physicians to the mainland. From 2006 to 2016, around 5,000 physicians had stopped working in PR. By the summer of 2016, there were only 9,000 physicians with active licenses. And with a population of 3.5 million people, this meant having like 5 doctors for every 2,000 people. The chaos that this causes in the daily lives of Puerto Ricans is very present and evident.  Some examples of this is when patients must wait many months to have an appointment with a specialist, or when someone that is sick, does not get treated for something simple, and then dies; or when there is an urge for a treatment and people opt to travel to the US to get the needed treatment.

If this already sounded like a shortage and terrible health conditions, after hurricane Maria, a massive amount doctors left the island, abandoned their practices and their patients and many hospitals closed. This includes OBs which left many women without adequate prenatal care. Although the midwives stepped in to help as they could, they lack the resources to help everyone as they would like and deserve.

In conclusion, although we pay the same Medicare and Social Security taxes as the rest of the US, we are not treated equally. All this produces an unbalanced health system that is not fair for the people nor for the health providers that are compromising their humanity and their Hippocratic Oath.


Alvarez, L. & Goodnough, A. (2015). Puerto Ricans Brace for Crisis in Health Care. Accessed online at

Bodenheimer, T. & Grumbach, K. (2012). Understanding Health Policy: A Clinical Approach, 6th Edition. McGraw-Hill, New York, NY.

GFR Media (2016). Peligrosa fuga de miles de médicos. Retrieved from

Written by Tamara Trinidad-Gonzalez, Student Midwife at Bastyr University originally for a class in the Professional Issues series: Health Care Systems and Health Policy

Racial Disparities Persist

Healthcare in the US, Reflections on racism and oppression in midwifery

Despite the national Healthy People objectives established every ten years for the last three decades by the Office of Disease Prevention and Health Promotion, maternal and infant health indicators in this country continue to demonstrate a significant need for improvement, particularly among racial and ethnic minorities (Mathews & MacDorman, 2006).  In their call to action to the public health profession, Garcia and Sharif (2015) commented that “the health consequences of living in a racially stratified society are illustrated by a myriad of health outcomes that systematically occur along racial lines, such as disproportionately higher rates of infant mortality” (p. e28).

Two areas of concern, in particular, have been identified as leading health indicators with regard to maternal and infant health in the US: all infant deaths and total preterm live births.  These two health indicators, in addition to many others, provide clear examples of the health disparities faced by people of color in the US.  The rate of infant deaths (within the first year of life) is more than doubled for black or African American babies when compared to white infants (10.8 per 1,000 vs 5.1 per 1,000 in 2013).  Infants of persons identified as American Indian or Alaska Native are also disproportionately affected (7.6 deaths/1,000 live births in 2013) (Mathews & MacDorman, 2006).  While overall infant deaths have been decreasing, the health care disparities outlined above have persisted since at least 2006, the earliest year analysis by race/ethnicity is provided publicly by  Preterm birth rates (before 37 completed weeks gestation) are also consistently found to be higher for mothers who are black or African American (16.0%), American Indian or Alaska Native (13.1%), and Hispanic or Latina (11.3%) when compared to white mothers (10.5%) in the US  (data from 2013).  While the causes of health care disparities and inequities are multifactorial, racial disparities are a well-documented factor.

NOTE: The phrase ‘maternal and infant health’ is used above due to its widespread use and recognition in public health literature.  The use of this phrase is not intended to exclude or ignore the health issues faced by transgender and genderqueer persons who may not identify as mothers.


García, J., & Sharif, M. Z. (2015). Black Lives Matter: A commentary on racism and public health. American Journal of Public Health, 105(8), e27-e30. doi://10.2105/AJPH.2015.302706

Mathews T. J., & MacDorman M. F. (2010). Infant mortality statistics from the 2006 period linked birth/infant death data set. National Vital Statistics Report, 58:17, 1-31. Hyattsville, MD: National Center for Health Statistics. Available from: .