Iowa Senator Chuck Grassley (R) has introduced the Healthy Moms and Babies Act (S 5015) to improve maternal health coverage. One of the requirements of the bill is mandatory state reporting, in public documents, of the quality measures for the state with respect to maternal care.
The proposal is intended to reduce the rates of Caesarean sections, to provide coordinated care for mothers including mental health care, and in various other ways to support care of pregnant and postpartum women.
The maternal mortality rate in the United States is not only higher than in comparable developed countries, but is also increasing, according to the CDC.
Puerto Rico may be exempt
The bill contains the following section:
APPLICATION TO TERRITORIES.—
“(A) IN GENERAL.—To the extent that the Secretary determines that it is not practicable for a State specified in subparagraph (B) to report information in accordance with the method made available under paragraph (1), this subsection shall not apply with respect to such State.
“(B) TERRITORIES SPECIFIED.—The States specified in this subparagraph are Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
In other words, it is possible that the Secretary of Health and Human Services could decide that Puerto Rico and the other territories do not need to report their quality measures for maternal care because it would be too hard to do so.
Under the U.S. Constitution, it is legal for the federal government to treat Puerto Rico — and all the current U.S. territories — differently from states. This is often presented as a benefit. For example, it has been explained that Puerto Rico doesn’t pay federal income taxes in many cases, so that the territory has greater flexibility to collect taxes from its residents.
In real life, that actually means that many people in Puerto Rico who do not earn enough to pay federal taxes did not, until tax year 2021, get the Child Tax Credit, which they would have received had they lived in a state. It also means that Puerto Ricans pay higher local taxes than people living in states. And the exemption of federal taxes on Puerto Rico-sourced income is often used as an excuse by Congress for the unequal treatment under many federal laws, such as the Supplemental Nutrition Assistance Program (SNAP), and Medicaid. So while the exemption of federal taxes on local income may seem to be a positive thing for some individuals, it is not generally a financial benefit for people living in Puerto Rico.
In the same way, the proposed exemption of U.S. territories from the application of the proposed policy seems to suggest that the bill will not burden territories with these reporting requirements if they seem “impracticable.”
What would it actually mean if Puerto Rico, the home of about 95% of the residents of the U.S. territories, did not report health care quality measures for maternal health?
- The federal government will not have accurate information on healthcare quality in Puerto Rico. At its simplest, this guarantees that the people who make decisions for Puerto Rico will not know how good or bad maternal care is in Puerto Rico. Without adequate information, they will not be able to make educated decisions for the territory.
- Since Puerto Rico has no senators and no voting members of the House, the territory has no one with voting power to tell its story. If getting healthcare data proves “impracticable,” Puerto Rico won’t even have information available to educate voting members of Congress. No one will know about the situation on the ground.
- Statistics for the United States as a whole will be inaccurate. Just as leaving out Mississippi’s figures or Connecticut’s would change the overall profile of the United States, leaving out Puerto Rico also gives a false, skewed impression of the U.S. health system. This means that all the decisions made for the United States would be predicated on incomplete and inaccurate data. Since Puerto Rico has a larger population than 20 states, there is no question that leaving out this data would invalidate the total data collection results.
Why is it “impracticable”?
Puerto Rico has an electronic health data project in existence. There are multiple universities and large numbers of STEM field graduates and professionals. Telecommunications coverage has been improving in the years since Hurricane Maria, and there are many reasons to continue to work toward a strong digital infrastructure for Puerto Rico.
The bill does not specify why data collection and reporting in the U.S. territories would be “impracticable.” Yet data collection could be the first step on a path toward positive reforms. In this situation, it may be preferable for Congress to call for data from the U.S. territories, just as it is asking from States. Funding and support should be prioritized as needed to make sure that Puerto Rico is able to provide the same mandatory reporting as in the 50 states.
Updated on November 4, 2022.