BY MOKIE PORTER

“We have come to listen to our veterans and to learn how best to address the pressing needs of rural American veterans in Puerto Rico,” said VVA President Jack McManus. He was speaking to Carlos Escobar, the Executive Director of the VA Caribbean Healthcare System, and members of its five-person leadership team. “Our role,” McManus said, “is to help anybody who wants to help veterans. The members of our organization are aware of what is going on in Puerto Rico, and VVA is committed to assuring that our brother and sister veterans here receive the same treatment as all veteran citizens of the U.S.A.”

The March 11 stakeholders meeting had been arranged by Jorge Pedroza, president of the VVA Puerto Rico State Council. The VVA delegation—McManus; Marc McCabe, VVA’s Strategic Adviser and Chief Service Officer; Alec Ghezzi, the interim VVA Benefits Director; and myself, VVA’s Communications Director—had traveled to the Commonwealth to learn first-hand about the obstacles impeding access to care for Vietnam veterans on the island. We were joined by leaders of Arecibo Chapter 398, and had spent the previous day meeting with Juaco Chapter 483 under the leadership of Joe Valentine.

 “We welcome your perspective,” said Escobar. “We aim to be transparent. It is no secret that there has been a diaspora—a loss of physicians on our island—where more than 70 percent of the veterans are Vietnam veterans.” With 348 hospital beds and 120 nursing home beds, the San Juan VA Medical Center is charged with providing the full range of patient care services for more than 150,000 veterans at its hospital and a network of satellite clinics in Puerto Rico and the U.S. Virgin Islands.

“Our challenge,” Escobar said, “is to get the care in this region up to par with the rest of the VA system. The perception is that we have a declining population; in fact, with 70 percent of the veterans we serve in their senior years, the need is greater than ever.”

Hospital Chief of Staff Dr. William Acevedo concurred: “The average age of our patients is older than those treated in the rest of the VA system,” he said. “The older you get, the more you use the system. We are short of providers. We want to improve our capacity for early diagnostics. We want to get to our patients before their conditions worsen.

“Transportation is also a huge challenge. We need to deinstitutionalize care and practice home-based primary care. The concept of relying on veterans to come to San Juan is not practical.”

 “Across the island, we have the same problem,” said Juan Rosado, president of VVA Chapter 398. “The center part of the island doesn’t have the luxury to move fast—the lighting and the roads are very bad—which pushes the veterans to go to doctors who are closer to their houses. As they continue to gain in years, they will stop coming.”

The VA is “looking at the continuity of care and we are exploring options for home-based primary care. Arecibo is a pilot,” said Iris S. Hernandez, Associate Director for Patient Care Services.

Rosado said that while he is glad to see improvements, his concern is the speed with which things happen. “It took 22 years for us to get a decent clinic in Arecibo,” he said. “We need to do more. We love this hospital. VA is in a losing battle against the private sector. The private sector is granting more access. The primary doctor in the private sector has no waiting time.”

“We want to improve our access to care, but staffing is one of our biggest challenges,” Escobar said. “Pay parity is one of the biggest obstacles we face. We have taken great strides in our attempts to hire. But we are at a serious disadvantage competing against the private-sector medical community.”

Residents of Puerto Rico are excluded from federal taxation, but VA employees are not. Additionally, the Commonwealth provides a tax incentive for private-sector medical personnel, reducing their total tax burden to an average of 4 percent. That, combined with the general shortage of professionals and the price of living—nearly three times higher than in the Continental U.S.—has made it difficult to attract medical professionals to the San Juan VA Medical System.

“One of the advantages I had when I needed help was that I had a congressman who could intervene on my behalf,” said McManus. “Through VVA, we have 100 senators. We want to help you. There are things we can do to bring attention. We will help you engage the power of 100 senators.”

Weeks after the December dedication of the new community-based outpatient clinic in Arecibo, veterans in Utuado were informed that their local VA clinic, which provides medical care to nearly 300 Vietnam veterans, would close on February 4, and henceforth they would receive their care from the CBOC in Arecibo.

McManus had taken immediate action and the decision to close the Utuado Clinic closure was swiftly overturned. In a letter to VA Secretary Denis McDonough, McManus wrote: “This news came as a serious blow to these elderly, rural veterans, most of whom suffer with chronic health conditions related to their Vietnam service. Travel is difficult for them. Most no longer drive. It takes over an hour to drive from Utuado to Arecibo through mountainous roads, not all which have been repaired since Hurricane Maria.

“Veterans and their families are underserved in Puerto Rico. Now is the time to up the service level. VA is not the only entity trying to get services to the rural areas. Let’s level the playing field. You are competing with the private sector. Let’s get the dollars to be equitable so VA can compete. Tax exemptions provide a strong incentive for medical professionals.  Let’s see if we can eliminate the federal tax burden on medical professionals who move to Puerto Rico to work for the Department of Veterans Affairs.”

In the week following his return to the mainland, on March 17, McManus met with Rep. Mark Takano (D-Calif.), the chair of the House Veterans’ Affairs Committee, to propose that Congress eliminate the federal tax burden on VA medical professionals in Puerto Rico.

“It is a well-known fact that Puerto Rico suffers from a lack of medical personnel,” McManus told Takano. “Even more problematic is the lack of access to medical professionals for veterans and their families. But there is a simple solution that will help address this deficit in care. Eliminate the federal tax burden on medical professionals who move to Puerto Rico to work for the VA.”

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