SAN JUAN, Puerto Rico — An incurable disease has given Jose Gonzalez Ortiz the health of an old man at age 42, and the collapsing Puerto Rican health system only adds to his pain.
He was refused the $300 worth of monthly medications he needs to treat the degenerative illness known as Lou Gehrig's disease that attacks the cells that control his muscles. His health care plan won't pay for the respiratory equipment that doctors say would ease his breathing. Unable to walk, he lurches about on a walker donated by his church because he was denied a wheelchair for his amyotrophic lateral sclerosis, or ALS.
"I'm so angry and frustrated," the former prison guard said at his home in the seaside town of Arecibo.
Despite the Christmas tree and lights his wife put up early to cheer up their home, this is a gloomy season for Gonzalez and 2.37 million other Puerto Ricans who rely on a health system funded by Medicaid and Medicare.
The island is bracing for steep funding cuts to federal health care plans that serve nearly 70 percent of the U.S. territory's 3.5 million people. Local officials have been talking with the federal government about the proposed funding loss, but believe they will be implemented nevertheless.
The cuts will affect the entire United States, but Puerto Rico is expected to feel them more acutely because the island already receives lower funding levels than the mainland, it has a poverty level higher than any U.S. state, and it is already in the midst of an economic crisis and a nearly decadelong recession.
"There's a devastating crisis coming on," said Dr. Jose Carlo Izquierdo, a neurologist and dean of the University of Puerto Rico's medical school.
Funding for Puerto Rico's Medicare Advantage program, serving about 560,000 of the island's more disadvantaged people, will be slashed by 11 percent in January, a move expected to lead to more expensive copays and the loss of some benefits. More cuts to Medicaid are anticipated over the next two years, affecting about 1.6 million Puerto Ricans like Gonzalez who rely on the funds through Mi Salud, a local government health care plan.
"Things are becoming worse and worse and worse, and we're not seeing the light at the end of the tunnel," said his wife, Brenda Torres Lopez.
Puerto Rico spends about $11 billion a year on health care, while the federal government provides nearly $6 billion through Medicare and Medicaid programs and is on track to cut at least half of that through 2017.
Medical care experts say the cuts will pressure doctors and hospitals to provide services for less money, and more physicians will likely leave Puerto Rico for better pay on the U.S. mainland.
Meanwhile, few doctors with specialties would remain on an island where about 45 percent live in poverty and the number of those 65 and older increased by 28 percent from 2000 to 2012.
"It's a perfect storm," said Dr. Antonio Puras Baez, a surgeon and chair of the urology department at the University of Puerto Rico. "Patients will be left without services."
Officials say Medicaid reimbursements for Puerto Rico are already 70 percent lower than on the U.S. mainland, while Medicare reimbursements are 40 percent lower. Medicaid provides health care for people of limited resources, while Medicare serves people 65 and older and those younger with certain disabilities. The programs reimburse hospitals and doctors providing care.
The planned cuts "will literally cause Puerto Rico's health system to collapse," said Ricardo Rivera, executive director of Puerto Rico's Health Insurance Administration. "Puerto Rico is paying the same Social Security and Medicare taxes as other U.S. states but is not receiving the same benefits."
Puerto Rico's Medicaid plan has relied on a one-time, $6.4 million block grant expected to run out in roughly a year. Without additional federal funding, officials say Puerto Rico would return to receiving less than $400 million a year in Medicaid funds. Oregon, with roughly the same number of people as Puerto Rico, gets $5 billion.
The forthcoming cuts come as Puerto Rico struggles with crowded doctors' office and appointment delays.
Before Gonzalez's neurologist moved to the U.S. mainland, she only saw him once every two months rather than every month because she had so many patients. Gonzalez was told to visit a pneumologist every month, but the one who was recommended couldn't see him for seven months.
"I was afraid he was going to stop breathing and die," said Torres.
Pedro Pierluisi, Puerto Rico's representative to the U.S. Congress, introduced legislation to end the disparity in health care funds in June, when the Centers for Medicare and Medicaid Services announced future cuts to the island's Medicare Advantage program.
New York Gov. Andrew Cuomo and New York City Mayor Bill de Blasio also have pledged to help Puerto Rico obtain equal funding by pressuring Congress into changing laws. President Barack Obama's administration has urged Congress to approve reforms to Puerto Rico's Medicaid program that would improve access to health care and expanded benefits.
Gonzalez and his wife, meanwhile, have considered moving to the U.S. mainland, but don't want to pull their two teenage boys out of school.
So they rely on the goodwill of others, such as church members who donated Gonzalez's walker.
"I trust in my God," said Torres, looking at her husband through her tears.