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Health and Social Services in Puerto Rico Before and After Hurricane Maria Predisaster Conditions, Hurricane Damage, and Themes for Recovery

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Health and Social Services in Puerto Rico Before and After Hurricane Maria Predisaster Conditions, Hurricane Damage, and Themes for Recovery Health and Social Services in Puerto Rico Before and After Hurricane Maria Predisaster Conditions, Hurricane Damage, and Themes for Recovery ANITA CHANDRA, TERRY MARSH, JAIME MADRIGANO, MOLLY SIMMONS, MAHSHID ABIR, EDWARD W. CHAN, JAMIE RYAN, NUPUR NANDA, MICHELLE D. ZIEGLER, CHRISTOPHER NELSON HS AC HOMELAND SECURITY OPERATIONAL ANALYSIS CENTER An FFRDC operated by the RAND Corporation under contract with DHS rr2603_cover_cc_v11.indd 1,3 9/8/20 7:26 AM Published in 2020 Preface On September 19 and 20, 2017, Hurricane Maria severely damaged the island of Puerto Rico. Coming just two weeks after Hurricane Irma, the storm significantly damaged local infrastructure and interrupted the provision of services essential to the people of Puerto Rico. In the aftermath, the president signed a Major Disaster Declaration for Hurricane Maria on September 20, 2017 (DR-4339) under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act).1 As attention turned from response to long-term recovery, Congress enacted a Supplemental Appropriation Bill authorizing funding for rebuilding efforts. The Act required the governor of Puerto Rico, in coordination with the Federal Emergency Management Agency (FEMA), the Department of Treasury, Department of Energy, and other federal agencies having responsibility under the National Disaster Recovery Framework, to submit within 180 days of enactment of the legislation a report to Congress that describes Puerto Rico’s 12- and 24-month economic and disaster recovery plan. The plan was developed in coordination with the Federal Oversight and Management Board (FOMB) established under the Puerto Rico Oversight, Management, and Economic Stability Act (PROMESA), the federal interagency, and key partners from private and nongovernmental entities using an agile process to identify recovery solutions. Under contract with FEMA, the Homeland Security Operational Analysis Center (HSOAC) provided substantial support in developing the plan by soliciting and integrating inputs from a wide variety of stakeholders, contributing analysis where needed, and drafting the plan. The plan included an overview of damage and needs, courses of action (COAs) to meet those needs, costs of the courses of action, and potential funding mechanisms for those costs. The governor’s team finalized the economic and disaster recovery plan for Puerto Rico, and the Governor submitted Puerto Rico’s final plan to the U.S. Congress on August 8, 2018. The plan defined priorities, goals, and expected outcomes that address both immediate needs and provide a foundation for longer-term sustainability. The planning effort was organized into 12 sectors (reflecting the National Disaster Recovery Framework). The purpose of this report is to describe the development of plan elements for the health and social services sector via the Health and Social Services (HSS) Sector team, including analytical material that was not included in the recovery plan but informed the planning process. We also describe the methodology behind the damage and needs assessment and discuss themes for recovery. Long-form COAs that provide greater detail than found in the plan (e.g., cost estimations, implementation considerations) can be found at the end of this report. As described 1 U.S. Department of Homeland Security, National Disaster Recovery Framework (NDRF), 2nd ed., Washington, D.C.: Department of Homeland Security, 2016. iii in greater detail later, the COAs comprise a collection of activities, policies, and actions developed to support the human capital investments identified in the recovery plan. While the National Disaster Recovery Framework (NDRF) includes education in the health and social services sector, in April 2018 FEMA determined that, given the scope and centrality of the sector’s future development, education would be treated as a separate sector and is detailed in a comparable but separate volume. While there is considerable overlap between Education and HSS, this report summarizes key findings from a damage and needs assessment and COAs designed to address health and social services–specific needs. The report may be of interest to individuals and organizations working on the implementation of the recovery plan or other aspects of the island’s recovery. It may also be of interest to those working on recovery in other regions affected by the 2017 hurricanes or others like it (e.g., islands, territories, small or remote communities) and those interested in broader recovery issues pertinent to health and social service topics. This research was sponsored by FEMA and conducted within the Strategy, Policy, and Operations Program of the HSOAC federally funded research and development center (FFRDC). More information about HSOAC’s contribution to planning for recovery in Puerto Rico, along with links to other reports being published as part of this series, can be found at www.rand.org/hsoac/puerto-rico-recovery. About the Homeland Security Operational Analysis Center The Homeland Security Act of 2002 (Section 305 of Public Law 107-296, as codified at 6 U.S.C. § 185) authorizes the Secretary of Homeland Security, acting through the Under Secretary for Science and Technology, to establish one or more FFRDCs to provide independent analysis of homeland security issues. The RAND Corporation operates the HSOAC as an FFRDC for the Department of Homeland Security (DHS) under contract HSHQDC-16-D-00007. The HSOAC FFRDC provides the government with independent and objective analyses and advice in core areas important to the department in support of policy development, decisionmaking, alternative approaches, and new ideas on issues of significance. The HSOAC FFRDC also works with and supports other federal, state, local, tribal, and public- and private- sector organizations that make up the homeland security enterprise. The HSOAC FFRDC’s research is undertaken by mutual consent with DHS and is organized as a set of discrete tasks. This report presents results of research and analysis conducted under task order 70FBR218F00000032, “Puerto Rico Economic and Disaster Recovery Plan: Integration and Analytic Support.” The results presented in this report do not necessarily reflect official DHS opinion or policy. For more information on HSOAC, see www.rand.org/hsoac. For more information on this publication, visit www.rand.org/t/RR2603. iv Contents Preface ............................................................................................................................................ iii Figures.......................................................................................................................................... viii Tables ............................................................................................................................................. ix Summary ......................................................................................................................................... x Acknowledgments ......................................................................................................................... xx Abbreviations ............................................................................................................................... xxi 1. Introduction ................................................................................................................................. 1 Puerto Rico’s Challenge and Opportunity .................................................................................. 4 Methodology ............................................................................................................................... 6 Organization of This Report ..................................................................................................... 11 2. Puerto Rico’s Health and Social Services Sectors Before the Hurricanes ................................ 12 Structure, Governance, and Assets ........................................................................................... 12 Key Assets ................................................................................................................................ 17 Key Challenges Facing the Health and Social Services Sector in Puerto Rico Before the Hurricanes ........................................................................................................................... 21 Chapter Recap ........................................................................................................................... 30 3. Damage and Needs Assessment ................................................................................................ 31 Health Care Infrastructure Damage .......................................................................................... 31 Health Impacts .......................................................................................................................... 32 Disruption of Social Services ................................................................................................... 35 Posthurricane Conditions as of March 2018 ............................................................................. 35 Chapter Recap ........................................................................................................................... 38 4. Themes for Recovery and Courses of Action ........................................................................... 39 Health and Social Services Portfolio Development .................................................................
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