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Health Reform Is In Need Of Reform

by Robert Becker

October 5, 2001
Copyright © 2001 THE PUERTO RICO HERALD. All Rights Reserved.

Puerto Rico's massive public health plan, known affectionately as "la tarjetita," or the little card, is ailing.

The health reform was perhaps the single most ambitious undertaking of former Gov. Pedro Rossello's administration. Launched in 1993, when Rossello took office in his first term, the sprawling and costly plan now covers some 1.8 million people - nearly haft of Puerto Rico's population. Rossello won reelection in 1996 largely on the success of the plan, which proved to be immensely popular with voters.

The health reform combined elements of traditional, government- underwritten socialized medicine with the latest thinking in privatization. It provided free health care to hundreds of thousands of medically indigent people, at the cost of hundreds of millions of dollars to taxpayers, and also allowed the government to shed its own costly and inefficient health facilities and services, which provided poor quality of care..

The idea was that the health reform would provide insurance coverage to all those Puerto Ricans who fell between the cracks of the health care system. As a group, they were not eligible for medical assistance, which covers the lowest end of the economic scale, nor did they have private health insurance, like Puerto Rico's middle and upper class.

RosseIlo, himself a pediatric surgeon, believed that the efficiencies achieved through privatization would offset the costs of extending health care to a whole new group of people. He set in motion a succession of sales to private groups of the government' s hospitals and clinics, a largely undistinguished system known for long waits and poor service.

The government also put out for bids the insurance coverage for each of Puerto Rico's regions, with the expectation that private sector competition would help hold down costs.

The savings never materialized on the scale envisioned. The health card proved all too popular, with the result that anyone and everyone seemed to be joining the program. The revenues generated by the sale of the government facilities and whatever efficiencies were achieved were not sufficient to off set the costs of the ever widening new plan. By the end of Rossell6's second term, the health plan required more than $1 billion in public subsidy, and estimates of ineligible recipients of the card ran into the tens of thousands of people.

Once it became apparent the plan was a huge financial burden, the administration's rhetoric shifted. Health care, they argued, was a proper expenditure of government funds, as a healthy population is a key part of economic growth.

The hybrid plan has produced hybrid results. More people were provided access to health care they had been previously denied. Child immunization levels, for example, were at an all time high, and outstripped stateside levels. But sooner or later someone had to pay the piper. At the beginning of this fiscal year, when the extent of government revenue shortfalls became clear, the bloated health reform plan became a primary target of the new administration of Gov. Sila Calderon.

Calderon's advisers immediately announced they would trim $300 million off the cost of the plan, a goal which it soon became apparent would be impossible to achieve. The governor's health officials also pledged to slow down or halt the ongoing sale of government owned facilities, a stance more in keeping with the Popular Democratic Party's Big Government approach.

PDP officials also said they would eject from the plan the many thousands of ineligible enrollees, including recent immigrants who were not citizens -- code words for the island's Dominican population, a group of recent arrivals who are the target Of considerable discrimination in Puerto Rico.

Calderon's health planners have rebid the insurance and service contracts for the island's health regions, with the idea of making them more cost conscious and stringent in their coverages.

That in turn provoked sharp criticism from Puerto Rico's mental health lobby, which complained that patients were confused about who their new providers were and how to go about getting services and medication. That is a major part of the health care system. Estimates of the island's population in need of mental health services range from the Health Department's 600,000 people, some 16 percent of the population, to the 950,000 patients, representing 25 percent of the population, estimated by the Pro-Mental Health foundation, the principal mental health providers lobby.

While the reform of the reform has provoked predictable criticism from New Progressive Party legislators, few would argue the system is in need of dire overhaul. Faced with budget crises erupting from every direction, the Calderon administration now faces the politically unpopular chore of restoring order to the scheme's finances.

Robert Becker, Managing Editor of The San Juan Star, writes the weekly Puerto Rico Report column for the Puerto Rico Herald. He can be reached directly at: dkarle@coqui.net

. La reforma sanitaria necesita reformas

El vasto plan de salud pública de Puerto Rico, popularmente conocido como "la tarjetita", está en aprietos.

La reforma sanitaria fue quizás el emprendimiento más ambicioso de la administración del ex gobernador Pedro Rosselló. Lanzado en 1993, cuando Rosselló asumió su primer mandato, el extenso y costo plan cubre actualmente a 1.800.000 personas, casi la mitad de la población de Puerto Rico. Rosselló ganó la reelección en 1996, en buena medida por el éxito del plan, que demostró ser inmensamente popular entre los votantes.

La reforma de salud proveyó atención médica gratuita a cientos de miles de personas carentes de servicios asistenciales, con un costo de cientos de millones de dólares para los contribuyentes.

Rosselló, cirujano pediátrico, creía que la eficiencia alcanzada a través de la privatización reduciría los costos de ampliar la atención médica a un inmenso nuevo grupo de personas.

Los ahorros nunca se materializaron en la escala prevista. La tarjeta de salud demostró ser demasiado popular, con el resultado de que todo el mundo pareció adherirse al programa.

Una vez que se hizo evidente la enorme carga financiera del plan, la retórica de la administración cambió. La erogación de fondos gubernamentales en atención sanitaria es correcta, argumentaron, porque una población saludable tiene un papel fundamental en el desarrollo económico.

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