Speaking at a roundtable on healthcare in San Juan Friday, Hillary Clinton said she would do "everything" in her power to "put Puerto Rico on a path toward equal treatment."
"I think no one who is fair-minded could listen to this and conclude anything other than the way Puerto Rico is being treated when it comes to health is inconsistent," Clinton said. "It is incoherent. It is inequitable."
During the hourlong panel, leaders of local health organizations gave Clinton their assessment of the different challenges that patients, healthcare providers and insurers face in Puerto Rico, from high deductibles to low salaries for physicians relative to those in the states. Clinton, who spoke little during the panel, listened and took notes, pausing to ask follow up questions.
"They don't have access?" Clinton asked, when one panelist told her that veterans in Puerto Rico are not eligible for some TRICARE plans. "Really?"
Much of the conversation centered on the low rates of reimbursement for federal health programs like Medicare and Medicaid.
Clinton has long argued that Puerto Rico should receive equal funding under Medicaid and Medicare programs, a promise she made here during her last presidential campaign. Sixty percent of Puerto Rican residents rely on federal health programs to pay for care today but, according to the Puerto Rico Healthcare Crisis Coalition, the island's programs receive much lower reimbursement rates than any of the mainland states.
"This is all moving to a head," Clinton said in her closing remarks. "The timing on a lot of these changes and the impacts on...the whole suite of healthcare programs is certainly going to have a dire effect on the people of Puerto Rico and it will further exacerbate the exodus of doctors and nurses and of families."
Clinton has also recently called for Congress to allow the Puerto Rico to restructure its staggering $72 billion debt load under Chapter 9 bankruptcy laws. The laws apply to states and municipalities but not U.S. territories like Puerto Rico.
"We're not talking about a bailout," Clinton wrote, careful to also say that Puerto Rico's economic crisis will require the island's leadership to develop its own long-term strategy. "We're talking about a fair shot at success."
When asked about it during a brief press conference that followed the roundtable, she reiterated her support of Puerto Rico's inclusion under Chapter 9 protection.
"I think there's some educating that needs to be done with the Congress and the American public," she said.
Clinton said she believes there are too many Americans who live in the states that don't know that Puerto Ricans are American citizens.
"We're talking about American citizens who deserve all the support they can get anywhere else," she said.
Friday marked Clinton's first trip to Puerto Rico since announcing her second bid for the White House. On a conference call with reporters on Thursday, Clinton's campaign manager Robby Mook said it was an important stop to make in order to organize her supporters here, who helped her win the Democratic primary in 2008. But the influence of Clinton's visit will likely extend back to the mainland, too, where a growing number of Latinos live in vital swing states like Florida and Ohio, as well as the Clintons' adopted home of New York.
Clinton's roundtable gathering stood in contrast to the public rally held at a restaurant on the southern side of the island on Friday by Florida Sen. Marco Rubio, whose campaign put out a press release ahead of his visit calling attention to the dueling appearances.
"Marco vs. Hillary in Puerto Rico this Friday," read the headline.
Though well attended by around 100 people, Clinton's event was not open to the public. According to a campaign aide, it was designed that way to let Clinton listen, rather than speak. Events like the roundtable characterized the early "listening tour" stage of Clinton's campaign back in the spring and early summer.
The aide said that Clinton's national political director, Amanda Renteria, will continue to reach out and follow up with supporters in Puerto Rico after Friday's visit. Clinton's travel schedule will be aggressively focused on the early states through the rest of the month.
Martin O'Malley, who made a trip in early August, is the only other Democratic candidate for president who has visited Puerto Rico this cycle. His campaign announced Friday that a group of local political leaders had endorsed O'Malley for his leadership on issues important to Puerto Rico, like H.R. 870, a bill introduced in the House in February that would amend the federal bankruptcy code to give Puerto Rico the same rights as states. In an interview Friday morning with a Puerto Rican radio network, O'Malley reminded the host that he visited Puerto Rico "far in advance" of Clinton.
"We visited with providers there, and I have been applying pressure," he said, according to a transcript provided by his campaign. "And that's what leadership is all about. And I'm glad Secretary Clinton has come around to addressing the issues that face us in Puerto Rico."
The parade of presidential hopefuls to the territory speaks to the growing power of Puerto Rican voters on the mainland, especially in Florida, the top destination for those fleeing the island's 12 percent unemployment rate and nine-year economic slump. The governor declared the massive public debt unpayable and said it needs restructuring.
Historically, Puerto Ricans have sided with Democrats. But Republicans say they do see an opening, at least with recent arrivals, and have been going into Puerto Rican communities for several years to woo potential voters.
Gregorio Matias, a 43-year-old police sergeant, said he decided to fully support Rubio on Friday after reading the Florida senator's op-ed opposing bankruptcy protection in the island's largest newspaper.
"I'm going to call all my relatives and tell them to vote for Rubio," he said, adding that they live in Florida, New York, New Jersey and Wisconsin. "Rubio offers what Puerto Rico has been waiting for: that we be treated as equals, not as third-class citizens."
Clinton, for her part, received an endorsement from New York City Council Speaker Melissa Mark-Viverito, a Democrat and Puerto Rico native earlier this week.
In closing at Friday's roundtable, Clinton pledged her "absolute commitment" to Puerto Rico and called for unity among Puerto Ricans when it comes to their healthcare and economic crises.
"It's like a medical condition," she said. "If you don't treat it, it will get worse."
The Associated Press contributed to this report.