One year after Hurricanes Irma and Maria made landfall, Puerto Rico and the U.S. Virgin Islands (USVI) are still feeling the storms' effects. Drawing on key stakeholder interviews and public reports, this brief provides an overview of recovery status and preparation efforts for the current hurricane season one year after the storms, with a focus on the territories' health care systems. It finds: Recovery has progressed, but it has been slow and uneven, and challenges remain. Although power has been largely restored to the territories, Puerto Rico still experiences power instability, and its two offshore islands are still not connected to the electrical grid. In both territories, economic recovery and home repair progress are moving slowly. Heading into a new school year, many children continue to face disrupted school schedules due to delays in repair and construction of temporary classrooms. Posthurricane outmigration has left a disproportionately elderly, disabled, and economically disadvantaged population in the territories as they cope with recovery. One year later, mental health remains a crisis in both territories. Puerto Rico has experienced an increase in both deaths from suicide and calls to the central suicide hotline over the nine months following the hurricanes. Residents also continue to deal with physical health challenges exacerbated by the storms, such as management of diabetes and other chronic conditions. The territories' health care systems have seen progress with recovery, but serious gaps remain. Providers in both territories have restored access to some services limited by hurricane damage, while other services remain closed as providers await damage assessment and rebuilding. Provider shortages in mental health, nursing, and certain subspecialties present challenges to service delivery in both territories. Recovery of the health care system in Puerto Rico's offshore islands and rural areas lags behind the rest of the territory. In USVI, hospitals and clinics remain damaged and function well below needed levels of service delivery and inpatient capacity. Federal financing has been critical to recovery, but stakeholders report barriers to accessing federal recovery funds and are concerned about the expiration of temporary Medicaid financing support at the end of September 2019. Territory health officials have used additional Medicaid funds from the February 2018 budget bill to support coverage and increase reimbursement rates, but they worry about long-term financing. Officials cited complex rules, extensive paperwork, rotating FEMA staff, and poor communication as key barriers to accessing the array of federal recovery funds. Health care providers have found support from nongovernmental organizations (NGOs) and philanthropy helpful in moving recovery forward with less bureaucracy. The territories are moving forward with broader health system changes, including significant spending cuts in Puerto Rico. The Financial Oversight and Management Board, created by Congress to oversee broader debt restructuring in Puerto Rico, approved the territory's May 2018 fiscal plan that calls for $9.5 billion in spending cuts over the next six years. Health care system changes outlined in the plan may complicate the territory's recovery from the hurricanes, as implementation of major changes is set for the fall of 2018. At the same time, USVI's broad delivery system efforts that began before the hurricanes are moving forward alongside the territory's work on hurricane recovery and preparation. In the midst of recovery from the 2017 hurricanes, territory officials and health care providers are preparing for the 2018 hurricane season. Top priorities include development of alternative energy sources, such as solar power and back-up generators, as well as improved processes to identify and track patients that may need medical transfers or special care considerations. Some officials reported that they have improved procedures for the periods immediately before and after a hurricane, while others reported that drills and early storm events reveal continued gaps in preparations for another storm. These officials expressed particular concern about areas that are still suffering the most from last years' storms. Both Puerto Rico and USVI have released comprehensive recovery plans, but these plans call for major capital investments. Questions remain about both the availability of additional federal financing to continue recovery efforts and the possibility of long-term changes to Medicaid financing before the expiration of temporary Medicaid funds at the end of September 2019. Looking ahead, the territories are focused on making it through the 2018 hurricane season and continuing toward full recovery and fiscal stability in the future.
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