Puerto Rico’s healthcare system faces a combination of financial, labor, and capital-access pressures, according to an analysis by Francisco Rodríguez-Castro, President and CEO of Birling Capital Advisors. Uncertainty over a potential Medicaid "funding cliff" compounds these factors and threatens both medical services and a significant portion of the island’s economic activity. Rodríguez-Castro says the issues are interconnected: hospitals with losses and heavy debt struggle to invest, the exodus and aging of physicians reduce service capacity, and reduced credit availability limits financing for recovery and modernization.
The analysis shows the island’s 58 community hospitals accumulated estimated losses of $1.085 billion between March 2020 and December 2021, the most recent data available. They held liabilities of about $2.18 billion, nearly 75% of it owed to banks. The share of hospitals with negative margins rose from 25% to 44% over five years.
In September 2025, the Medical Association warned that 17 to 24 private hospitals could close or file for bankruptcy within two years. The physician workforce is also shrinking. The Department of Health counted 9,492 active, licensed physicians in October 2021 (6,424 specialists and 3,068 general practitioners), a 46% drop over a decade.
The average primary care physician was 60 years old in 2018, versus a national average of 53, and only 45% of family medicine residents trained between 2011 and 2017 were still practicing in Puerto Rico in 2018. If 2021 trends continue, Rodríguez-Castro estimates the island could have between 5,100 and 7,600 physicians by 2035.