Advocacy efforts intensify in Washington for the approximately 1.7 million people who rely on Medicaid and Medicare Advantage for health care
Washington, D.C. – A delegation from the Medicaid and Medicare Advantage Products Association of Puerto Rico (MMAPA), joined by other health care leaders, concluded a visit to Washington, D.C., this week to advance concrete solutions for the more than 1.7 million people who rely on both programs for access to health care, and to ensure that data and policy options that address the unique characteristics of Puerto Rico’s health care system on the federal agenda.
During the visit, the delegation met with the offices of members of Congress Pete Sessions, Don Bacon, Ben Ray Luján, Raúl Ruiz, Claudia Tenney, Rob Menéndez and Carlos Giménez as part of MMAPA’s ongoing educational outreach effort, which will continue throughout the reminder of 2026 and into 2027. The delegation is also participating in Better Medicare Alliance’s 2026 Medicare Advantage Leadership and Policy Forum and the briefing “The Funding Cliff and the Path Forward,” convened by Resident Commissioner Pablo José Hernández, in which MMAPA’s president played an active role.
“Limiting funding does not limit need. The discussion cannot be limited to how much money is allocated or for how long. Patients still need doctors, medications, hospitals and treatments. If access deteriorates and an individual or a family moves to a state to receive those services, the need shifts to another market, along with the public spending required to address it,” said Solange de Lahongrais, president of MMAPA.
In Puerto Rico, Medicaid operates with fewer resources to serve a population with greater needs than in the rest of the United States. While average Medicaid spending in the states is around $897 per beneficiary per month, in Puerto Rico it is approximately $349, or 61% less. In addition, the island lacks support available in the states, such as the Medicare Savings Program (MSP) and Long-Term Services and Supports (LTSS), and receives NAP rather than SNAP funding for food assistance. In a jurisdiction where more than 37.3% of the population lives below the poverty level and median household income is around $27,000, Medicaid is not a supplemental benefit for many of its beneficiaries, but their primary gateway to the health care system.
The congressional forum organized by Resident Commissioner Pablo José Hernández, titled “Medicaid in Puerto Rico: Understanding the History,” provided a comprehensive overview of the history and structure of Medicaid funding in Puerto Rico, the temporary federal measures that have sustained the program, and the implications for the island if Congress does not act before current funding expires at the end of fiscal year 2027.
As the 2027 budget allocation approaches, MMAPA, the Government of Puerto Rico and the private sector remain in discussions with House Energy and Commerce Committee staff about legislation the committee is developing with the goal of introducing it before the end of the year. “We are keeping the discussion active, sharing data and presenting alternatives to advance solutions in time and prevent Puerto Rico from facing another funding cliff,” said de Lahongrais.
For Medicare Advantage, the timeline is different, and the window for action is immediate. Roberto Pando, chair of MMAPA’s Medicare Advantage Public Policy Committee, explained: “This effort comes at a crucial moment. CMS is developing Medicare Advantage payment policies for 2028, and MMAPA has submitted language to the agency for consideration that proposes using U.S. Virgin Islands (USVI) data as a proxy to establish Puerto Rico’s benchmarks. We CANNOT forget that MA funding remains 41% below the average and 20% below payments to the Virgin Islands.” In fact, Congressman Raúl Ruiz will introduce a bill to incorporate this language into Puerto Rico’s Medicare Advantage program.
The proposal addresses a unique market reality: approximately 683,000 beneficiaries—96% of the Medicare-eligible population—are enrolled in Medicare Advantage, while only about 27,000 remain in traditional Medicare, Parts A and B. That small population forms part of the basis used to determine payments in a market where virtually all beneficiaries have chosen MA. “We cannot expect the experience of fewer than 4% of beneficiaries to adequately represent a market where 96% have chosen Medicare Advantage,” Pando added. “CMS has a concrete alternative on the table and the administrative authority to act.”
The proposal has gained support from the Government of Puerto Rico, the private sector and members of Congress. MMAPA, for its part, remains in discussions with CMS and continues to share information about the unique characteristics of Puerto Rico’s market.
Approximately 1.3 million Medicaid and CHIP beneficiaries—four out of every ten Puerto Rico residents—rely on the program to access health care. Unlike the states, Puerto Rico operates under a capped federal allotment that will require periodic congressional action. The current structure requires a new federal allocation beginning October 1, 2027.
Puerto Rico also brings a record of results to the Medicaid discussion. Federal funding approved in recent years has come with requirements for provider payments, program integrity and accountability that the program has implemented. That greater stability has also made it possible to improve payments and expand services.
“Medicare Advantage and Medicaid require different solutions, but they share the same goal: ensuring that patients can receive the services they need in Puerto Rico and that we can retain and attract the health care professionals who care for them,” de Lahongrais concluded.
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