It didn’t have to be this way. In addition to financial mismanagement by officials on the island, mass emigration to the mainland United States, and general financial and employment doldrums on the island, one of the reasons cited by Puerto Rican leaders for the current mountain of debt is a chronic federal underfunding of its Medicaid program, which covers about half of its population.

While states receive a federal matching percentage for every dollar they spend on Medicaid enrollees—a match rate that is enhanced for enrollees under the Affordable Care Act’s Medicaid expansion and adjusted for the poverty rate in each state—the match rate for Puerto Rico and the other territories is much lower, and there is a global cap on the amount of funds they can receive every year, which was $329 million for Puerto Rico in 2015, good for only 14 percent of total costs that year.

Although the ACA provided Puerto Rico nearly $6 billion in a one-time eight-year allotment in Medicaid and Marketplace funds, even with that addition, the federal government still pays less per enrollee than it does for even the poorest states. That funding will be exhausted this year, which might drop half of the island’s Medicaid population to the ranks of the uninsured.

This limited block grant funding scheme, now considered a potential model for funding Medicaid under various Republican Obamacare repeal plans, was almost destined to fail in Puerto Rico. Not only has the Puerto Rican Medicaid block grant failed to keep up with real health costs, it has lagged further and further behind the expansion of the program in the states under the Affordable Care Act. Their spending increased especially as reforms like the Affordable Care Act added more eligible enrollees with generous federal matching funds, but Puerto Rico’s hard caps remained.

The block-grant structure also illustrates the worst possible scenario for states under the Republican plans: Funding that cuts federal spending by simply not providing enough to sick people, and a health-care infrastructure that cannot adjust or mobilize to fight epidemics.

A 2005 letter from Eduardo Bhatia, then the executive director of the Puerto Rico Federal Affairs Administration, details that constant shortfall. “If the Puerto Rico Medicaid cap enacted at $20 million in 1968 would have grown at the same rate the Medicaid program has grown, the cap today would be about $1.7 billion instead of its current $219 million,” he wrote. “Puerto Rico would not only have a different Medicaid program today, but it would have a different healthcare system.” That was 12 years ago, and even factoring in the yearly one-time Obamacare funding as a yearly injection, current federal funding for Puerto Rico wouldn’t have even met Bhatia’s dream scenario then, let alone meet actual costs today.