Healthcare

Healthcare and education are among the most important programs undertaken by the government, and in Puerto Rico, both programs are heavily reliant on federal funding. Even though Puerto Rico has won important battles in recent years to improve the island’s treatment in both health and education programs, the commonwealth government’s funding still isn't on par with the 50 states. Furthermore, over the next few years, budget cuts are likely in these two critical areas as both Republicans and Democrats aim to bring U.S. government spending under control. Ahead are the answers to questions on the future of healthcare and education.

Editor’s note: Every four years, come election time, CARIBBEAN BUSINESS hosts editorial-board interviews with the gubernatorial candidates on the most important issues affecting our economy. This marks the third in a series of articles discussing wide-ranging issues: the general economy, job creation, public safety, federal funding, energy, healthcare, permit reform, education and political status. This third installment presents each candidate’s view on healthcare and education.

CB: What is your position regarding public and private healthcare in Puerto Rico, in the context of possible cuts to federal funding and financial challenges the system faces?

Fortuño: Medicaid funding isn't dependent on President Obama's healthcare. We had Medicaid funding before Obama and we'll have Medicaid funding after Obama. People should keep that clear. What [Resident Commissioner] Pedro Pierluisi and I did is that he covered the Democratic side and I covered the Republican side, and we convinced people to add an amendment to the president's healthcare plan for additional funding beyond the funding we were already receiving for Medicaid purposes, which we call Mi Salud here, but, in effect, is really Medicaid. And, that was included there.

When the House of Representatives approved legislation to do away with the president's healthcare reform, I was able to get Republican leaders on the floor on the record to clarify and state they were fully cognizant of the fact we had included an amendment in this legislation and the language would normally be in the Medicaid legislation and not in the president's healthcare proposal, and that they would work with me to make it up somehow.

The Supreme Court's decision doesn't affect our level of funding and certainly not our base level of funding. That is a separate legislation. The issue with that case was mainly the individual mandate section or portion of the legislation that doesn't apply to territories, and I negotiated that part. I assume you are aware that if you don't have healthcare, legislation forces you to purchase it, otherwise you will be fined. That doesn't apply to us, and essentially, I said, if you aren't providing parity to us in Medicaid funding, then don't impose this on us, and if you do so, I'll sue you. And they said, 'no we don't want a lawsuit, don't worry, territories are excluded.' So we are excluded from that portion.

CB: After two years of Mi Salud, which do you see, fee-for-service or managed care, as the appropriate path to universal healthcare and why?

Fortuño: I'm still looking for a healthcare program anywhere in the world that is perfect. I'm still looking, I haven't found one. There are fl aws in every single system. Our system has to be compliant with federal regulations. It isn't like we could say, 'let's bring in Finland's program.' Well, that would be great, if Finland would be willing to provide 40% of the funding, then we could implement Finland's program here. But as long as Finland isn't willing to chip in, we'd better stick to what the federal guidelines provide.

So everyone understands this, it sounds great to sit down here and start talking about how and what things should resemble, it's just that almost half the funding is coming from Washington, D.C., not from Helsinki or whatever. So in that sense, I believe we all have to be very careful when people start talking about what something should look like.

I believe in competition and think that it brings out the best in people. And, that also applies to physicians. I believe, by the same token, that physicians should be paid fees that are reasonable. They must be paid on time and I also believe they shouldn't be thinking about the legal implications of what they do for anyone who comes in to receive a service, especially through the emergency room, and that is why I have been so adamant in terms of paying our healthcare providers on time and in our local legislation.

I included language that is similar to Medicare in terms of how quickly you have to be paid regardless of whether you are under Mi Salud or a private healthcare program; and second, I have promoted legislation, some of which has already passed, that stops our physicians from practicing their profession defensively, thinking whether they need a lawyer in the emergency room all the time.

I believe that's what is wrong with our system, and you've seen the results of addressing this properly in Florida and Texas and how physicians went back to those states when they approved adequate legislation. We have approved homestead legislation and that was done less than a year ago. We also approved legislation that actually promotes more residency programs in our hospitals, and actually applies the medical center's caps on lawsuits to any type of procedure performed by hospitals under this program and that are willing to take in and tend to people coming in through the emergency room. And we have already hospitals filing for that. I haven't gotten everything I wanted, but I think it's important in the process that we have adequate service for everyone, whether you have Mi Salud or a private healthcare insurance program.

CB: What is your position regarding public and private healthcare in Puerto Rico, in the context of possible cuts to federal funding and financial challenges the system faces?

García Padilla: If the Republicans had their way, it would have been tragic for the country. Let's not forget that it was [Gov.] Fortuño Burset himself who sent letters to Republicans in Congress calling for the elimination of the Obama healthcare plan, but he receives the funds and spreads them around to his friends. I part from the premise that prudence won out at the end of the day.

My healthcare plan is one directed at the patient and can be achieved with less resources while providing better service. The other day, someone was asking if I believed in managed care and I told the person I believed in good care, in quality care; that includes managed care. However, it isn't limited to managed care, but includes managed care.

CB: Which would you prefer, a single-payer plan or a plan that operates as it does now?

García Padilla: I think we could combine both. I would break with the regional monopolies of those who provide service. I believe the Hipaa [Health Insurance Portability & Accountability Act] groups are fine.

The Lochner v. New York case, which took place during the Roosevelt administration, reminds me a great deal of the assault on Obamacare. Archaic, Republican, Hooverians trying to impose themselves on new ideas. As a matter of fact, I was going over some of Hoover's speeches, and he once said bitter times—doesn't that ring a bell, bitter times; only in our case it wasn't bitter, it was poisonous—call for bitter measures. I believe we are living in similar times and that we will be going through similar transformations asthose that occurred in that era.

CB: What is your position regarding public and private healthcare in Puerto Rico, in the context of possible cuts to federal funding and financial challenges the system faces?

Dalmau: First, I believe our health system is a deficient one, ever since 1994, when the system wasn't only transformed, but the physical structures of the hospitals that belonged to the people of Puerto Rico were sold at dirt-cheap prices. Those were the Clinton years and it was thought that a buoyant economy would allow the financing of a health reform with a universal health card. That didn't happen. Not only did that not happen, but also it was aggravated by the financial crisis.

We can't follow the route of getting back those physical installations because it would be too costly and there would be too many obstacles. I do think we need a universal healthcaresystem where the government is the sole source of reimbursement for serviceproviders. Right now, we areusing insurance companies thatwere created for profit, and Ithink there are things that shouldn't be held inthat framework, and one of them is health. Rightnow, under Mi Salud, you can go to the doctorand they will tell you that you need treatment andcall the insurance company, and some bureaucratwith a chart will tell them 'no, no, no, you areonly entitled to treatment 'B." The patient doesn'treceive the appropriate treatment and their healthworsens.

Right now, we spend some $2 billion on healthcare reform. What I propose is a universal healthcare system in which we can give access to care for those 250,000 people in Puerto Rico who don't have enough money to pay for a private healthcare plan and still don't qualify for the public plan. This plan would be headed by a public, nonprofit entity that would negotiate and determine, through a collective-bargaining agreement with providers, the levels of care and payment for treatment. This has to go hand in hand with a study of health in Puerto Rico and the illnesses in the population. And it doesn't mean there won't be private healthcare plans. Those should exist to cover what isn't covered by the universal healthcare plan— plastic surgeries for instance.

But there is a moral and ethical obligation—and this is a debate we must have in this country— to debate the state of healthcare in Puerto Rico, because it is deficient healthcare. I believe that we have abandoned preventive healthcare. You have 27% of youths in Puerto Rico who are obese. That goes up to 66% when in adulthood, which puts tremendous pressure on the healthcare system, with diabetes and high cholesterol, which leads to heart disease. We have identified a quarter of the population in schools who could be educated about healthy nutrition and eating habits, and physical education. And that doesn't mean a program to create athletes, but rather to raise consciousness.

So I believe a healthcare plan as I am suggesting, as well as remedial policy to alleviate a generational financial burden on the healthcare system, can be mutually complimentary systems.

And as a footnote, I want to add that people will ask whether we will renounce accepting federal funds [Medicaid and Medicare] that we receive? The answer is 'no.' Not under the current status. People ask me whether I received Pell grants, and I'll tell them, "sure, but not enough." For the amount the U.S. gets from Puerto Rico, I got little.

We were run over by the truck of colonialism, and for it, we are receiving reparations. Now, when we obtain independence, of course we can finance reform with other revenue streams.

The reminder of our colonial condition is there in the threat to additional healthcare funding that Puerto Rico is scheduled to receive.

CB: Would you consider extending the Education Department director's term beyond four years to promote continuity in the agency?

Fortuño: The problem is not the secretary or whoever that person may be. The problem is the system hasn't worked for way too long and it's too big, and I have to go back to the record, but we were in receivership for seven years. We fixed that. Our funding and [the federal funding], a third of the agency's budget, were at risk because we were in receivership. So we were able to fix that.

What do we need to do? First of all, we need to have a clear idea of where we need to take education. We should take education to where the marketplace is. So we joined forces with Universidad del Sagrado Corazón, the Chamber of Commerce and others, and we determined what the profile of a student should be. And that's why we are now focused on math, science, being fully bilingual and being able to handle technology. I know people are saying, 'Oh, where's history, where's sociology, etc.' Math, science, being fully bilingual and handling technology are the key issues. If we can't do those five correctly, then we can forget talking about anything else.

Secondly, we must have adequate facilities for our students. Otherwise, how do we expect them to stay in school? And that's why we came up with the Schools for the 21st Century program. What's great about these schools isn't just that they look better than any private school in Puerto Rico. They also have technology in every single classroom. We need more scientists, chemists, physicists, mathematicians; that's what we need. We talk about manufacturing and it being 40% of the GDP and all that, but what are we doing to train our children? Nothing. We also have to bring in the community. Each one of those schools has a community pavilion, which often times includes facilities for performing arts and sports in the same place.

CB: There is one in Guaynabo.

It is being finished. So are Cataño's, Toa Baja's, Hormigueros' and Cabo Rojo's; already finished. Five are already open and we should have about 70 open by the end of the year. We have 103 under construction. Then we have adequate facilities for special-education kids. Can you believe that 23% of our students are special-education students? So, are we just going to write off 23% of the workforce? That makes no sense.

The second item I've said is that we must graduate fully bilingual students within 10 years.

It makes no sense what some people are saying. This has nothing to do with politics. Actually, if I were an independentista [pro-independence], this would be even more important than as an estadista [pro-statehood]. But, on top of that, if you're going to be competitive in the world, you have to speak English.

CB: Ours is the biggest school system in the U.S. Would you consider breaking it up into smaller districts?

We have good mayors on both sides of the aisle and we must bring them in to assist us more. I'm not saying that they will be determining what type of math will be taught or anything like that, but I believe that many of our mayors, from both sides, will be willing to chip in more fully. There is no reason why they can't participate more.

Then, higher education. Where are the jobs going to be created? Clearly, our public-education system hasn't been geared toward the marketplace. I have told those that I have named to the board of the University of Puerto Rico that we need to shift the existing resources, because there aren't going to be any new resources; to make sure we train people in areas that are producing jobs and will continueto produce jobs in the next few decades.

CB: Would you consider extending the Education Department director's term beyond four years to promote continuity in the agency?

García Padilla: I'm seriously considering extending the length of the secretary of the Education Department's term, maybe not 10, but perhaps six or five; perhaps eight. But that isn't enough to improve the Education Department.

We need for the department to graduate students that are university ready and employment ready. Today, that isn't happening. Every year, 40,000 students enter the public-school system in Puerto Rico. Every year, 28,000 students graduate from our public-school system. That means we lose 12,000 students; that's more than a 25% loss along the way. Of those who graduate, only 15,000 begin post-graduate studies, be it community colleges or universities.

Of those 15,000, less than 7,000 enter a UPR [University of Puerto Rico] campus. And, do you know that our jurisdiction is the only one in the U.S. where people prefer private elementary and secondary schools, but public university?

The objective of the Education Department is results. Today, with a budget of more than $3 billion, teachers have to pay for the photocopies and materials for their classroom. All this is happening with a more than $3 billion budget. Today, a student can get to fourth grade without learning how to read or write.

My policy regarding the department is the following: A school that isn't good for my children, is not good enough for anybody.

CB: So your children would study in public school?

If the schools were up to the grade, they would, but schools that aren't good enough for my children aren't good enough for anybody. Just because governors can pay for private schools shouldn't make them oblivious to the situation. A governor should be of the position that if a school isn't good enough for his children, it isn't good enough foranybody's and must be fixed. What we have to do is bring them up to grade andwe can accomplish this.

CB: What steps would you take?

In all of the success stories of education in all the schools throughout the world, there is a common factor. More than two-thirds of the U.S. Education Department's entire budget is spent on schools. In Puerto Rico, it is less than one-third. I will spend at least two-thirds of the department's budget on the schools. What is Gov. Luis Fortuño's offer? That every four years he will remodel and fix 100 schools? It would take 60 years to fix all the schools in Puerto Rico. There are 1,500 schools. It would take 15 government terms.

CB: Would you be in favor of implementing a substitute-teacher program?

Explain the program to me.

CB: Well, the problem is that if a teacher is absent today, students end up having to go home or merely hanging out in the yard.

I've run into them in the street and asked them, 'Why aren't you in school today?' They reply, 'El mister [the teacher] didn't come to class today.' I think we have to achieve, and I achieved this at DACO [Consumer Affairs Department], that public servants be more motivated. Teacher assistants could perhaps be used as substitute teachers.

I want students to be inside schools—that includes during lunch. If a student is outside school grounds and has an accident, his parents aren't responsible for his safety, the school is.

To accomplish this, I need teachers to be motivated. Another common denominator of successful schools around the world is that the school director is a motivator and the teachers are motivators. This includes the existence of substitute teachers. If you increase the school budget, it creates room for substitute teachers.

CB: Would you consider extending the Education Department director's term beyond four years to promote continuity in the agency?

Dalmau: No, I am opposed to such a proposal. In a department that is already as highly politicized as it is, I think it would be a mistake.

An elected governor with an agenda that has been validated by the people should have the discretion to appoint an administrative team that will implement his platform, especially in an agency as important as the Education Department.

What I can tell you is that there is a problem of polarization in the Education Department. You can appoint the director for a five-year term, a 10-year term, even a 20-year term and not solve the problem. It is a structural problem that begins with recruitment and goes on to promotions to positions of leadership. What we must do is end the polarization in the Education Department. The political party to which you belong determines whether your desk will be in a corner, stuck to the wall, with three newspapers on top of one another, or if you are in a position of leadership.

The problem can be resolved if positions were established based on merit, experience, knowledge and productivity. This goes hand-in-hand with the implementation of procedures to protect employees' rights, especially at the recruitment stage. The problem is that when the government changes, all of the transitional positions are filled and eventually become permanent. The problem with the government isn't that it is too big. The problem is the paralysis that occurs with the human resources of the government. There, you have one of the best examples of duplication of duties for the same function in the government. When you have parallel government administrative structures, one red [Popular Democratic Party] and one blue [New Progressive Party], frankly, that in no way helps accomplish goals and wastes a huge amount of money. It is the governmentagency with the largest budget in Puerto Rico.

CB: Would you favor breaking up the department into regions, much the way it is in the U.S.?

Dalmau: The problem with regionalization in Puerto Rico is that it will create a regime that is even more polarized than it is today. The structure would be at the mercy of the mayors within the region and the push they have at getting their people selected for leadership positions. There wouldn't be a central organization that if properly executed would have better protections. In second place, it would create a more unequal system. It will depend on where you live as to the quality of the education you receive. For example, if you live in Bayamón, San Juan, Carolina or Guaynabo—the powerful municipalities—you will receive a quality education. These municipalities have more resources and are capable of providing better education. What would a school district in Comerío, Barranquitas or Corozal look like? We would have to evaluate it in those terms. However, if what you are referring to is how funds are distributed, it is my belief the individual schools should have greater authority over how money is spent in the school, since they are the ones who know what the needs of the school are.

I think that at this stage, during the second decade of the 21st century, to have some schools where there is no toilet paper is completely unacceptable. This is a result of the bureaucratic hurdles in the procurement process. This is something thatshould clearly be in the hands of the schools.

CARIBBEAN BUSINESS Executive Editor Carlos Márquez; Managing Editor Philipe Schoene Roura; Senior Reporters John Marino, Eva Lloréns Vélez, José L. Carmona, Alex Díaz and Jaime Santiago; Reporters Alexander López and Mario Belaval Díaz contributed to these stories. Next week: Don't miss the candidates debate over perspectiveson banking and tourism industry.