Por Ricardo Roselló Nevares
En nuestra última columna, establecimos la importancia de que el gobierno tenga una filosofía y visión clara de los servicios de salud que recibe la ciudadanía. Vimos igualmente cómo se desarrollaron en Puerto Rico dos sistemas paralelos de prestación de servicios médicos: uno privado, con las mejores instalaciones para las personas pudientes; y otro público, pagado enteramente por el gobierno, con servicios deficientes, para la población médico indigente. El sistema público creaba dependencia, pues el gobierno tenía dominio sobre la población necesitada. También se prestaba para la manipulación política, y llegó a tal punto ¡que hasta los alcaldes dispensaban recetas!
Debido a esta condición dual, ineficiente y costosa, se dio un cambio radical de paradigma durante los años 90, cuando el gobierno deja atrás su rol de proveedor directo de servicios y se convierte en un comprador de seguros de salud para la población. Esta nueva visión logró mejorías significativas en los servicios médicos para la población médico indigente. De hecho, para el año 2000, Puerto Rico llegó a ser una de las pocas jurisdicciones en el mundo, y la única en todo Estados Unidos, donde el virtualmente el 100 por ciento de la población contaba con cobertura médica. El nuevo paradigma creó asimismo una tendencia de ahorros para el fisco, ya que adquirir seguros médicos para la población resultaba significativamente más económico que mantener hospitales y centros de tratamiento.
Pero, ¿qué ha pasado desde entonces para que nuestro sistema de salud se encuentre nuevamente en una situación precaria?
Luego del 2000, dos administraciones de gobierno subsiguientes, que esbozaban una filosofía de dependencia del pueblo en el gobierno, decidieron dar marcha atrás a los logros alcanzados. Se mantiene, en parte, la tarjeta de salud el gobierno, pero se regresa nuevamente la inversión pública (a menor escala) en proveer servicios directos al pueblo. Para sufragar esos costos, se decide recortar la cantidad de personas en el plan médico, y como resultado, sobre 400 mil puertorriqueños se quedaron sin tarjeta de salud.
Para el 2009, se implementa el plan ‘Mi Salud’, cuya filosofía es la misma que la de los años 90. No obstante, el plan está enfrentando dificultades que no había tenido antes. ¿Por qué? La debacle actual se puede resumir en tres puntos:
Presupuesto de los años 90: Se estableció el sistema con un presupuesto que no tomó en consideración el valor del dólar (ha bajado 30 por ciento) y los costos de las medicinas y tratamientos médicos (han subido 50 por ciento). (Fuente: Bureau of Labor Statistics, Congressional Budget Office)Tres aseguradoras vs. ocho en los 90: Tener varias aseguradoras crea diversificación y competencia, lo que ayuda a mantener costos bajos y servicios eficientes. Si sólo tres aseguradoras se encargan de 1.3 millones de beneficiarios, se le da demasiado poder a estas tres empresas, y se corre el riesgo de que si una cae (como sucedió), entonces queda un tercio de los beneficiarios sin cubierta médica.
Eliminación de médicos primarios como ‘gate keepers’ (porteros) del sistema: Muchas aseguradoras usan a los médicos primarios como un ‘control’ para evitar el uso abusivo de sus planes. Luego de examinar al paciente, el médico primario indica si ese paciente necesita verse con un especialista. Al eliminar el ‘gate keeper’ del plan del gobierno, se agiliza el proceso, pues el paciente va al especialista directamente. Eso en principio es bueno, pero también los especialistas son muchísimo más caros que los médicos primarios. Por ende, el costo para el sistema será mucho más alto.
Por estas razones, el plan Mi Salud, de seguir como está diseñado ahora, está destinado a fracasar. Entonces, ¿cómo evitamos que fracase?
Algunos han sugerido un modelo de ‘single payer’ o pagador único, donde el gobierno, en vez de ser comprador de un seguro médico, se convertiría en asegurador. Esto crea nuevas realidades: (1) como asegurador, el gobierno será el que carga con el riesgo total del sistema; (2) tendrá que desarrollar un aparato burocrático para substituir las aseguradoras, el cual no existe; (3) el gobierno carece de peritaje en este área; (4) se eliminaría el sector privado de seguros de salud en Puerto Rico (el sector más grande en la industria de seguros en PR), lo que significaría eliminar la competencia, junto a miles de trabajos (el sector médico completo, representa 6% de nuestra fuerza laboral); (5) el gobierno ha tenido un historial negativo manejando servicios de salud, como fue evidenciado durante los 70 y 80; (6) se le vuelve a dar demasiado poder al gobierno y se le quita al ciudadano. ¡Imagínate que no te cubran no por ser de un partido u otro!
La sugerencia del pagador único crea el mismo problema que teníamos hace 25 a 30 años: un sistema ineficiente, inefectivo, controlador y politizado.
En vez, la sugerencia es mantener la estrategia de comprador de un seguro, donde el gobierno hace lo que sabe hacer (pagar, fiscalizar), y deja el mercado privado, especializado y ágil que provea mejores servicios. También restituir al médico primario como ‘gate keeper’ para mantener los costos del sistema mucho más bajos. Y por último, inducir la participación de más aseguradoras para ampliar las redes y la competencia.
En términos del financiamiento del sistema sugerido, se requiere que todos compartamos las responsabilidades. Que el gobierno (estatal, federal) se encargue de proveer seguros a las poblaciones con menos recursos económicos y más vulnerables (ej. envejecientes). A la clase media trabajadora, que se le dé un subsidio significativo mediante mecanismos ofrecidos en la reforma nacional de Obama (Centro de Intercambio de Seguros). La empresa privada, que tenga la responsabilidad de proveer seguros para sus empleados con cierto nivel de ingreso, a cambio de incentivos contributivos. Y los individuos, tendrán que participar en los gastos, como deducibles y copagos.
Este modelo se puede implementar ya. Se necesita legislación. Y si queremos ir más lejos, se puede enmendar la Constitución a fin de proveerle el derecho a la salud a todos los puertorriqueños.
Como podemos ver, tanto la visión como el diseño integral del sistema son fundamentales para una ejecución efectiva. Los modelos donde el gobierno juega un rol que sobrepasa su capacidad de peritaje con el propósito de obtener más control sobre el pueblo reducen la calidad y eficiencia del servicio, y aumentan la dependencia del individuo. Este tipo de modelo es un microcosmo del sistema sociopolítico del ELA, y mientras sigamos con este sistema sociopolítico, tendremos terreno fértil para fomentar modelos similares de ineficiencia, control gubernamental y dependencia del pueblo, no sólo en la salud, sino en otros renglones como la economía, la educación, y demás.
Está en nosotros reconocer esta tendencia y requerir un cambio a un modelo sociopolítico que ponga el poder nuevamente en manos del pueblo.
Mostrando entradas con la etiqueta Pedro Rossello. Mostrar todas las entradas
Mostrando entradas con la etiqueta Pedro Rossello. Mostrar todas las entradas
jueves, 11 de agosto de 2011
jueves, 7 de julio de 2011
Economic inequality and its negative effects on society (Part 1)
By : DR. PEDRO ROSSELLÓ / caribbeanbusiness
Edition: July 7, 2011
(This is the first of a three-part series)
"We can have a democratic society, or we can have wealth concentrated in the hands of a few; but we cannot have both." -Louis Brandeis
Recently, CARIBBEAN BUSINESS presented a plan for the economic development of Puerto Rico (June 9). In considering any general plan for economic development, let me suggest a fundamental element that should be included as a pillar of any plan: the issue of inequality.
In our public discourse, we have thoroughly argued the problems that political inequality can generate. At times, we have touched upon the hardships created when social inequality arbitrarily limits citizens' mobility within a society. But we have yet to fully ascertain the threats and challenges that economic inequality could pose for our contemporary society in Puerto Rico.
Economic disparity can be considered one of the greatest impediments to achieving a fair and prosperous society. There is ample empirical evidence and two basic premises driving this theory, the first being that a more equitable society is a better society. Implicit herein is the philosophy that a market economy should be driven not only by crude economic principles, but also by considerations of fairness, justice and care for the social environment.
The second premise is that increasing material economic standards does not always translate into a better quality of life for citizens. Historically, we have equated an increase in economic standards with a "better" life, presupposing that economic growth was the engine of prosperity. But recent studies point to the reality that prosperity through economic growth has all but stopped in the richest countries, and only continues to be an important factor in poor developing countries.
There is extreme economic inequality in our world today. The 400 richest people on the planet possess as much wealth as do the 3 billion in the world with the lowest incomes, who survive on less than $2 per day, per individual. Between 1987 and 1993, the population with an income of less than $1 a day grew by 100 million, reaching a total of 1.3 billion. By the beginning of this 21st century, the concentration of wealth was so unequal that 85% of the world's population represented only 7% of the world's markets.
The most structured index to measure inequality is the Gini coefficient, employed by the United Nations, which ranks countries on a scale from zero (0) [denoting the country with the most equality] to one (1) [denoting the greatest level of inequality].
Using this system, Namibia (0.707) ranks as the country with the highest inequality, while Japan (0.249) shows the greatest level of equality. Latin American and Caribbean nations rank among those with greater inequality: Bolivia, 0.601; Paraguay, 0.589; Colombia, 0.586; Brazil, 0.590; Panama, 0.561; Haiti, 0.592; and the Dominican Republic, 0.516. There is no official metric for Cuba. On the European front, Spain (0.347) and France (0.327) run close to Canada (0.376) and Australia (0.352) in terms of equality, while the Northern European nations of Sweden (0.250), Finland (0.269) and Denmark (0.257) follow right behind Japan as the world's most egalitarian societies.
In the United States we see a significant level of inequality, with a worrisome growth trend. After 1929, when the Gini coefficient was first reported at 0.450, the nation reached its highest level of equality in 1968 (0.386). Since the 1970s, the lowest level of equality was recorded in 2006 (0.470), stabilizing in 2009 (0.468). By 1995, 1% of the U.S. population controlled 47% of the wealth. After that, the government deregulation and free-market policies that existed between 1995 and 1999 allowed 86% of market gains to go to the richest 10%. At the time, just 1% of the population (2.7 million) owned as much wealth as the 100 million Americans with the lowest incomes.
In addition, over the three decades prior to 2000, the average income of American taxpayers went down 7%, while the income of the richest 1% rose by 148%...and the top 0.1% saw their income grow by 343%!
Regarding Puerto Rico, we could be forgiven for thinking that, as the territory with the lowest income per capita and greatest level of unemployment, it would have the greatest level of equality. Not so. In 2006 and 2007, our island had the highest level of inequality under the U.S. flag, with a Gini of 0.536 and 0.544, respectively. By municipality, Mayagüez (0.599) and San Juan (0.582) showed greater inequality; while Bayamón (0.462) and Toa Baja (0.479) showed less.
What effect might these inequities have on the quality of life of our people?
There is a proven correlation between levels of illness and social problems and levels of inequality. For a given level of income, it is better to live in a more egalitarian place. Egalitarian societies tend to be healthier—there is less infant mortality, longer life expectancy and less mental illness. They also report less usage of illicit substances, less incidence of violence, fewer teenage pregnancies, and higher levels of academic achievement. On this last point, it has already been established that academic achievement depends on the equality gradient of a society—the greater the equality, the higher the general level of education.
Conversely, inequality tends to render countries and jurisdictions socially dysfunctional across an entire spectrum of indicators. A quick glance over recent local headlines reveals serious signs of social dysfunction: escalating crime and violence, decreasing academic performance and education levels, and unremitting examples of public- and private-sector corruption.
All these realities point to an undeniable fact: The optimal development of a society is achieved as its citizens become ever more equal. So equality becomes far more than a moral question regarding how to behave as a society; it becomes a practical matter of allowing the most favorable advancement of our people.
What can we do to mitigate this alarming inequality? Which public policies could drive us to achieve greater equality, and therefore greater justice and progress?
We shall address these important questions in our next column.
Edition: July 7, 2011
(This is the first of a three-part series)
"We can have a democratic society, or we can have wealth concentrated in the hands of a few; but we cannot have both." -Louis Brandeis
Recently, CARIBBEAN BUSINESS presented a plan for the economic development of Puerto Rico (June 9). In considering any general plan for economic development, let me suggest a fundamental element that should be included as a pillar of any plan: the issue of inequality.
In our public discourse, we have thoroughly argued the problems that political inequality can generate. At times, we have touched upon the hardships created when social inequality arbitrarily limits citizens' mobility within a society. But we have yet to fully ascertain the threats and challenges that economic inequality could pose for our contemporary society in Puerto Rico.
Economic disparity can be considered one of the greatest impediments to achieving a fair and prosperous society. There is ample empirical evidence and two basic premises driving this theory, the first being that a more equitable society is a better society. Implicit herein is the philosophy that a market economy should be driven not only by crude economic principles, but also by considerations of fairness, justice and care for the social environment.
The second premise is that increasing material economic standards does not always translate into a better quality of life for citizens. Historically, we have equated an increase in economic standards with a "better" life, presupposing that economic growth was the engine of prosperity. But recent studies point to the reality that prosperity through economic growth has all but stopped in the richest countries, and only continues to be an important factor in poor developing countries.
There is extreme economic inequality in our world today. The 400 richest people on the planet possess as much wealth as do the 3 billion in the world with the lowest incomes, who survive on less than $2 per day, per individual. Between 1987 and 1993, the population with an income of less than $1 a day grew by 100 million, reaching a total of 1.3 billion. By the beginning of this 21st century, the concentration of wealth was so unequal that 85% of the world's population represented only 7% of the world's markets.
The most structured index to measure inequality is the Gini coefficient, employed by the United Nations, which ranks countries on a scale from zero (0) [denoting the country with the most equality] to one (1) [denoting the greatest level of inequality].
Using this system, Namibia (0.707) ranks as the country with the highest inequality, while Japan (0.249) shows the greatest level of equality. Latin American and Caribbean nations rank among those with greater inequality: Bolivia, 0.601; Paraguay, 0.589; Colombia, 0.586; Brazil, 0.590; Panama, 0.561; Haiti, 0.592; and the Dominican Republic, 0.516. There is no official metric for Cuba. On the European front, Spain (0.347) and France (0.327) run close to Canada (0.376) and Australia (0.352) in terms of equality, while the Northern European nations of Sweden (0.250), Finland (0.269) and Denmark (0.257) follow right behind Japan as the world's most egalitarian societies.
In the United States we see a significant level of inequality, with a worrisome growth trend. After 1929, when the Gini coefficient was first reported at 0.450, the nation reached its highest level of equality in 1968 (0.386). Since the 1970s, the lowest level of equality was recorded in 2006 (0.470), stabilizing in 2009 (0.468). By 1995, 1% of the U.S. population controlled 47% of the wealth. After that, the government deregulation and free-market policies that existed between 1995 and 1999 allowed 86% of market gains to go to the richest 10%. At the time, just 1% of the population (2.7 million) owned as much wealth as the 100 million Americans with the lowest incomes.
In addition, over the three decades prior to 2000, the average income of American taxpayers went down 7%, while the income of the richest 1% rose by 148%...and the top 0.1% saw their income grow by 343%!
Regarding Puerto Rico, we could be forgiven for thinking that, as the territory with the lowest income per capita and greatest level of unemployment, it would have the greatest level of equality. Not so. In 2006 and 2007, our island had the highest level of inequality under the U.S. flag, with a Gini of 0.536 and 0.544, respectively. By municipality, Mayagüez (0.599) and San Juan (0.582) showed greater inequality; while Bayamón (0.462) and Toa Baja (0.479) showed less.
What effect might these inequities have on the quality of life of our people?
There is a proven correlation between levels of illness and social problems and levels of inequality. For a given level of income, it is better to live in a more egalitarian place. Egalitarian societies tend to be healthier—there is less infant mortality, longer life expectancy and less mental illness. They also report less usage of illicit substances, less incidence of violence, fewer teenage pregnancies, and higher levels of academic achievement. On this last point, it has already been established that academic achievement depends on the equality gradient of a society—the greater the equality, the higher the general level of education.
Conversely, inequality tends to render countries and jurisdictions socially dysfunctional across an entire spectrum of indicators. A quick glance over recent local headlines reveals serious signs of social dysfunction: escalating crime and violence, decreasing academic performance and education levels, and unremitting examples of public- and private-sector corruption.
All these realities point to an undeniable fact: The optimal development of a society is achieved as its citizens become ever more equal. So equality becomes far more than a moral question regarding how to behave as a society; it becomes a practical matter of allowing the most favorable advancement of our people.
What can we do to mitigate this alarming inequality? Which public policies could drive us to achieve greater equality, and therefore greater justice and progress?
We shall address these important questions in our next column.
Rossello v. United States and the Right to Vote for Puerto Rico
By Jo McKeegan / Published July 5, 2011
During a week in which we celebrate the American colonies for seeking independence in large part due to denial of representation in the British parliament, it’s time for us to have a candid conversation about voting rights in our own present day “colonies”, starting with the American territory of Puerto Rico.
Brought in the Inter-American Commission on Human Rights by former governor of Puerto Rico Pedro Rossello, Rossello v. United States addresses the lack of a right to cast a ballot and have such ballots counted in national elections for president and Congress by residents of Puerto Rico. Petitioner Rossello has been disenfranchised, along with all other residents of Puerto Rico, despite his American citizenship, based solely on his area of residence within the United States. Currently, any American moving their residence to Puerto Rico would similarly be disenfranchised. This glaring discrimination against United States citizens living in Puerto Rico cannot be allowed to continue under international law and FairVote fully supports Rossello in his efforts.
The United States government is improperly denying the ability to vote to at least 3.7 million of its citizens in stating that the Resident Commission non-voting member of Congress is sufficient to address Puerto Rico’s needs. It is simply not reasonable to believe that one non-voting representative to Congress is equivalent to two senators, approximately six members of the House of Representatives, and a vote for the president and a vice president. The residents of Puerto Rico are being systematically disenfranchised and relegated to second class citizenship by their own government.
Puerto Rico’s current disenfranchised status is not acceptable. Unemployment in Puerto Rico is over 16% - grotesquely high even in an area where unemployment is always higher than that of the mainland. Residents of Puerto Rico pay the same social security and Medicaid taxes as mainlanders; however, they generally receive about 93% less in Medicaid coverage, something many believe is due to Puerto Rico’s inability to lobby for itself in Congress. Puerto Rico is hemorrhaging over 35,000 people a year and those who do leave are usually the highest educated, highly skilled, young, and Republican. In short, not having a voice at the national level is having a real effect on four million American lives.
Failing to provide basic suffrage rights to Puerto Rico is particularly ironic in a time of way when Puerto Rican Americans serve in our armed services at higher rates than most of our states. Petitioner claims that no other area of the United States suffered so many casualties of war prior to becoming a state as Puerto Rico has, or had more decorated and high ranking service members. Puerto Rican soldiers can be ordered into battle by a Commander in Chief for whom they have no power to vote.
And yet all evidence demonstrates that Puerto Ricans greatly value suffrage rights. Voter turnout in election for governor of Puerto Rico are higher than the gubernatorial election of any governor in the United States. In fact, 81% of the 2.4 million registered voters went to the polls in 2004, and Puerto Ricans make Election Day a holiday for their elections.
Voting rights in other American "colonies" differ. The phrase “the Constitution does not follow the flag” is often tossed around during this conversation to justify the varying levels of right in territories held by the United States. Additionally, “territory” is a broad term. For example, Americans living in American Samoa are U.S. nationals, but not U.S. citizens. The U.S. Virgin Islands require American citizens from the mainland to go through customs. Guam’s constitutional has never been approved by the Unites States Congress. People with residence in any territory, including Guam, the Virgin Islands, the Northern Mariana Islands and American Samoa all have no right to vote for national representatives, in the form of a voting member of Congress or a elector vote for the U.S. President.
The political leaders of an American territory should not have to sue their own country in an international court in order to be heard as full citizens. But the series of cases controlling Puerto Rico’s status are racist (written by the same court as Plessy v. Ferguson) and a national embarrassment. Under the current system, without a right to vote in the national government, the discrimination against American citizens living in its colonies/territories will continue. For that reason, FairVote supports the efforts of Rossello on behalf the 3.7 million disenfranchised Puerto Ricans in his attempt to gain the voting right he is due as an American citizen.
President Obama’s recent visit to Puerto Rico was the first such state visit since one by President John Kennedy, and even that first-in-a-half-century visit was seen by many analysts as primarily a means to raise campaign funds and appeal to Puerto Ricans living in the continental United States. The president's pledge to support the will of Puerto Ricans should they vote on statehood again ("When the people of Puerto Rico make a clear decision, my administration will stand by you.") is welcome—but no substitute for immediately seeking means to address the broader problem of how we treat American citizens living in Puerto Rico.
During a week in which we celebrate the American colonies for seeking independence in large part due to denial of representation in the British parliament, it’s time for us to have a candid conversation about voting rights in our own present day “colonies”, starting with the American territory of Puerto Rico.
Brought in the Inter-American Commission on Human Rights by former governor of Puerto Rico Pedro Rossello, Rossello v. United States addresses the lack of a right to cast a ballot and have such ballots counted in national elections for president and Congress by residents of Puerto Rico. Petitioner Rossello has been disenfranchised, along with all other residents of Puerto Rico, despite his American citizenship, based solely on his area of residence within the United States. Currently, any American moving their residence to Puerto Rico would similarly be disenfranchised. This glaring discrimination against United States citizens living in Puerto Rico cannot be allowed to continue under international law and FairVote fully supports Rossello in his efforts.
The United States government is improperly denying the ability to vote to at least 3.7 million of its citizens in stating that the Resident Commission non-voting member of Congress is sufficient to address Puerto Rico’s needs. It is simply not reasonable to believe that one non-voting representative to Congress is equivalent to two senators, approximately six members of the House of Representatives, and a vote for the president and a vice president. The residents of Puerto Rico are being systematically disenfranchised and relegated to second class citizenship by their own government.
Puerto Rico’s current disenfranchised status is not acceptable. Unemployment in Puerto Rico is over 16% - grotesquely high even in an area where unemployment is always higher than that of the mainland. Residents of Puerto Rico pay the same social security and Medicaid taxes as mainlanders; however, they generally receive about 93% less in Medicaid coverage, something many believe is due to Puerto Rico’s inability to lobby for itself in Congress. Puerto Rico is hemorrhaging over 35,000 people a year and those who do leave are usually the highest educated, highly skilled, young, and Republican. In short, not having a voice at the national level is having a real effect on four million American lives.
Failing to provide basic suffrage rights to Puerto Rico is particularly ironic in a time of way when Puerto Rican Americans serve in our armed services at higher rates than most of our states. Petitioner claims that no other area of the United States suffered so many casualties of war prior to becoming a state as Puerto Rico has, or had more decorated and high ranking service members. Puerto Rican soldiers can be ordered into battle by a Commander in Chief for whom they have no power to vote.
And yet all evidence demonstrates that Puerto Ricans greatly value suffrage rights. Voter turnout in election for governor of Puerto Rico are higher than the gubernatorial election of any governor in the United States. In fact, 81% of the 2.4 million registered voters went to the polls in 2004, and Puerto Ricans make Election Day a holiday for their elections.
Voting rights in other American "colonies" differ. The phrase “the Constitution does not follow the flag” is often tossed around during this conversation to justify the varying levels of right in territories held by the United States. Additionally, “territory” is a broad term. For example, Americans living in American Samoa are U.S. nationals, but not U.S. citizens. The U.S. Virgin Islands require American citizens from the mainland to go through customs. Guam’s constitutional has never been approved by the Unites States Congress. People with residence in any territory, including Guam, the Virgin Islands, the Northern Mariana Islands and American Samoa all have no right to vote for national representatives, in the form of a voting member of Congress or a elector vote for the U.S. President.
The political leaders of an American territory should not have to sue their own country in an international court in order to be heard as full citizens. But the series of cases controlling Puerto Rico’s status are racist (written by the same court as Plessy v. Ferguson) and a national embarrassment. Under the current system, without a right to vote in the national government, the discrimination against American citizens living in its colonies/territories will continue. For that reason, FairVote supports the efforts of Rossello on behalf the 3.7 million disenfranchised Puerto Ricans in his attempt to gain the voting right he is due as an American citizen.
President Obama’s recent visit to Puerto Rico was the first such state visit since one by President John Kennedy, and even that first-in-a-half-century visit was seen by many analysts as primarily a means to raise campaign funds and appeal to Puerto Ricans living in the continental United States. The president's pledge to support the will of Puerto Ricans should they vote on statehood again ("When the people of Puerto Rico make a clear decision, my administration will stand by you.") is welcome—but no substitute for immediately seeking means to address the broader problem of how we treat American citizens living in Puerto Rico.
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