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New Report on Health Centers in U.S. Territories and Freely Associated States

A new report from the Kaiser Family Foundation examines health centers in U.S. territories and Freely Associated States (FAS). Health centers are community clinics staffed by medical professionals.

The five U.S. territories – American Samoa, the Northern Mariana Islands, Guam, Puerto Rico, and US Virgin Islands – rely heavily on health centers to provide primary healthcare services. Puerto Rico in particular has 22 health centers. There was no change in this number during the pandemic.

The researchers asked health centers which health issues and which social issues caused the most concern. Heart disease and diabetes topped the list of health concerns, followed by obesity, mental health issues, and cancer.

Social issues were led by poverty and the pandemic, followed by a lack of job opportunities, poor health education, and lack of physical activity. The social issues and the health issues are intertwined.

While the data for Puerto Rico was not separated from that of the other territories, Puerto Rico is home to 95% of all U.S. citizens living in U.S. territories.

The Kaiser study also covered three independent countries that have signed compacts of free association with the United States.  The three countries, which are referred to as the Freely Associated States (FAS), include the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands.

Citizens of the FAS  are not U.S. citizens, and they are generally ineligible for U.S. health services such as Medicaid.  According to the Kaiser study, 81% of patients at FAS health centers lacked health insurance.  The Freely Associated States are not eligible for Medicaid, and until very recently, FAS migrants could not access Medicaid even when they moved to a state. In Puerto Rico, 63% of patients were covered by Medicaid.

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Mental health services

10% of visits in Puerto Rico were for mental health services, including substance abuse treatments. This is an increase since 2019, though the number of total visits to health centers has decreased by 12%.

According to the Asociación de Salud Primaria de Puerto Rico (ASPPR), the mental health needs of visitors to the community health centers are “becoming increasingly complex.”  They see “lingering effects” of the natural disasters of recent years intensified by the experience of the pandemic.

Health centers in the territories and FAS also provide social and supportive services, including transportation and food or nutrition services.


While 24% of health center visits in Puerto Rico are telehealth visits (phone or video), health centers on the Island say that lack of internet service and appropriate hardware among patients limit the number of such visits they can schedule.

Both rural populations and elderly people are more likely to have these challenges. While health centers saw increases in funding and staff during the pandemic, they continue to face challenges in staffing as they compete not only with other center on the Island but also with healthcare job opportunities in the States, where payscales are much higher.

While telehealth technology has helped mainland healthcare providers cope with labor shortages and rising costs, Puerto Rico’s less robust telecommunications infrastructure and preexisting healthcare challenges limit the opportunities to use this technology.

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