April 11, 2008
THE LETTER AND THE LAW
HRSA still needs to take control
A letter from a high-level Health Resources and Services Administration (HRSA) official to Puerto Rican AIDS activist José Colón signifies HRSA's strongest language yet regarding San Juan and Puerto Rico's mismanagement of federal Ryan White dollars.
In response to Colón's letter detailing the failings of Puerto Rico's AIDS infrastructure to Health and Human Services (HHS) Secretary Michael Leavitt, Assistant Surgeon General Deborah Parham Hopson replied last week by outlining the steps that HRSA, a branch of HHS, is taking to address the crisis. Hopson told Colon that HRSA "understands and shares your deep concern and frustration with the challenges of the care and treatment systems" in Puerto Rico. But she stopped short of recognizing advocates' demands that HRSA appoint a third party intermediary to oversee Puerto Rico's $53 million a year in federal AIDS funds.
"Jose Colón wrote a poignant and piercing letter to the U.S. Secretary of Health related to the HIV/AIDS crisis in Puerto Rico. Deborah Parham confirmed what the HIV/AIDS community in Puerto Rico has been saying for nearly two years," said Dennis deLeon, executive director of the Latino Commission on AIDS.
HHS policy states that "if a recipient fails to comply with the terms and conditions of an award" Leavitt has the power to temporarily withhold cash payments, withhold awards or "take any other remedies legally available." Such withholding is exactly what happened in the case of Baltimore, Washington, D.C. and other eligible metropolitan areas that ceded control of federal Ryan White dollars to HHS. But this might be trickier when it comes to Puerto Rico.
"Because of the legacy of colonialism, it seems like HHS treats Puerto Rico differently than other EMAs," Colón said, although he is clear that he thinks the only way the mismanagement of funds will improve is for HRSA to take over. Colón, an HIV-positive activist who lives in Puerto Rico briefly went on a medication strike in May to protest the AIDS Drug Assistance Program waiting list on the island.
The crisis goes on
Puerto Rico receives more than $53 million in Ryan White Care Act funds but activists have documented numerous cases of people living with HIV/AIDS who are unable to access medication. The commonwealth still offers no prevention programs for IV drug users, who account for a majority of new infections, and community-groups still wait for desperately needed funding. In December 2006, the FBI raided four San Juan Health Department offices, seizing 400 boxes of documents in a criminal investigation into possible misuse of Ryan White grants.
The lack of a centralized reporting system in Puerto Rico makes it impossible to know the true number of yearly infections. But according to the Kaiser Family Foundation, more than 30,000 people in Puerto Rico have HIV/AIDS, and more than 19,000 Puerto Ricans have died from AIDS. And despite intense media coverage that led in August to a much-touted appointment of Jorge Delgado Rivas as an assistant to Puerto Rico's Secretary of Health and a yet-to-be implemented 11 point plan, advocates on the ground report no improvements.
According to Hopson's letter, and the Update's additional follow-up with HRSA, some of the steps HRSA has taken to address the crisis are:
- "Restricted drawdown procedures" for both Puerto Rico and San Juan. This means instead of delivering the funding in a lump sum, both EMAs are monitored each month before funding is sent through.
- Recommending that both San Juan and Puerto Rico employ a contracted fiscal intermediary to supervise funds. San Juan has refused the recommendation, but Puerto Rico "has indicated that it is considering the use of a Pharmacy Benefits Manager to oversee the management of its pharmaceutical services."
- Providing "conference call and technical assistance" to grantees, as well as an on-site visit.
While these steps should be applauded in theory, it's unclear if HRSA's actions will amount to anything real.
"This letter is positive. It means that HRSA has paid attention, at least partially, to the voices of the activists demanding better administration of funds. But HRSA needs to do more. I believe the crisis remains the status quo," said New York City Issues Organizer and Policy Analyst Tamara Oyola-Santiago. "As long as Municipality of San Juan refuses to name a third party, corruption will continue."
James Albino, who recently left the National Minority Council on AIDS and is continuing to advocate on behalf of Puerto Ricans with AIDS, agreed. "Restrictive draw down, program monitoring and technical assistance for the last two years have done little to address the most critical of issues," Albino said. "What is the status of patient care? How many patients are not getting service? Why does Puerto Rico continue to outpace most of the of the country in incidence and mortality? After 20 years of operating an ADAP program why is there no protocol for qualifying patients, for providing insurance co-pays or for accurately assessing and forecasting the number of patients that go without medication? How long can the community based organizations, the heart of the healthcare delivery system survive without a reliable reimbursement system?"
While the media is focusing on the 19 indictments facing Puerto Rican governor Anibal Acevedo Vila, Colón doesn't think the scandal will necessarily affect the efforts of the commonwealth's AIDS advocates. "There's always something going on," he said.