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The mechanics of reform

Yale Medicine Magazine, 1999 - Winter


In 1993, during his first term as governor, Pedro J. Rosselló, M.D. ’70, sought to eliminate the two-tiered health care delivery in Puerto Rico that divided care into public and private systems. His health reform has given 1.5 million of the 1.7 million medically indigent islanders insurance cards that provide access to managed care services throughout Puerto Rico. The government health system—understaffed, under-funded and overburdened—is to be dismantled, and the local government and Medicaid funds that supported it are to be diverted to the health reform.

In 1993, the Puerto Rico Health Insurance Administration was created as the supervisory agency of health reform, authorized to organize regional health alliances and contract with insurers for coverage. Blue Cross of Puerto Rico received a $30.2 million contract to serve the small northeastern city of Fajardo, the pilot program for the health reform, chosen for its high infant mortality, high rate of teen pregnancy and low life expectancy. Since then, three other insurance companies have joined the reform plan, providing coverage to 1.5 million Puerto Ricans. By June 1999, 1.6 million people are expected to receive coverage.

In Fajardo in January 1994, Dr. Rosselló distributed the first 400 personal health insurance cards, known as la tarjetita, the little card, which give holders access to basic medical services such as vaccinations and checkups. By the time it is fully implemented, in June 2000, the reform plan is expected to cover about 55 percent of the island’s population, including everyone at or below 200 percent of the poverty level and all government employees.

Before health reform about 1.2 million people, 34 percent of the island’s population, had partial medical coverage through Medicaid and another 450,000 people, or 11 percent, depended on public health systems provided by the island or municipal governments. They will be covered by the reform plan, which also includes Medicare subscribers who cannot afford supplementary care.

The impact of the pilot program in Fajardo was immediate. Within 17 days of the start of health reform, the ratio of patients to primary care providers went from 1,325-to-1 to 484-to-1. Participation by physicians is voluntary, but as health reform spread across the island, many physicians saw the number of fee-for-service patients decline. In addition, an increased number of health care centers and pharmacies became available.

“Of the total resources that we invested in health, about 15 percent were federal, mostly Medicaid funds, and 85 percent were state,” says Dr. Rosselló. “Instead of using this to run our own hospitals and pay public service doctors and nurses, we are using those resources to buy insurance. It’s using those resources we had before. We are using them in a different way.”

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