Po-tay-to or po-tah-to Single payer or social welfare There is always more than one side to an argument, especially when the debate is about healthcare.

Puerto Rico avoided the drama of the botched launch of the health insurance exchanges that the states endured. As a U.S. territory, the island was not required to participate in the health insurance exchanges.  Rather, Puerto Rico used its $925 million federal funding allocation for healthcare reform to expand its Medicaid program, Mi Salud, to an additional 278,000 residents.

That's a good thing, right? Surely some coverage is better than no coverage and some reimbursement is better than little to none for providing care to uninsured patients or those treated through charity care.

But some Puerto Rico physicians argue that the island's healthcare system is becoming a social welfare state. Already, 63 percent of Puerto Rico residents receive government-based healthcare coverage through Mi Salud or Medicare compared to only 35 percent of residents who have commercial insurance. Puerto Rico's uninsured rate is 7 percent. Physicians contend with lower reimbursement rates and the number of patients they must see per day to sustain a viable practice the same predicament many of their peers in the states face.

However, the number of physicians in Puerto Rico has dropped by 13 percent in the last five years, from 11,397 to 9,950, according to Puerto Rico's Medical Licensing and Studies Board. Many of those physicians relocated to the mainland in search of higher salaries and better reimbursement rates. Family and general practitioners in Puerto Rico earn about $72,000 a year, while in the United States they earn about $180,000, according to 2012 statistics from the U.S. Bureau of Labor. Yet the grass may not always be greener in some of the mainland's more popular cities.

Looking at the cost of living index on Expatistan's website, New York City is 74 percent more expensive than San Juan, while the Washington, D.C. metropolitan area is 42 percent more expensive, and Miami is 14 percent more expensive. Forty-three percent of New York City residents receive government-sponsored healthcare coverage compared with 43 percent who have commercial insurance. Fourteen percent of New York City residents are uninsured. The Washington, D.C. area has fewer residents (23 percent) receiving government-based healthcare and has the most residents (66 percent) with commercial coverage.  Only 11 percent of Washington, D.C.-area residents are uninsured. Forty-seven percent of Miami residents receive government-sponsored healthcare coverage compared to 33 percent who have commercial coverage. Thirty percent of Miami residents are uninsured.

Conversely, the cost of living in Jackson, Miss., is 4 percent less expensive than San Juan. Mississippi's economy more closely resembles Puerto Rico's economy and physicians looking to exchange island life for the mainland would be welcomed, especially in the more rural areas. Only 34 percent of Jackson's residents receive government-based healthcare coverage compared to 43 percent who receive commercial coverage. More than 16 percent of Jackson's residents are uninsured.

As physicians relocate, they are often looking for affiliations with academic centers, contracts with employment arrangements, and less exposure to risk. Many times they are tired of the business of medicine and want to focus on the delivery of medicine, which usually is code for, I want to slow down and let someone else worry about the money. Unfortunately, there is no magic pill for how the physicians must deliver their services, just like there is no magic pill for the patients who need these physicians the most.

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