When the Puerto Rico Department of Health ordered the immediate closure of Hospital del Maestro in late August 2025, it marked the end of a 60-year era for San Juan families and sent shockwaves through the island’s already fragile healthcare system. The shuttering of this once-venerable institution, licensed for 255 beds but operating only 18 at the end, was not just a local tragedy. It was the latest, most visible casualty in a much broader crisis—one that stretches from Puerto Rico’s urban centers to the remote reaches of the Northern Mariana Islands, exposing the deep fissures caused by chronic underfunding, demographic shifts, and systemic inequity in U.S. territories.
According to Pasquines, the Northern Mariana Islands Advisory Committee to the US Commission on Civil Rights released a report on June 25, 2025, laying bare the dire state of healthcare access within the NMI’s justice system. The report, based on in-person visits, public hearings, and testimonies from all corners of the system—former inmates, healthcare workers, legal advocates, and officials—detailed a landscape riddled with deficiencies. Detainees, both adult and juvenile, face extended waits for medical attention, a chronic shortage of qualified professionals (especially mental health providers), and a near-total absence of dental care. Even with an on-site medical unit, Department of Corrections inmates encounter delays, lack of trained staff, and must often rely on off-site treatment through the Commonwealth Healthcare Corporation (CHCC). Yet, these arrangements are plagued by inconsistent coordination and limited capacity, leaving many without timely care.
The challenges extend well beyond adult prisons. Juvenile detention centers and specialty courts—such as those for drug and mental health cases—fail to reliably provide needed services. As the committee’s report warned, “juvenile offenders often go without necessary medical or mental health services,” undermining the very purpose of these rehabilitative programs. Pretrial detainees, legally presumed innocent, are not spared either; the report highlighted the risk of “unnecessary involuntary medication,” raising fundamental questions about civil rights protections in U.S. territories. “Safeguarding the rights of individuals within CNMI’s justice system to access adequate healthcare has been a serious ongoing problem and concern in the Commonwealth of the Northern Mariana Islands for decades,” said NMI Advisory Committee Chair Catherine Cachero. She urged policymakers to adopt the committee’s recommendations, which include clear grievance procedures, regular staffing assessments, secure tablets for medical requests, integrated electronic records, and expanded residential treatment facilities on Saipan.
This call for reform comes at a moment when geographic isolation, limited resources, and strained infrastructure have left the Northern Mariana Islands—and Puerto Rico—vulnerable to systemic breakdowns. The fate of Hospital del Maestro is a case in point. As W Journal PR reported, the hospital’s troubles began long before its final collapse. The first major blow came in 2010 with the failure of Westernbank, one of its main lenders, which left the hospital with little access to credit. Over the next decade, rising costs and a shrinking patient base—driven by the outmigration of more than 736,000 residents, including many healthcare professionals—eroded the hospital’s financial footing. The remaining population was older, sicker, and more dependent on Medicare and Medicaid, increasing costs while reducing revenues.
Management decisions compounded these structural weaknesses. Instead of seeking outside expertise or innovative leadership, the hospital’s board leaned on insiders, missing opportunities for strategic renewal. The COVID-19 pandemic in 2020 and 2021 dealt the final blow: occupancy rates fell to 30%, revenues evaporated, and entire wings—including the ICU and pediatrics—were shuttered. By 2023, Hospital del Maestro was a shadow of its former self, and its closure in August 2025, following a bankruptcy filing that revealed $13.4 million in assets against $39.7 million in liabilities, was seen as inevitable by many observers.
But the demise of Hospital del Maestro is emblematic of a much bigger problem. Across Puerto Rico, a wave of hospital bankruptcies and closures has swept the island, driven by what W Journal PR calls a “perfect storm” of chronic federal underfunding, demographic decline, unsustainable debt, and weak governance. Between March 2020 and December 2021 alone, Puerto Rico’s hospitals lost an estimated $1.085 billion, with federal CARES Act relief covering only $300 million of that shortfall. The result: a $785 million gap that many institutions simply could not bridge.
At the heart of this crisis lies a stark funding disparity. While healthcare spending on the mainland averages $13,000 per person annually, Puerto Rico receives just $4,000—a 69% shortfall that translates to nearly $29.8 billion in lost funding every year. This gap is rooted in what advocates describe as discriminatory Congressional formulas for Medicare and Medicaid, despite Puerto Ricans contributing to the same federal programs as mainland residents. Over the past decade, this has amounted to $300 billion in lost funding, stunting investment and limiting access to care.
And yet, Puerto Rico has managed to achieve some remarkable outcomes. Life expectancy has risen from 74.26 years in 1995 to 80.69 years in 2023, outpacing the U.S. average by more than four years. This progress is due in part to Plan Vital, the government insurance program that now covers nearly half the island’s population, and a high overall insurance coverage rate of 92%. But as W Journal PR notes, “insurance does not equal access.” Patients endure long waits for basic appointments, expectant mothers struggle to find OBGYNs, and chronic illnesses often go untreated until they become critical—a direct consequence of underfunding and workforce shortages.
The financial landscape has only grown more challenging. The collapse of major banks like Westernbank, R-G Premier Bank, and Eurobank in 2010, followed by the exit of international lenders and the failure of Doral Bank in 2015, has left Puerto Rico’s healthcare providers with few credit options. Today, only four commercial banks remain, and lenders are wary of backing a sector beset by volatility, high leverage, and chronic underfunding. Alternative lenders have stepped in, but their resources are limited and their capital comes at a higher cost, making long-term sustainability elusive.
Faced with this systemic risk, advocates are calling for bold action. Among the proposals is the creation of the National Wellness Hospital Lending Program (NEW-HOPE), a $1.5 billion facility modeled on the Troubled Asset Relief Program (TARP) that stabilized U.S. banks during the 2008 financial crisis. NEW-HOPE would provide low-cost loans, credit guarantees, and targeted investment to keep hospitals open, restructure debt, and modernize services. Alongside this, a Healthcare Investment Program (HIP) would allow hospitals to issue senior debt or warrants to Puerto Rico’s fiscal authority, unlocking much-needed capital for recovery and growth.
But financial fixes alone won’t be enough. The roadmap for renewal also calls for ending Congressional discrimination in funding, investing in prevention and holistic care, strengthening workforce retention with competitive pay and loan forgiveness, and modernizing infrastructure through research and innovation. The stakes could not be higher: hospitals are not just providers of care, but economic anchors and training grounds for future professionals. Their collapse ripples outward, threatening jobs, community stability, and public health.
As the Northern Mariana Islands report and the saga of Hospital del Maestro both make clear, the human cost of inaction is immense. Every year, Puerto Rico’s hospitals are underfunded by $9.86 billion, and doctors and providers lose another $7.77 billion. Mothers wait months for prenatal care, elderly patients endure endless hours in overcrowded clinics, and specialists are so scarce that families are often forced to seek treatment on the mainland. Healthcare, as both reports argue, is not just a budget line—it is a human right. The time for action is now, before another institution falls and the cost of inaction becomes irreversible.
