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Puerto Rico’s Looming 2019 Medicaid Fiscal Cliff

By admin | September 26, 2019

Puerto Rico and its residents have experienced numerous crises and shocks in the last decades, including an economic depression dating back to 2006; a public debt crisis resulting in the largest municipal bankruptcy in U.S. history and a federally appointed fiscal oversight board pursuing deep budget cuts; a demographic crisis with population dropping by more than 600,000 residents since peaking at 3.8 million in 2004; and most recently, the devastation and cascading effects left by the hurricanes of 2017. The cumulative effect of these crises has taken a hard toll on the economic and social well-being of its people, disproportionately impacting the most vulnerable populations and communities. These interrelated crises feed on each other, propelling a vicious downward spiral.

Another potential shock is the territory’s imminent Medicaid fiscal cliff, and ensuing public health crisis. In the past, temporary lifelines to Puerto Rico’s Medicaid program have prevented a total system collapse, but by the same token, these short-term extensions of supplemental funding have thwarted efforts to completely reform the system and make it more effective.  The uncertainty caused by this situation is highly detrimental to all stakeholders, especially people whose health and well-being depends on receiving vital care but have few resources to make ends meet in this challenging economic environment.

Differences in Puerto Rico’s Medicaid Program

The U.S. Medicaid program was created to provide vital healthcare services to financially and medically needy populations.  In Puerto Rico, however, that same population that is adversely affected by a disparate and inadequate federal funding structure.  Medicaid programs in the states benefit from an open-ended federal financing structure, receiving federal funds as a function of actual costs and needs. In Puerto Rico, where median household income stood at $19,775 in 2017, compared to $42,009 in Mississippi, the poorest state, and $57,652 in the United States as a whole, the program has been chronically underfunded.  In the poverty-ridden territory, funding limitations further constrain program delivery evidenced in the form of lower eligibility levels, lower federal funding, fewer mandatory benefits, lower provider payments, and lower spending per enrollee.

Lower eligibility levels: To determine income eligibility for participation in Medicaid, Puerto Rico uses the Puerto Rico Poverty Level (“PRPL”) and not the Federal Poverty Level (“FPL”) as in the states, which results in a significantly lower income eligibility threshold. The PRPL is approximately 45% of the FPL for an individual, and 34% for a family of four.

Lower federal funding: Medicaid programs in the U.S. benefit from an open-ended financing structure, receiving federal funds based on actual costs and needs. States with the highest per capita incomes of the U.S. enjoy a Medicaid federal matching rate of 50%, while the poorest, Mississippi, received a Federal Medical Assistance Percentage (“FMAP”) of 76.4% in fiscal year 2019. If Puerto Rico’s FMAP were “calculated by the same statutory formula used for the 50 states and D.C., Puerto Rico’s FMAP would be 83%, although the unbounded FMAP would be 93.34%.” In addition to the lower federal share, Puerto Rico’s Medicaid federal financing is also subject to an annual ceiling or cap, operating effectively as a block grant. Puerto Rico receives an arbitrarily capped allotment, known as the Section 1108 cap, typically resulting in an effective Medicaid federal match rate below 15%. Puerto Rico’s federal funding was capped at $367 million in FY2019, while Medicaid expenditures in the island totaled $2.7 billion. The projected FY2020 cap is expected to be $375.1 million, despite spending projections adding up to $2.8 billion. As per current law, Puerto Rico will also have access to $446 million under the Patient Protection and Affordable Care Act (“ACA”) Section 1323, and $59 million under Social Security Administration (“SSA”) Section 1935(e), also referred to as the Enhanced Allotment Plan (“EAP”), which helps cover prescriptions drugs costs to beneficiaries dually eligible for Medicaid and Medicare, for a total of $880 million in federal spending.

Fewer mandatory benefits: Notwithstanding the great needs and demands for acute and long-term care services – which will likely continue to grow in tandem with the aging population trend and the rising prevalence of chronic health problems – Puerto Rico’s Medicaid program does not cover all mandatory Medicaid benefits. Long-term services, home and community-based services to older adults and people with disabilities with functional limitations and chronic health conditions, are examples of support offered in U.S. states but not available to the residents of Puerto Rico.

Lower provider payments: Disproportionately low provider payment rates and its negative effect on provider availability, and quality and access to care, is a major obstacle for Puerto Rico. The majority of municipalities (i.e. 72 of 78) of Puerto Rico are deemed “medically underserved areas” due to the shortage of medical and healthcare professionals. The Medicaid provider reimbursement rate in Puerto Rico for primary care services from July 2016 to July 2017 was 19% of the Puerto Rico Medicare fee compared to 66% in the U.S. Similarly, maternity services were reimbursed at 50% of the Puerto Rico Medicare fee vs. 81% in the U.S. The substantial differences between Puerto Rico’s Medicaid reimbursement rates and those in the states and the uncertainties regarding the island’s Medicaid financing structure, have played a role in the exodus of physicians and healthcare providers. The number of doctors has decreased from approximately 14,000 in 2006 to currently close to 9,000. There is a particularly acute deficiency of specialty care providers.

Lower Medicaid spending per enrollee: Total Medicaid spending per enrollee is significantly lower in Puerto Rico when compared to all 50 states. According to FY 2020 projections by the Medicaid and CHIP Payment and Access Commission (“MACPAC”), average benefit spending per full year enrollee in Puerto Rico will be $2,144, representing 64% of the lowest per capita spending state ($3,342), 32% of the median ($6,763), and 16% of the highest per capita spending state ($13,429).

Increased Healthcare Needs

Less funding has, in effect, translated to increased needs. The percent of adults reporting fair or poor health in 2017 reached 37.1% in Puerto Rico, compared to 25.3% in Mississippi, and 18.4% in the U.S. The healthiest jurisdiction, according to this indicator, was the District of Columbia reporting 10.8%.  Disparities in chronic health indicators are also significant. Diabetes prevalence in Puerto Rico in 2017 was 17.2%, compared to 10.5% in the U.S.  Asthma and high blood pressure prevalence was 12.2% and 44.7% in Puerto Rico, compared to 9.4% and 32.3% in the U.S, respectively. A robust healthcare system with adequate federal funding could help mitigate the high prevalence of chronic conditions on the island.

Necessary Congressional Action

The chronic underfunding of the island’s Medicaid program has historically placed an undue fiscal burden on Puerto Rico’s budget and prompted federal action. During the last decade, Congress has enacted legislation to provide limited, temporary supplemental funding and avoid a massive healthcare crisis. In 2009, additional federal funds for Puerto Rico’s Medicaid program were appropriated through the American Reinvestment and Recovery Act (“ARRA”), followed by the ACA in 2010, the Consolidated Appropriations Act of 2017, and most recently, through the Bipartisan Budget Act (“BBA”) of 2018 following the devastating 2017 Atlantic hurricane season. In the aftermath of Hurricanes Irma and Maria impacting the island on September 2017, Congress provided an additional $4.8 billion to Puerto Rico’s Medicaid program beyond the annual Section 1108 cap, time-limited funds that were made available from January 1, 2018 to September 30, 2019. The expiration date authorizing the use of that last tranche of funding is soon approaching, and all other temporary federal funds are expected to be exhausted shortly thereafter.

Only prompt Congressional action can help avert a health care crisis in Puerto Rico. If Congress fails to act, it could lead to catastrophic direct and indirect effects. The Medicaid and CHIP Payment and Access Commission (“MACPAC”) estimated that enrollment at the current level of benefits would need to decrease between 36% (455,475) to 53% (669,943) if no new federal funds are made available. The Fiscal Oversight and Management Board for Puerto Rico has warned that “absent action by Congress, by fiscal year 2021, the Commonwealth’s Medicaid costs are projected to comprise roughly 23% of the General Fund’s budget.”

The FMAP that applies to Puerto Rico’s Medicaid program should be computed using the same formula used for the states, considering the average per capita income of Puerto Rico relative to the U.S. national average.  To ensure that the most vulnerable populations of Puerto Rico have access to a more robust, predictable, reliable, and accessible Medicaid healthcare system, Congress must act quickly and remove the federal cap on Medicaid funding altogether and compute the FMAP using the same average per capita income-based formula as done for the states.  Providing Puerto Rico with an adequate level of federal funds for its Medicaid program will also help it return to a path of fiscal stability and economic growth. The urgency of this matter cannot be overstated. Congressional action is promptly needed to stave off another historic humanitarian crisis.

When designing the solution, policy deliberations and prescriptions must be framed within the proper context.  Policymakers must remain keenly aware of the historic critical juncture Puerto Rico is traversing and the larger moral imperatives at play. Puerto Rico’s current dire economic, fiscal, demographic, and post-natural disaster recovery and reconstruction reality must be an essential part of the broader equation. This critical juncture presents an opportunity for Congress to redress a historical wrong, strengthen Puerto Rico’s fragile healthcare system, improve access to critical health services for vulnerable populations, and make headway towards putting Puerto Rico on a stronger fiscal and economic footing.

Further, more than a last-minute temporary fix is needed to provide Puerto Rico with a reliable and sustainable healthcare system.  A permanent, long-term fix to Puerto Rico’s Medicaid program is needed to once and for all guarantee comprehensive, accessible, quality care to low-income families, children, the elderly, and people with disabilities.



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Puerto Rico’s next crisis is coming, and only Congress can stop it

By admin | September 26, 2019



 THE HILL–— 09/11/19


Congress reconvenes this week and will tackle many issues that are crucial for our country. Among them is the imminent man-made crisis facing Puerto Rico and other U.S. territories when funding from the 2018 Bipartisan Budget Act and the Affordable Care Act runs out at the end of September and December 2019.

For Puerto Rico, this means that starting Oct. 1, 2019, the beginning of FY 2020, the island would only receive an estimated $366.7 million in federal Medicaid matching dollars to cover its Medicaid beneficiaries. To be clear, 1.6 million people in Puerto Rico are reliant upon Medicaid – that is nearly half the entire population of the island. Such a drastic cut in funding would not adequately support the needs of beneficiaries and could worsen health outcomes for the island’s people.

For years, Puerto Rico’s second-class status as a territory of the United States has exacerbated the island’s humanitarian crisis. Because of antiquated policies, such as those on Puerto Rico’s federal funding support for Medicaid, residents’ health care has been gravely limited, which has perpetuated serious, systematic problems.

In recent weeks, we’ve seen the people of Puerto Rico fighting back against the problems plaguing their island. The news stories coming from the island have been surprising yet thrilling. More than half a million people took to the streets demanding an end to government corruption and influence-peddling that culminated in the resignation of the governor. This was democracy in action; nothing short of accountability and transparency from their government would be accepted.

Now is the right time for Congress to address the inherent inequality of Medicaid funding for Puerto Rico and all U.S. territories. Arbitrary and unfair regulatory hurdles set up decades ago by Congress have perpetuated a lack of accountability and transparency and must be changed to meet the needs of the people today.

Critical for advancing this goal, the “Community Health Investment, Modernization, and Excellence Act” (H.R. 2328) includes the Territories Health Care Improvement Act, which would make substantive changes to how Medicaid is administered in territories like Puerto Rico. If approved by Congress, H.R. 2328 could go on to provide $12 billion to secure the Medicaid program on the island for four more years.

The people of Puerto Rico have clearly demonstrated their appetite for transparency and accountability, and the mandatory safeguards written into the law ensure that federal funding would always be used to benefit patients.

H.R. 2328’s robust monitoring mechanism for strict oversight of federal Medicaid funds includes much-needed provisions that would better ensure federal funding dollars for Medicaid are used properly. To start, H.R. 2328 would authorize the Department of Health & Human Services’ Office of Inspector General to perform audits of all federal Medicaid funding on an annual basis, including work plans to monitor and/or investigate contracting practices related to the Puerto Rico Medicaid program. The Centers for Medicaid & Medicare Services would oversee all contracts awarded utilizing Medicaid funding. Puerto Rico itself would establish a system for tracking amounts paid by the federal government, as well as local matching of Medicaid funds, and would have information available with respect to each quarter. Furthermore, the Government Accountability Office would issue a report on contracting oversight and approval for the Puerto Rico Medicaid program no later than two years after the date of enactment.

As is clear after weeks of protests and years of unrest, Puerto Rico can no longer afford to operate under the status quo. Such oversight measures proposed by H.R. 2328 are badly needed to help set the island’s Medicaid program up for success and better serve the millions of residents reliant upon health care. But all of this won’t happen if Congress doesn’t act now.

Puerto Ricans are citizens of this country, and they cannot be held accountable for the egregious actions of elected officials and the contractors working on their behalf. Those actions should be condemned, and the right people prosecuted. But absent any congressional action, it may be the population that is dependent on Medicaid for health care that pays the ultimate price for the wrongdoings of their leaders. If Congress does not pass H.R. 2328, millions of people could become uninsured and sick, further sinking the island into a humanitarian crisis.

Michael J. Melendez, LMSW is Principal of MJM CONTIGO, LLC. and was the former the Associate Regional Administrator of the Center for Medicare & Medicaid Services (CMS) Division of Medicaid and Children’s Health Operations for the New York Regional Office.

Dr. Jaime R. Torres was the former regional director of the US Department of Health & Human Services, Region II—serving New York, New Jersey, Puerto Rico and the US Virgin Islands. They are board members Latinos for Healthcare Equity.



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Administration ends protection for migrant medical care

By admin | August 29, 2019

Associated Press

August 26, 2019

Administration ends protection for migrant medical care

By Philip Marcelo

The Trump administration has eliminated a protection that lets immigrants remain in the country and avoid deportation while they or their relatives receive life-saving medical treatments or endure other hardships, immigration officials said in letters issued to families this month.

Critics denounced the decision as a cruel change that could force desperate migrants to accept lesser treatment in their poverty-stricken homelands.

In Boston alone, the decision could affect about 20 families with children fighting cancer, HIV, cerebral palsy, muscular dystrophy, epilepsy and other serious conditions, said Anthony Marino, head of immigration legal services at the Irish International Immigrant Center, which represents the families.

Advocates say similar letters from Citizenship and Immigration Services have been issued to immigrants in California, North Carolina and elsewhere.

“Can anyone imagine the government ordering you to disconnect your child from life-saving care — to pull them from a hospital bed — knowing that it will cost them their lives?” Marino said.

“This is a new low,” Democratic Sen. Ed Markey said. “Donald Trump is literally deporting kids with cancer.”

A Citizenship and Immigration Services spokeswoman said the policy change was effective Aug. 7.

It affects all pending requests, including from those seeking a renewal of the two-year authorization and those applying for the first time. The only exception is for military members and their families.

Going forward, applicants will be able to seek deportation deferrals from a different agency, Immigration Customs and Enforcement, according to the spokeswoman.

Letters sent to Boston-area families last week and reviewed by The Associated Press, however, do not mention that option. They simply order applicants to leave the country within 33 days or face deportation, which can hurt future visa or immigration requests.

Without the discretionary deferrals, immigrant families facing serious health issues have few other options for relief, medical experts in Boston argued Monday.

The deferrals, they added, do not provide families a pathway to citizenship, though they can qualify for government-funded health benefits and receive legal permission to work while their children receive medical treatment.

“They’re not coming for a free ride. They’re coming to save their children,” said Joe Chabot, a director at the Dana-Farber/Boston Children’s Cancer and Blood Disorders Center. “It’s bewildering.”




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Harris’s Fake Medicare-for-All Plan

By admin | August 5, 2019

The American Prospect

August 1, 2019

Harris’s Fake Medicare-for-All Plan

By Robert Kuttner

In the extensive jousting over Medicare for All, Kamala Harris has evaded scrutiny for the most insidious aspect of her plan: It significantly expands for-profit insurance at the expense of true Medicare by promoting more use of commercial products spuriously known as “Medicare Advantage” and calling that a version of Medicare for All.

One of the successes of Republicans and the insurance industry in recent decades has been to take private, for-profit insurance plans whose business model is based on denying needed care—and brand them as “Medicare.” This tactic, ironically, proves the popularity of universal public programs; Medicare is held in such high regard that private companies feel the need to steal its brand. As the saying goes, hypocrisy is the tribute that vice pays to virtue.

Two examples are the “Medicare” drug benefit, which is purely private, and so-called Medicare Advantage plans, which Harris would dramatically expand.

Unlike true Medicare, Medicare Advantage plans are commercial products offered by private insurers. Medicare’s only role is to collect your taxes and pass them along to these insurance companies.

There are two key differences between Medicare Advantage and standard public Medicare. The first is that a Medicare Advantage plan is an intensely “managed” HMO. The plan dictates what doctors and hospitals you can see, what drugs are covered, which conditions can be treated by which procedures at insurer expense. By contrast, standard Medicare does not limit your choice of doctor and hospital, or what the doctor can order.

Why would patients put up with such restrictions? Because there are some things that standard Medicare doesn’t cover. That’s why more-affluent older people with standard Medicare tend to purchase what’s known as “Medigap” insurance, to cover what Medicare doesn’t—starting at about $4,000 and a lot more for true comprehensive first-dollar coverage.

Medicare Advantage is no more expensive to seniors than standard Medicare—because insurers are so relentless at restricting what’s actually permitted as opposed to what’s nominally covered. But with true Medicare for All, those gaps in what’s covered would be eliminated—and there would be no need for commercial “Medicare Advantage.”

Medicare Advantage insurers use one other sneaky and perverse trick. They try to save costs by targeting their marketing to younger, healthier seniors, less likely to get sick. True Medicare doesn’t need do to that because it is for everyone. With commercial “Medicare Advantage,” insurers make their profits precisely to the extent that they deny care one way or another.

That’s what’s so insidious about Harris’s approach. She would expand the commercial part of the system, falsely branded as a variant of Medicare, and take us further away from true seamless and universal coverage.

Thus the real meaning of “Medicare Advantage.” Advantage: industry. Disadvantage: consumers and patients.

According to some, many seniors like Medicare Advantage, and so it would be folly for Democrats to kill it, just as they supposedly like their employer-provided plans. But this is akin to saying that a refugee “likes” crossing rough seas on a makeshift raft. These plans are popular only given the lack of good alternatives.

In the presidential debates, Harris’s critics have gotten all tangled up in issues of how much her plan would cost and the meaning of the ten-year phase-in. They have missed the single worst thing about it—the reliance on more private insurance. It is a travesty to use the term “Medicare” to characterized this deceptive front for expanding the reach of the commercial insurance industry.




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Congressman Pallone Opening Remarks at Hearing on Medicaid Funding Cliff in the U.S. Territories

By admin | July 22, 2019

Energy and Commerce Chairman Frank Pallone, Jr. (D-NJ) delivered the following opening remarks today at a Health Subcommittee hearing on, ““Strengthening Health Care in the U.S. Territories for Today and Into the Future:”

Today, our Committee continues its efforts to ensure that all Americans have access to health care, whether they live in one of the 50 states or one of the five territories.

The territories are on the verge of a financial and humanitarian crisis.  Experts predict that unless Congress acts, none of the territories will have enough federal funds to support their Medicaid programs next year.  Puerto Rico could potentially spend all its federal funds in a matter of months, facing a shortfall of billions of dollars for the year.

It’s no secret how we got here.  For years, the territories have been operating their Medicaid programs under federal funding caps that haven’t kept up with the needs of the people who live there.  The Affordable Care Act provided increased funding that’s helped the territories for the past decade, but that expires at the end of this year.  Natural disasters in the territories have also put increased strain on their Medicaid programs that required Congress to provide additional support to ensure people didn’t lose access to care.

Medicaid in the territories doesn’t operate like it does in the states.  Each territory only receives a certain amount of federal funds that’s supposed to last them the whole year.  It’s essentially a block grant.  In the states, increases in state Medicaid spending are matched with an increase in federal Medicaid funding.  This means that in times of economic downturn, or in the period following a natural disaster, when state Medicaid spending increases, the state receives an automatic increase in federal Medicaid dollars.  That’s not how it works for the territories.  Once they spend their annual allotment, they have to pay for their Medicaid costs using local funds.  This outdated system forces the territories to pay a substantial amount out of their own pockets to ensure the people there have access to health care.   It’s also a stark reminder of why block grants for Medicaid simply don’t work.

The federal funding shortfall means most of the territories aren’t able to provide the full range of benefits that state Medicaid programs are required to cover.  Payments to doctors and hospitals are so low that providers are leaving the islands for the states.  While Congress has provided some time-limited increases to the territories’ Medicaid funding, we need a longer-term solution.  Doling out federal funds in dribs and drabs has led to uncertainty about the financial future of the programs and calls into question the long-term sustainability of the territories’ Medicaid programs if Congress fails to act.

That’s why we are here today – to discuss the Medicaid cliff facing the territories and what we can do to avert a catastrophe.  As we will hear today, without additional funds, hundreds of thousands of people in the territories could lose their health care coverage.  Some territories have said they would have to stop covering prescription drugs, dental care, durable medical equipment, and community health centers.  Others have said they expect to lose even more providers.

None of this has to happen.  We can all see the cliff coming, but if we work together, we can stop the territories from going off it.  We can ensure that they can continue to provide care to the people who need it the most.  We can stop the flight of doctors and providers from the islands.  And we can provide the certainty and sustainability that the territories deserve.

Several members recently introduced legislation that would provide Puerto Rico with both the amount of federal funds requested by the Governor, and establish a path to help transition its Medicaid program to a full, state-like program.  This would provide sufficient funds to Puerto Rico to ensure its people receive the health care services they need.  I want to thank the Members for their hard work on this bill, especially Rep. Soto on our Committee.  I hope this can potentially be a roadmap to help strengthen the Medicaid program in other territories.

I also want to thank the witnesses for being here today, particularly those that traveled long distances to share your expertise with us.

Thank you.




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Sanders, Co-sponsors Unveil Legislation to Put Territories on Par with States for Medicaid

By admin | June 11, 2019

WASHINGTON, June 11 – Sen. Bernie Sanders (I-Vt.) along with seven other cosponsors in the Senate, introduced legislation Tuesday to address the immediate humanitarian needs in the territories, including Puerto Rico and the U.S. Virgin Islands.

The Territories Health Equity Act of 2019 (S. 1773) would correct long-standing inequities in federal health care funding for Medicaid and Medicare, and give the nearly four million Americans living in the U.S. territories of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands access to the health care they need. The bill is cosponsored in the Senate by Sens. Jeff Merkley (D-Ore.), Kirsten Gillibrand (D-N.Y.), Richard Blumenthal (D-Conn.), Kamala Harris (D-Calif.), Cory Booker (D-N.J.), Elizabeth Warren (D-Mass.), and Ed Markey (D-Mass.). Rep. Stacey Plaskett (D-V.I.) introduced the companion bill (H.R.1354) together with 37 cosponsors in the House. The Senate version of the bill is endorsed by the American Federation of Teachers, Latinos for Healthcare Equity, BoricuActivate, Boricuas Unidos en la Diaspora (BUDPR), and the International Association of Machinists & Aerospace Workers Union.

Over a year and a half after Hurricane Maria, much of Puerto Rico and the Virgin Islands remain devastated. The vast majority of residents in Puerto Rico—a full 85 percent—report they are worried they will be unable to access health care if they need it. Nearly one in four people living in Puerto Rico report they or a family member have developed a new or worsened health condition as a result of Hurricane Maria, and one in three report they or someone in their home have had trouble accessing medical care. Similarly, in the face of an increased demand for services, the U.S. Virgin Islands has been unable to spend the Medicaid dollars required to secure federal matching funds.

Temporary Medicaid funding for Puerto Rico and the U.S. Virgin Islands expires in September. This funding cliff could be disastrous for the more than 1.5 million people covered by the program. In Puerto Rico alone, an estimated 900,000 people could lose coverage.

The legislation introduced today would provide the territories with the same need-based, open-ended Medicaid funding that is currently available to the fifty states and the District of Columbia by eliminating the arbitrary cap on annual federal Medicaid funding and increasing the federal matching rate for the territories’ Medicaid expenditures. The bill would also address Medicare disparities by updating hospital reimbursements and increasing funding for the territories to provide prescription drug coverage to low-income seniors. Above all, the bill would ensure that Americans living in the territories are eligible for health coverage that is as comprehensive as the coverage available to Members of Congress.

“It is unconscionable that in the wealthiest nation in the world we have allowed our fellow citizens to suffer for so long. The full resources of the United States must be brought to bear on this crisis, for as long as is necessary,” said Sanders. “We must go forward to ensure a strong health care system in all the territories and address inequities in federal law that have allowed the territories to fall behind in almost every measurable social and economic criteria.”

“I would like to thank Senator Sanders for introducing the Senate companion bill to H.R. 1354, Territorial Health Equity Act of 2019. Both bills make improvements to the treatment of the United States territories under the Medicare and Medicaid programs. I am appreciative that Senator Sanders continues to support on matters that are critical to the well-being of residents in the U.S. territories,” Plaskett said.

“Families in Puerto Rico, the U.S. Virgin Islands, and other territories deserve access to the same federal health care programs as families throughout the rest of the United States—no exceptions,” said Senator Warren. “We are introducing the Territories Health Equity Act to end discriminatory double standards in the way Medicare and Medicaid are administered in the U.S. territories.”

“As co-sponsors of the House version of this Bill we are excited to have Senator Sanders joining us in the fight for Territorial healthcare equality. These measures will bring much needed parity in the Medicaid funding levels for Guam and relieve a legacy pressure point that has been choking our healthcare budgets for decades,” said Delegate Michael F.Q. San Nicolas (D-GU-At Large)

“More than 3,000 U.S. citizens died in the wake of Hurricane Maria, largely due to the incompetence and delay of President Trump’s federal response. Instead of being allowed to recover, Puerto Rico is being threatened with cuts, with one million residents at risk of losing their already-insufficient Medicaid coverage in September. I applaud Senator Sanders and his colleagues for introducing the Territories Health Equity Act of 2019 to ensure that Puerto Rico’s vulnerable families receive full, open-ended federal funding for need-based care. This is a vital step in Congress’s recognition that Puerto Rico can no longer be treated as a colony, and moreover, a step toward social justice,” said Carmen Yulín Cruz, Mayor of San Juan, Puerto Rico.

“The U.S. government can no longer turn its back on the American citizens of Puerto Rico, and treat us as second class citizens. That is why we support Senator Sanders’ Territories Health Equity Act of 2019 which will finally result in a permanent fix to the discriminatory and unequal Medicaid and Medicare funding for Puerto Rico, the USVI and all territories. This is more urgent than ever since Puerto Rico faces an upcoming ‘Medicaid cliff’ which, if not funded by the end of 2019, may result in 600,000 Puerto Ricans become uninsured overnight,” said Dr. Jaime R. Torres of Latinos for Healthcare Equity.

“U.S. territories have had to withstand decades of unequal and colonialist treatment. In the last couple of years, they have also had to withstand the increasing impacts of climate change with direct hits from record-setting tropical cyclones. This time, the already suffering and vulnerable people in these U.S. territories face another catastrophic threat, this time to their medical care, which can be easily adverted by the U.S. Congress, if its members decide to put the well-being of its colonial subjects at the same level as those U.S. citizens living in the states,” said Edil Sepúlveda, Co-founder of Boricuas Unidos en la Diáspora.

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By admin | June 7, 2019

Dear Presidential Candidates:

We, the undersigned organizations, representing millions from the Puerto Rican Diaspora and allies, strongly urge you to publicly support a comprehensive platform addressing the fiscal and economic crises facing the Commonwealth of Puerto Rico.

The people of Puerto Rico, U.S. citizens and residents alike, are still recovering from devastating firsts —including the worst natural disaster and largest bankruptcy proceeding in U.S. history— a depressed economy, and imminent fiscal cliffs in public health, schooling and higher education, public pensions, and nutritional assistance. Many of these challenges are the result of artificial, arbitrary, and often discriminatory decisions made by the federal government in how it treats Puerto Rico. Only bold action spurred by presidential leadership – together with detailed policy prescriptions – can move the needle on these complex issues.

As a presidential candidate, we strongly urge you to publicly support the following policy priorities. Though action is needed on many more fronts, Puerto Rico needs:

A Marshall Plan-type mobilization to fully rebuild and recover after Hurricanes Irma and Maria

Full participation of Island residents in critical federal anti-poverty programs such as:

–        Medicaid

–        Child Tax Credit (CTC)

–        Earned Income Tax Credit (EITC)

–        SNAP

Economic tools such as:

–        Jones Act exemption

–        Fix how federal tax reform law treats the Island and provide tax incentives for job creation, along with improved labor standards

–        Significant public debt relief

Recognition of the right to self-determination of the Puerto Rican people along with a permanent and self-sustained, inclusive, fair and transparent process to end 121 years of U.S. colonialism in Puerto Rico

We stand ready to assist you and your team to answer any questions or provide more in-depth analysis of Puerto Rico issues and look forward to your prompt response as we prepare to periodically report back to the public on the policy positions taken by all presidential candidates.


Alianza for Progress/Florida
Asociación de Puertorriqueños en Marcha (APM), PA
Americas for Conservation and the Arts
Bay Area Alliance for a Sustainable Puerto Rico, Leadership Committee
Bay Area Boricuas
Boricua Vota
Boricuas de Corazón, Inc
Boricuas Unidos en la Diáspora
Catalino Productions
Diáspora en Resistencia
El Puente
Faith in Florida
Fort Washington Collegiate Church
Green Latinos
Hispanic Federation
Iniciativa Acción Puertorriqueña
Juan Antonio Corretjer Puerto Rican Cultural Center
La Tertulia Boricua of San Francisco Bay Area
LatinoJustice PRLDEF
Jangueo Boricua
Misión Boricua
National Boricua Human Rights Network
National Conference of Puerto Rican Women
National Puerto Rican Agenda
Organize Florida
Our Revolution Puerto Rico
Parranda Puerto Rico
Puerto Ricans in Action (Los Angeles)
Puerto Rican Arts Alliance
Puerto Rican Alliance of Florida
Puerto Rican Women in Action
Puerto Rico Advocacy Group
Puerto Rico Connect
The Puerto Rican Agenda of Chicago
Women’s March – FL

Signatories as of June 7th, 2019

CASA Maryland
Corazones Unidos Siempre Chi Upsilon Sigma National Latin Sorority, Inc.
Daily KOS
El Centro de Servicios Sociales/Ohio
El Puente Puerto Rico: Enlace Latino de Acción Climática
Florida Immigration Coalition
G-8, Grupo de las Ocho Comunidades Aledañas al Caño Martín Peña, Inc.
Hispanic Roundtable/Ohio
Latino Victory Project
Latinos for Healthcare Equity
MoveOn Political Action
National Urban League
New Florida Majority
Puerto Rican Leadership Council of South Florida
Vieques en Acci?n
Young Latino Network/Ohio
Edgardo Miranda, creator of La Borinqueña
Nilda Medina, Executive Director, Incubadora Microempresa, Bieke, Inc.
Roberto Rabin, Director, Vieques Historic Archives & General Manager of Radio Vieques



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2019 Medicaid funding cliff could cause mass migration from Puerto Rico

By admin | April 3, 2019

“Chronicle of a “disaster” foretold” — an ominous phrase coined by author Gabriel Garcia Marquez that no longer characterizes a fictional novel, but a very real and terrible occurrence that may happen in Puerto Rico at the end of this year.

Puerto Rico is still recovering from the historic destruction caused by Hurricanes Irma and Maria and now, to add insult to injury, close to one million residents are in peril of losing their Medicaid coverage in 2019. A man-made, perfect storm that could impact not just Puerto Rico, but also states like Florida and other states where residents could potentially relocate to maintain their Medicaid coverage.

Citizens of the United States since 1917, the island’s residents are among the poorest in the nation, with 43.5 percent living below the federal poverty line, compared to 14 percent nationally. Those living under the poverty line are most reliant on public services like Medicaid.

Puerto Rico, with a total population of 3.4 million, covers 1.3 million residents under Medicaid at a total cost of $2.62 billion a year. If it were a state, the federal Medicaid reimbursement rate would cover most of the cost. But because Puerto Rico is a U.S. territory, it is ruled by discriminatory, archaic and unacceptable Medicaid rules that limit the federal funding the island receives to cover these U.S. citizens.

Unlike in the states, where federal Medicaid funding is not capped and the federal share varies based on states’ per capita income, federal funding for Medicaid in the territories is subject to a statutory cap and a fixed federal matching rate. Because of this, Puerto Rico’s Federal Medical Assistance Percentage (FMAP) is capped at 55 percent when it would be closer to 83 percent if it was calculated similarly to rates set for U.S. states.

Under these unequal, discriminatory regulations, Puerto Rico experiences a significant burden to cover its medically indigent. This steep fiscal burden has contributed significantly to Puerto Rico’s troubled fiscal situation, which helped lead to the government declaring bankruptcy. It also helps explain why health outcomes on the island are generally worse than in the states, with residents having higher rates of heart disease, diabetes and infant mortality.

Now these problems may become even worse. In February 2018, Congress approved additional funding for Puerto Rico through the Bipartisan Budget Act (BBA), which provided $4.8 billion for Puerto Rico. These relief funds expire at the end of September 2019, which means that just a few months from now, 900,000 Puerto Rican residents could lose their Medicaid coverage.

Not only would this be disastrous for those already struggling on the island, but it could also financially burden southern states like Florida and northeast states like Massachusetts, Connecticut, New York and Pennsylvania, where residents of Puerto Rico most commonly migrate. If health conditions continue to worsen on the island, residents will have no choice but to move to where they have historically sought better health services on the mainland.

This health-driven migration could cost about $9.7 billion for the federal government and $6.1 billion divided among various states. By comparison, the cost of providing these services in Puerto Rico would total less than $4 billion.

This potential mass migration is 100 percent preventable. Congress can act to immediately end the unequal funding of Medicaid for Puerto Rico and achieve stability in the island’s health care system.

Through legislative fixes, Congress can change the formula of how the cap is calculated by covering the cost of all residents at or under 100 percent of federal poverty level, as is currently applied to the 48 contiguous states and Washington DC. This is one of multiple solutions that could help stabilize Puerto Rico’s health care system, getting rid of the cap would go a long way towards increasing the island’s financial assistance and getting its residents back on their feet.

One way or the other, Congress will have to help Puerto Rico’s residents and provide them with the health services they need to thrive as part of our country’s essential fabric. If Congress does not act soon, the probable disaster of Puerto Rico’s Medicaid funding cliff will not be just for the island to bear alone.

Dr. Jaime R. Torres is the president of Latinos for Healthcare Equity and the former regional director of the U.S. Department of Health & Human Services, Region II, serving New York, New Jersey, Puerto Rico and the U.S. Virgin Islands.

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Plaskett’s Bill Calls for Eliminating Health Care Inequities in U.S. Territories

By admin | March 28, 2019

Delegate to Congress Stacey Plaskett on Wednesday again called for equitable treatment of United States territories when it comes to healthcare funding, announcing that she is reintroducing the Territories Equitable Health Act that seeks to lift the cap on the federal Medicaid match that exists only for U.S. territories.

“This has been an issue for decades. It has become an even more significant issue in the aftermath of the natural disasters that the territories have all experienced in the past two years,” Plaskett told reporters at a press conference in Washington.

In the Virgin Islands, even though residents pay the same taxes for Medicaid, Medicare and Social Security as employees anywhere in the country, federal law has set a cap on the federal match for Medicaid payments at 55 percent. Federal Medicaid match in the 50 states and Washington D.C., however, are open-ended; these jurisdictions enjoy a federal match from 50 percent up to 81 percent for the poorest states.

“That is not fair. It is not within parity, and it is not equitable,” Plaskett said. “This is a fundamental underlying problem that the territories have: a limited federal medical assistance percentage, in addition to a cap on overall funding.”

The Medicaid funding cap for the territories means once the cap is reached, the territories must bear the full cost of Medicaid services.

“The caps are antithetical to the purpose of the program, to be able to expand and contract based on local need,” Plaskett said.

Rep. Jenniffer Gonzalez-Colon (R-PR), who stood beside Plaskett at the press conference, said Puerto Rico is suffering from the same restrictions, with Medicaid federal match capped at 55 percent even though 45 percent of Puerto Rico’s population falls below the poverty threshold, compared with Mississippi’s 21 percent.

The situation was worse before the Obama-era Affordable Care Act. In 2005, the U.S. General Accounting Office found that the territories only received about $50 per capita in Medicaid funding, while states received $800 per capita. The Affordable Care Act provided supplemental funding for the territories starting July 2011, according to Plaskett, which also allowed for the increase of funding from 55 percent to 100 percent in the aftermath of Hurricanes Irma and Maria. That support, which is crucial, according to Plaskett, expires in September 2019.

In the case of Puerto Rico, the territory received a direct allocation of $3.8 billion dollars that resulted in 100 percent of federal cost share for Medicaid and Medicare services, but that also ends in September 2019.

“If we are not addressing [that] in this kind of bill, we’re going to have, in the 2020 budget, a lot of federal funding [that] will revert statutorily to the cap of 55 percent,” said Gonzalez. “That’s the reason we need to fix, in the long term solution, this situation with federal medical assistance percentage.”

The low rate of federal matching funds is arbitrary, according to Plaskett, and has forced the government of the Virgin Islands to spend more local Medicaid dollars than a state would. The 55 percent local match also meant keeping the Medicaid eligibility rolls down, setting unrealistic income requirements that exclude individuals who would have qualified for Medicaid in states. This results in residents of territories moving to states that can provide better for their healthcare needs.

“Before the 2017 hurricane season, a state-like FMAP alone, if we had been treated in the similar manner as the states, it would have provided the government hospitals in the Virgin Islands approximately $22 million per year in local matching funds and would have reduced the uncompensated care costs, and subsidized the local treasury,” Plaskett said.

Plaskett said the effects of the low federal match were seen after the 2017 hurricanes, when hospitals were destroyed because “hospital administrators have to make the decision between putting a new roof on, supplementing, or paying doctors and nurses and healthcare individuals.”

In addition, Plaskett said, even before the storm, the territory’s two hospitals — Schneider Regional Medical Center on St. Thomas and Juan Luis Hospital on St. Croix — were excluded from the Medicaid Disproportionate Share for Hospitals program, or DSH, in spite of the significant amount of uncompensated care.

Plaskett’s legislation, HR 1354 or “The Territories Health Equity Act of 2019,” with support from representatives from other territories, aims to lift the Medicaid caps and provide for fair inclusion of the territories in Medicaid, Plaskett said.

The Territories Health Equity legislation would also address low hospital payments under Part A.  Hospitals in the Virgin Islands receive Medicare compensation under Part A through a system using what Plaskett calls out-of-date reimbursement formulas. Payments to the two hospitals are based on 1982 and 1996 costs, annually adjusted for inflation, but due to the large permanent changes in services, Plaskett said, the cost of care at both hospitals is not comparable to the inflation-adjusted expenses of their base year.

The legislation would also include small territories in the Medicaid DSH program, Plaskett said, improve the treatment of territories under Medicare Part D, or its low-income subsidy programs.

“We must confront the difficult reality that these territories and citizens and residents have [been] neglected and allowed to fall behind. This bill attempts to bring parity of Medicaid services,” Plaskett.

Rep. Darren Soto (D-FL), who arrived later in the press conference to show support for the bill, has been “a champion and huge supporter” of U.S. territories, according to Plaskett, particularly of Puerto Rico and the USVI. After the 2017 hurricanes, Soto was one of the first people to step forward and offer support to the two Caribbean territories, she said.

“We cannot overlook health care equality in our nations’ territories as well,” said Soto, pointing to the cultural and economic connections his state has with Puerto Rico and the Virgin Islands.

“We take no enjoyment in knowing that there has been an exodus of doctors from Puerto Rico to Florida. We want Puerto Rico, we want the Virgin Islands to succeed and that means we have to have a well-funded system that has topnotch hospitals, that has access to healthcare, that creates a system where doctors want to continue to practice in the Virgin Islands…in Puerto Rico,” Soto said.

As for bipartisan support and the bill’s prospects for passage, Plaskett said many members of Congress from both sides of the aisle support the bill, including members of Congress representing districts in New York, Florida and Texas that have many constituents from the U.S. territories. Soto is a member of the committee of primary jurisdiction for the bill, the Committee of Energy and Commerce. Plaskett said she has also had conversations with Committee Chairman Rep. Frank Pallone (D-NJ) and Rep. Diana Degette (D-CO), who chairs the Subcommittee on Oversight and Investigation under the Committee on Energy and Commerce.


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Life and Limb–Inside the Rio Grande Valley’s Amputation Crisis

By admin | March 9, 2019

Daniel Zamora still remembers the smell. At first he didn’t realize anything was wrong. A small blister appeared on his left pinky toe where his sneaker rubbed against his skin. He had developed blisters before, but this one wouldn’t go away. First the tip of the toe darkened, slowly turning the jet-black color of his hair. Then the color spread toward the rest of his foot.

He was used to ignoring such things. It was 2016, and Zamora, now 55, had gone his whole life without health insurance. Born in Matamoros, Mexico, he moved across the border with his family to Brownsville when he was about 6 years old. For decades, Zamora, a legal permanent resident, worked maintenance jobs for low pay and no benefits. He couldn’t afford to take time off or see a doctor. Sometimes, when he wasn’t feeling well, he’d brew an herbal tea from the leaves of the moringa tree just outside his front door. He often tried curing his cuts and blisters with ointment or rubbing alcohol. Occasionally, if things got really bad, he reluctantly went to the emergency room, where, he says, doctors made snide remarks about his inability to pay.  So he waited. Maybe it would pass.

Finally, the smell got unbearable. Like road kill in the hot South Texas sun. A couple of months after the blister appeared, Zamora drove 2 miles to Valley Baptist Medical Center, where doctors quickly diagnosed him: His diabetes, uncontrolled for years, had blocked blood flow to his toe, preventing it from healing. What began as a minor blister was now a life-threatening emergency. Zamora says the doctors sent him home with medication to treat the wound, but a few weeks later he went back to the ER, where he had two toes on his left foot amputated to prevent gangrene from spreading up his leg.

When Zamora found out he had diabetes, about 10 years ago, it didn’t come as much of a surprise. In the Rio Grande Valley, nearly one in three people has the disease, triple the national rate. The Valley is among the poorest and least-insured regions in the country. It’s also overwhelmingly Hispanic, a population that has a higher risk of developing type 2 diabetes.

Perhaps the most visceral indication of the Valley’s diabetes crisis is the shocking number of people living with amputations. The rate of diabetic amputations in the Valley was about 50 percent higher than the state rate in 2015, according to data from the state health agency. In Cameron County alone, where Zamora lives, hospitals recorded 281 diabetic amputations that year. That’s more than 50 percent higher than the national rate, according to the Centers for Disease Control and Prevention. The estimated amputation rate in smaller Willacy County, just north of Cameron, was more than four times the national rate. “Good gracious,” said Ed Gregg, a CDC epidemiologist, when looking at the data. “What’s going on with Willacy?”

When he first found out he was diabetic, Zamora says, he “didn’t pay too much attention to it.” Both of Zamora’s parents died from diabetes, which is the seventh-leading cause of death in the United States. His father used a wheelchair for the last years of his life, after a diabetic amputation above the knee. In the Valley, there’s a fatalism associated with the disease, often considered an inevitable inheritance.

What Zamora didn’t realize is how big an impact a small blister would have on his life. For months after the surgery, he couldn’t walk. Nor could he afford professional wound care, so his son came by each day to change the bandage. Zamora had to quit his job cleaning a nearby gym because it required him to be on his feet and lift heavy weights. Along the way, he racked up about $100,000 in medical bills, which he’ll never be able to pay. When he developed an ulcer on his other foot, he went to see a doctor in Matamoros, because it would be cheaper. Finally, last summer, Zamora’s disability qualified him for Medicaid and Medicare.

When I ask how he’s doing, Zamora’s typical response is: “surviving.” He’s frustrated that he had to wait until he was very sick and couldn’t work to get health coverage from the government.

“Being diabetic is real bad…” Zamora’s voice trails off. “A lot of people die from it.”

He’s adjusting to life as an amputee, but he still loses his balance, wobbling “like an egg” when he walks. That, along with vision problems due to the diabetes, makes manual labor difficult. But without a high school diploma, he has few job options. For now, Zamora is surviving on a disability check that’s even less than the $1,300 a month he made at the gym.

It’s a story told over and over again in the Valley: You don’t know you have diabetes until it’s severe, because you rarely see a doctor. You get a cut or blister but ignore it, because diabetes-related nerve damage means you can’t feel it, or you’re too busy working or taking care of your family to go to the doctor. The wound gets infected. By the time you get help, the infection is so bad that amputation is necessary. You can’t afford proper care, so sometimes the wound gets infected again. You get another amputation.

In the Valley, there’s a fatalism associated with the disease, often considered an inevitable inheritance. Diabetic amputations have a domino effect on the lives of patients and families. It begins with the patient exiting the workforce, sometimes decades early, “which creates every complication we can think of,” said Belinda Reininger, regional dean at the UTHealth School of Public Health in Brownsville. “The family’s economic situation is negatively impacted; children may have to start working and supporting their parents, slowing or putting aside their educational attainment goals. … We’re already an area known for living $20,000, $25,000 below the median income of the state — to lose your wage earner is just tremendous. That’s at the family level; you magnify that to the society level and it continues to ripple.”

Each diabetic amputation represents not just a personal tragedy, but a failure of the U.S. health-care system. The epidemic also suggests a possible future for the rest of the country, as life expectancy increases, the Latino population booms and health officials grapple with how to get diabetes under control. The number of adults diagnosed with diabetes in the United States quadrupled between 1980 and 2014. CDC researchers now project that the number will nearly triple by 2060.

A new study published in Diabetes Care in November found that following a two-decade decline, the rate of diabetic amputations nationwide increased in recent years, especially among young and middle-aged adults. Gregg, who worked on the study, told the Observer that though diabetes care overall has improved, the “alarming” findings are a “wake-up call.” He says amputations are important indicators that something went wrong with diabetes management, because they’re generally preventable in patients who can access diabetes education and primary care.

Lisa Mitchell-Bennett, a project manager at UTHealth, put it more bluntly: “We’re literally cutting people’s limbs off, when they could just be taking medication. It’s kind of crazy in a developed country.”

When patients at risk of amputation resist Noel Oliveira’s instructions to stay home from work and off their feet, he has a simple response: Enjoy life one-legged! That tends to make them listen.

A family physician who’s originally from Brownsville, Oliveira opened the first wound care center in the Rio Grande Valley in the early ’90s. At his Edinburg clinic, tucked into a complex of buildings at Doctors Hospital at Renaissance, most of his patients are diabetic, with stubborn wounds that refuse to heal. He tries to prevent amputations by treating severe cases like Zamora’s. Before, diabetics had to travel hours to get this kind of care, said Oliveira, who co-founded the Rio Grande Valley Diabetes Association in 2007.

“In every corner of the United States, and the globe, diabetes and obesity has become a problem. In our area, it’s just magnified,” he said when I visited him at his office in December. The clinic was cheerfully appointed with Christmas decorations; a shiny banner reading NOEL hung across Oliveira’s door.

He shows me the mementos in his office: a black T-shirt reading “Renaissance Rockers,” the name of the band he plays guitar in with other doctors at the hospital. There’s a photo with FBI agents he treated, and another from when he served as a WWE team doctor. (“They don’t mess around, man.”) On his desk is a Selena-themed thermos next to a DVD of Dr. No — his nickname around the clinic.

Nearly bald and sparsely mustached, Oliveira is blunt yet warm with his patients. Over the course of his career, he’s seen more wound care practices like his crop up across the Valley; coupled with medical advances, that means there are more opportunities to prevent the loss of limbs, he says. But Oliveira and other doctors describe persistent obstacles.

“The lifestyle in the Valley is high-work, low-income,” said Oscar Corral, a podiatrist in McAllen. Dealing with devastating wounds is routine, because caring for oneself often takes a backseat to looking after family and putting food on the table.

Corral recently stopped doing amputations because it was too upsetting. He focuses now on preventive foot care. “Everybody’s big on the amputations, but not big on the preventive care part. They’re so busy doing hospital consults on patients that already need an amputation. … They don’t have time to do the preventive care.”

When I visit Oliveira’s clinic, he’s seeing an elderly man named Israel Guerra who’s had uncontrolled diabetes for years. Like Zamora, he didn’t have health insurance until late in life, when he qualified for Medicaid and Medicare through disability. A couple of years ago, a doctor amputated half of Guerra’s left foot after blisters on his toes refused to heal. In November, he lost his right leg just above the knee. “That one was his good leg, one he could rely on, walk better on,” Guerra’s daughter Esmeralda says, pointing to his right leg. She holds up his left shoe, which is half-filled with foam. “But now, now this one is the good one.”

Guerra is at the clinic because of a small wound near his groin. He lies on the bed staring at the ceiling, pulsing his right thigh up and down. At first he didn’t want to tell the doctors he could still feel the leg — a common “phantom limb” sensation — because they’d think he was crazy. Sometimes his missing leg still itches; he tries to soothe it by scratching the air where it used to be.

It’ll be months before Guerra can get a prosthetic leg. In the meantime, Esmeralda, who has a family of her own, says she left her waitressing job at Denny’s to help with his care. She tears up when I ask how it’s going. “He’s very motivated. He’s actually being stronger for us than we’re doing for him.”

McAllen podiatrist Joseph Caporusso, who Guerra says did his first foot amputation, told me that he performs at least one toe or partial foot amputation each week, often on repeat patients. The hope is to prevent repeat amputations through proper wound care. “Once you have an amputation, it’s kind of like falling down a mountain,” he said. “My job is to stop it at hopefully the top of the mountain, before you fall more.”

Oliveira leaves Guerra and his daughter with a set of instructions: Don’t pack the wound too tightly. Keep it clean. Move the leg so the muscles don’t atrophy. And later, when you’re back on the dance floor, no fast songs. Oliveira raises his arms to an imaginary partner and sways slowly. “Solo canciones románticas.” Only romantic songs.

The message Oliveira gives patients is one of empowerment, to take control of their own health. He recounts a recent visit with a patient who ignored his instruction not to work while his foot healed. The man returned to the clinic weeks later with an infection that threatened to consume his foot. After Oliveira removed the gangrene, the man followed the doctor’s orders by staying home, wearing appropriate shoes and lowering his blood sugar. It looks like he will save his foot. “It’s dang hard, bro, but you’ve got to do it,” Oliveira recalls telling him. “If you want to stay two-legged, 10-toed, that’s what you’ve got to do.”

A few buildings over from Oliveira’s clinic, a support group meets at the hospital each month to help each other in the difficult process of recovering from and living with an amputation. Most of the participants have diabetes, including the group’s founder, Elizabeth Reynoso, whose leg was amputated in 2015 after a small cut from clipping her toenail got infected. She started the group to find people who understood and shared her experience. “When you lose your leg, it’s like losing a loved one,” she said after a presentation about depression and mental illness in the November meeting. “There’s anger, there’s depression, there’s sadness, there’s what-ifs, why me. You question it a lot. You need the help in dealing with that.”

Diabetes is sometimes called the “silent killer” because so many people don’t realize they have it until it’s too late. Both type 1 and type 2 diabetes can be managed with proper medication and care, but the American Diabetes Association estimates that of the 30 million people living with diabetes in the United States, nearly a quarter don’t know.

“Everybody’s big on the amputations, but not big on the preventive care part. They’re so busy doing hospital consults on patients that already need an amputation. … They don’t have time to do the preventive care.”

In the Rio Grande Valley, the numbers are more stark. Researchers at UTHealth estimate that nearly 30 percent of adults in the Rio Grande Valley are diabetic, and more than one-third of Valley diabetics don’t know they have the disease. Another 32 percent of Valley residents have prediabetes.

By the time people seek treatment, the complications can be devastating. “When you see people going blind, missing part of their body, down here the first thing you ask is, ‘Are they diabetic?’ The majority of the time the answer is ‘yes,’” said David Ceron, 42, a former teacher in McAllen. He recently published an e-book called The Adventures of Exo and Cy to teach kids how to prevent diabetes through healthy diet and exercise. In his family, the disease is rampant. Ceron, his mother and all seven of his siblings have had diabetes. Three siblings had amputations; two of them died from diabetes. The third, Carmen Zuniga, 61, lost her sight, developed heart problems and last year began dialysis for 12 hours every week.

“What’s been really shocking and disturbing is oftentimes the age these patients will present with such horrific conditions,” said Christopher Romero, a doctor at Valley Baptist Medical Center in Harlingen. “They’re often younger than one might expect to have developed such severe complications. So it’s probably a result not only of it being poorly managed, but also being late in diagnosis.” Even for patients who are diagnosed early in life, “making it to the doctor is just the tip of the iceberg when it comes to the challenges in dealing with diabetes,” said Romero.

On an unseasonably hot and sticky November afternoon, Daniel Zamora steps onto a scale in the cramped kitchen of his one-bedroom home near downtown Brownsville. “Pobrecito,” he mutters. Poor scale.

Zulema Medrano, a community health worker, or promotora, and diabetes educator at the local nonprofit Proyecto Juan Diego, laughs and scribbles Zamora’s weight in her notebook: 251 pounds. It’s gone down since their last check-in a few months earlier; that’s good news. The bad: Zamora’s blood sugar level is dangerously high, putting him at risk for more complications. Does he know why it might have spiked?

Zamora shakes his head. “La comida,” he guesses. Colorful fruit-and-vegetable-shaped magnets pepper the outside of his mostly empty refrigerator. On his kitchen table, next to his pile of pill bottles and blood-sugar tests, is a bag of limes, which he squeezes into water in place of soda. He’s trying to eat better, but it’s hard. Zamora’s favorite foods are ones he has eaten his whole life: menudo, enchiladas, tamales. He lists them slowly, as though dreaming up his next meal. Plus, healthy food is expensive, he says. At the corner store, he can get a plate of taquitos for just a few dollars.

Sometimes, for a bit of exercise and fresh air, Zamora takes a slow walk around his public housing complex, looping down a couple of blocks and back to his own, where, he says, he pays just over $150 in rent each month. An old bench press sits just inside the front door, stacked with papers, gathering dust.

A community health worker, Zulema Medrano, measures Daniel Zamora’s waist at his home.  SOPHIE NOVACK

Zamora is enrolled in the Salud y Vida diabetes program, a partnership of local nonprofits, hospitals and universities. Funded in large part through a Medicaid Section 1115 waiver from the federal government, the program serves as a bridge between individuals and the health-care system, providing home visits and blood-sugar tests every three months, and seven classes on managing the disease.

Medrano and I leave Zamora and drive north on the highway back to her office, past towering fast-food signs and strip malls that connect Brownsville’s residential neighborhoods. She sighs, “Daniel’s not doing good right now.” Medrano decided to help diabetic patients like Zamora because her mom has had the disease for 30 years. Medrano, who has hypertension, used to be on that path too, previously weighing 200 pounds. Then she started eating better and taking Zumba classes through Proyecto Juan Diego, where she heard about the promotorajob. But she no longer attends the exercise classes. “I’m too busy!”

Medrano shares a frustration I’ve heard from doctors across the Valley: People too often follow the advice of friends, family and neighbors instead of medical professionals. “If they don’t help us, how can we help them?” she says of patients skipping their meds or using unprescribed remedies. Part of it is cultural, Medrano explains: “That’s a typical thing with us, the Mexican people,” she laughs. “Normally with the people we work with, they believe other people and not their doctor. … They say that doctors only want their money.”

“When you lose your leg, it’s like losing a loved one. There’s anger, there’s depression, there’s sadness, there’s what-ifs, why me. You question it a lot.”

But it’s hard to separate cultural explanations from systemic ones. In the Valley, health care access is often sporadic and inconsistent, and community health centers are overburdened and underfunded; many people never form lasting relationships with health professionals. Zamora has spent his life without insurance, without a consistent doctor, forgoing necessary medicine or stretching doses because of cost. And he’s survived. So why should he take two different kinds of insulin now, he wonders — is that really necessary?

Another community program aims to reach people at risk of diabetes before it gets too bad. At a makeshift clinic in the pulga, or flea market, in Alamo, nestled among booths hawking tropical fruits, used clothing and Mexican candy, health workers offer free diabetes testing and consultation. Posters about nutrition and exercise cover the turquoise walls of the clinic, which resembles an elementary school classroom. So far, the grant-funded project has screened a few thousand Valley residents. Anyone who tests positive is referred to an appointment at a low-cost community health clinic.

When I ask doctors and advocates across the Valley how the diabetes epidemic can be reversed and amputations reduced, they point to two broad and interconnected priorities: access to preventive health care and education. Funding community programs like Salud y Vida and the pulga clinic is an important first step. But in the long term, a patchwork of grant-dependent programs and cash-strapped clinics can only do so much.

The biggest leap forward would be for Texas to expand Medicaid under the Affordable Care Act. Yet Republican lawmakers, opposed to Obama’s signature law, have repeatedly declined billions in federal funds that would extend health care coverage to about 1 million poor Texans. In the Rio Grande Valley, about 100,000 people would be newly eligible for coverage, according to a December study from the Urban Institute, a Washington, D.C., think tank.

There’s a strong economic case for better access to preventive care, too. In Texas alone, there were just over 31,500 hospital discharges due to diabetic lower extremity amputations from 2014 to 2016, costing more than $3.4 billion, according to state data. That’s an average cost of about $108,700 per amputation. Just over half the amputations were covered by Medicare. About 15 percent of the cases were uninsured patients like Zamora, where the hospitals were likely on the hook for much of that cost.

“Anywhere we can keep people from having their first entrance into the medical system be in the emergency room, we’re saving money,” said Reininger, the UTHealth dean, who pointed to health coverage and “incentivizing prevention” as important steps. “If we build trails and people are more physically active, does that help? I think it does. When we do school-based interventions and we prevent kids from becoming diabetic at 14, do we save money in the long run? Absolutely.”

There’s been slow progress. Communities in the Valley have started farmer’s markets, organized races and built hiking paths in recent years. But a broader shift is needed, Reininger said, in how the country prioritizes health, and how it invests now for the sake of long-term savings — of taxpayer dollars, lives and limbs.

“We are not going to solve this issue one foot at a time, one toe at a time,” she said. “That is only putting a little Band-Aid on a very big issue.”

Top caption: Elizabeth Reynoso, whose leg was amputated in 2015, is the founder of a support group for amputees in the Rio Grande Valley.

Life and Limb

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