A new prescription for Puerto Rico

On a chilly evening last March, Pedro J. Rosselló strode to a podium at the Yale Law School to argue that Puerto Rico, the U.S. island-commonwealth he has governed since 1993, should become the nation’s 51st state. In the audience at this symposium on the island’s political status were members of the issue’s three dominant political camps—advocates either of statehood, independence or continued commonwealth status. While the governor doubted that his remarks would change any minds, it was an important speech. He would deliver essentially the same message a few days later to the U.S. Senate, where he was scheduled to testify in support of the United States-Puerto Rico Political Status Act, which proposed placing the long-debated question of status in the hands of Puerto Rican voters.

For Governor Rosselló, a Yale-educated physician and public health expert, the Law School symposium was a homecoming of sorts. A successful pediatric surgeon and former health director for the city of San Juan, he spent four years in New Haven, graduating cum laude from the School of Medicine as president of the class of 1970. Since his election as governor six years ago in the first of two landslides, he has pursued major structural change in Puerto Rico with enormous energy. Topping the list: health care reform, which has created a single-payer system for almost half the island’s population during the last four years; and statehood, a highly charged issue with a still uncertain future. In a December referendum on self-determination, 50.2 percent of the voters chose “none of the above,” widely seen as both a protest against the vote and support of commonwealth status. But Dr. Rosselló took comfort in the showing for statehood, which garnered 46.5 percent of the vote. “Today the people spoke and they said statehood is the future of Puerto Rico,” he insists in the face of the ambiguous results.

“Puerto Rican statehood,” Dr. Rosselló told the Law School audience last spring, “will create a bilingual, bicultural bridge, linking the American continents. It will spur trade, investment, and greater prosperity for peoples all around our hemisphere.” He added: “It will convert our island from a disenfranchised outpost to an evermore valuable asset as the Americas team up to compete as a single trading bloc in the global marketplace.”

His advocacy of political and economic causes does not end at his home borders. To avoid crossing a labor picket line, he asked that the venue for his speech move to the Law School from New Haven’s Omni Hotel, where workers were locked in a unionization dispute with management. As he entered the hall, he received a standing ovation, even from those on other sides of the most important debate in Puerto Rico.

It is clear that, as governor, he incites strong passions. His constituents have twice given him overwhelming victories—and they have erupted in fury at some of his policies, with unions nearly shutting down the island for several days last summer, for example, over his proposal to privatize the government-owned telephone industry. Undeterred, Dr. Rosselló seems capable of pressing forward with issues that he considers important, regardless of the uproar from various quarters.

“Any change will create controversy because you alter the status quo,” he said during an interview in Connecticut last spring as he prepared for his Yale speech. Possessing an easygoing charm and, at 54, still showing the trim figure of the nationally ranked tennis player he was in his youth, he arrived fresh from an afternoon jog and shower and deftly fielded questions about health care reform, statehood and his time at Yale.

Since Puerto Rico became a commonwealth in 1952, with the island’s political destiny in the hands of Congress, nothing has inflamed and divided islanders more than their political status. In a nonbinding 1993 referendum, the commonwealth option prevailed in a narrow victory over statehood, 48.6 percent to 46.3 percent.

Now, not only as governor, but also as last year’s president of the U.S. Council of State Governments and chair of both the Democratic and Southern Governors’ Associations, Dr. Rosselló has secured a platform for a goal he has pursued since his medical school days. During much of 1998, however, other events competed for his attention. The year began with a rebuke from the Inter-American Press Association, which accused him of abusing his office by withdrawing government advertising from a newspaper critical of his administration. Dr. Rosselló responded that the government was simply seeking a more effective advertising medium. In July, 50 unions struck for two days over the telephone privatization plan. And in September, Hurricane Georges killed 11 people in Puerto Rico, caused an estimated $2 billion in damage and left 17,000 homeless.

An eye on health care

His 1996 reelection by the largest margin of any Puerto Rican governor in 32 years attests to an administration distinguished by more than discord, dissent and disaster. Since his inauguration in 1993, access to health care has increased, the crime rate has dropped by half, taxes have gone down nearly 20 percent, community schools have replaced a centralized education bureaucracy, and public servants have received major salary hikes and the right to unionize. Eager to wean the island’s economy from dependence on federal tax exemptions, he has modernized the industrial infrastructure, streamlined permit requirements and created incentives for tourism and exports.

While Dr. Rosselló’s health plan has angered some, almost everyone in Puerto Rico agrees that change was sorely needed. Before health care reform, only about half the island’s population had private insurance or the means to pay for medical services. The other half, the 1.7 million islanders considered medically indigent, relied on Medicaid and a government health system hampered by bureaucracy, inadequate funding and political partisanship. The island has the highest infant mortality rate and the lowest average infant birth weight among all U.S. states and territories. It also had the frightening distinction of being home to seven of the 10 hospitals with the highest death rates in the United States.

Despite those deficiencies, many Puerto Ricans were simply too poor to seek medical care outside the government-run clinics. Of the 3.8 million islanders, 58 percent live at or below poverty level. The per capita income in 1996 was $8,403, about half that of the poorest of the 50 states, Mississippi.

Dr. Rosselló has resolved to replace the parallel, but unequal, health systems with a single, managed care system. “The government is redefining its role,” Dr. Rosselló says. “Instead of being the direct provider, it is using its resources to buy insurance for people. The goal is a transition from two separate systems, one public and one private, into one system, which is accessed through health insurance.” Why was change needed? “The problem of the previous system,” the governor says, “was that the outcomes were very different.” Infant mortality, for example, was shown to be higher in the public system than in the private.

In 1993, Dr. Rosselló signed a bill passed by the island’s legislative assembly that created the Puerto Rico Health Insurance Administration. The PRHIA immediately launched a pilot program in Fajardo, a city on the island’s northeastern coast with high infant mortality and teen pregnancy. By the end of 1998, health reform had enrolled 1.5 million people. Since the reform began, more physicians, pharmacies, clinics, hospitals and health care centers have become accessible to the medically indigent. The island’s infant mortality rate declined from 12.7 per thousand in 1995 to 10.5 per thousand in 1996. Outcomes studies are also under way to measure the reform plan’s impact on people’s health. The cost of delivering health care has not gone down, but it has not increased as rapidly as before the reform. “If we had continued the old system, it would not have gone down,” Dr. Rosselló says. “It would have gone up at a steeper rate.”

No longer providing direct medical care, the government health department is concentrating on preventive measures, such as vaccinations. It is also selling its hospitals and clinics to pay off the debt for the construction of those facilities. Support for the health reform, however, has not been unanimous. Although Dr. Rosselló cites studies showing a patient satisfaction rate of 90 percent, a report prepared by the College of Physicians and Surgeons of Puerto Rico in 1996 gave the reform mixed reviews. For the medically indigent, the report noted better and faster access to primary care, laboratories, medications, emergency rooms and hospitals. But it also found widespread discontent over reimbursement among physicians, who struck in protest for 10 days in 1996.

Doctors who participate in the reform plan receive a capitation payment of $46 per patient per month. Physicians say it is too low because medical coverage is broad and because physicians have no control over ancillary services, such as those provided by laboratories, pharmacies and emergency rooms. Doctors are working more, earning less and spending less time with their patients. “The problem with the reform,” says José Román de Jesús, M.D., a former president of the Puerto Rico Medical Association who led the study, “is that they have done it too fast, without stopping to analyze problems that exist, look for alternatives and then move ahead.”

Dr. Rosselló responds that physicians must simply adapt to new incentives under the health reform. “Before,” he says, “you made more money the sicker the patient was. The new paradigm is you make more money the healthier your patient is.”

The path to politics

Dr. Rosselló’s route to a political career began in medicine. After his graduation from Yale, he went on to residency at Beth Israel Hospital in Boston, where he trained with renowned Harvard cancer specialist Judah Folkman, M.D. (While at Yale, Dr. Rosselló married his wife, Maga, the former Irma Margarita Nevares, with whom he has three sons, one a Yale College graduate.) In 1976, he returned to Puerto Rico to start the academic career he had contemplated while in New Haven—a pediatric surgery practice and a teaching post at the University of Puerto Rico (where he remains on the faculty). But back at home he saw his surroundings with new eyes. “What I encountered on the island was sobering,” Dr. Rosselló wrote in his 1993 proposal for health reform. “Our health service delivery system fell far short of the standard to which we aspired: that is, quality care for all, regardless of the patient’s economic circumstances.”

In 1981 he earned a master’s degree in public health from the University of Puerto Rico and, four years later, became director of health in San Juan, the island’s capital. He chaired the pro-statehood New Progressive Party’s 1988 platform committee, which called for health care reform. Of his decision to enter politics, he says, “The triggering factor was my desire to improve health care delivery in Puerto Rico. I did not expect to be in the public health field and even less in the political arena when I made my career choice initially.”

The unexpected transition from a surgeon to a nationally prominent political figure is in keeping with his character, say medical school friends who recall his prowess both with a scalpel and a tennis racket. He had been captain of the tennis team during his undergraduate days at Notre Dame, and he brought some of that same leadership and competitive drive to his medical studies. “He made a number of important contributions to the field of pediatric surgery,” says Robert J. Touloukian, M.D., a Yale professor of surgery and pediatrics and one of his instructors. Among his accomplishments, Dr. Rosselló originated an esophageal lengthening procedure that is now used all over the world.

Robert Rosa, M.D. ’70, met Rosselló as a first-year student and was his anatomy class partner. “What led him into politics, I think, was a great concern for Puerto Rico and its people,” says Dr. Rosa. “That was probably the motivating factor, that he could provide the kind of leadership and direction that he felt Puerto Rico needed.” Another classmate, W. Romney Burke, M.D. ’70, recalls long conversations in Spanish in which his friend spoke in favor of statehood. “I would not have predicted his becoming governor,” says Dr. Burke, now a urologist in Oregon. “But I’m not surprised.”

Speaking at Yale last March, Dr. Rosselló ticked off reasons why statehood would be good for Puerto Rico and dismissed the standard objections. Proponents of English as the nation’s official language worry about admitting a state where the majority speak Spanish. Bilingualism, answers Dr. Rosselló, is a cornerstone of Puerto Rico’s role as “midwife” to the commercial integration of the hemisphere. Political delegations from certain small states believe the admission of Puerto Rico will cost them seats in the House of Representatives. A 1911 act of Congress limiting House membership to 435 seats, Dr. Rosselló says, could be amended to increase the size of the House. To those who argue that the current commonwealth status offers the best of both worlds, conferring U.S. citizenship without federal income taxes, he countered that the status quo perpetuates the congressional oversight that has ruled the island since 1898.

Although the House of Representatives approved the bill in March 1998, the Senate adjourned last year without addressing it. The Senate did pass a resolution recognizing the right of Puerto Rican voters to express their views in a referendum and make them known to the president and Congress. Puerto Rican officials then scheduled for December 13 a nonbinding referendum offering five choices: commonwealth, statehood, free association, independence and none of the above. With the bulk of the vote divided between statehood and “none of the above,” the next step is unclear. Dr. Rosselló’s opponents, who urged voters to cast their ballots for “none of the above” to protest the plebiscite, saw the results as an affirmation of the status quo. But the governor vowed to press his campaign to make Puerto Rico the 51st state. “It’s a watershed moment,” he says. “For the first time there is a consensus in Puerto Rico that there has to be a change in political status.”

Among the beneficial effects of statehood, Dr. Rosselló believes, would be a redistribution of wealth as the more affluent become, for the first time, subject to federal income tax. “We have to recognize that statehood for Puerto Rico does have an internal impact of having wealth redistributed from the top level to the bottom level,” he says. “That is a goal that I am very much in favor of.”

His political goals might appear to conflict with his own interests as a physician and a member of the island’s higher social ranks. Dr. Rosselló and his three sisters grew up in a household rich in political and social connections. Their father, a prominent psychiatrist who had held high government and university posts, inspired Dr. Rosselló to become a physician by his example. The family’s roots in Puerto Rico go back several generations, to ancestors who migrated from Mallorca, a Spanish island in the Mediterranean.

Dr. Rosselló insists his own interests, however, are secondary to the social benefits of the policies he endorses. “They represent the common good, the best options for our people.” Statehood also would prove a boon to health care, Dr. Rosselló believes. It would invert the present funding formula so that federal funds would provide 83 percent, rather than the current 15 percent, of the island’s health budget.

“In a very conscious way we have tried to make this big change. It has not been without difficulties and it still has some resistance,” he says, adding that he borrowed ideas from President Clinton’s 1993 national health reform proposal. “Eventually it will serve at least as a discussion model. As a health advocate, this is central to me. I think Puerto Rico is on the verge of establishing a principle that is dear to health advocates, that health care is not the privilege of some, but the right of everyone.”