TOA BAJA, PUERTO RICO – At the Casa Ismael clinic for HIV positive men with severe health complications, the staff immediately used to change the patient's diapers after they were soiled.
Last week, however, clinic administrator Myrna Izquierdo told nurses who had to stop. To save money, the nonprofit clinic, which is dependent on the patient's food stamp money for funding, will ask patients to sit in diapers where they have repeatedly urinated, sometimes for hours.
The Casa Ismael Clinic is concise on the funds partly due to cuts in food brands that hit about 1.3 million people in Puerto Rico this month – a new crisis for an island still struggling for the effects of Hurricane Maria in September 2017.
"We just don't have the money right now," said Izquierdo, 56, in an interview at the clinic's sparse first-floor office, where some of the ceiling tiles are still missing since the hurricane. Izquierdo drew a chart with each patient's name annotated with the cost of his adult diapers for the month. "It is very difficult. It is so unfair. That cut must kill us."
The federal government gave additional food stamp to Puerto Rico after the hurricane, but Congress lacked the deadline for re-authorization in March as it focused on other issues before they left a week-long recess. Federal lawmakers have also been placed by the Trump administration, which has prevented the extra help as unnecessary.
Now, about 43 percent of Puerto Rico's residents are having a sudden cut to the advantage they trust in groceries and other essentials.
And while Congress may soon address this issue, the elimination of the wider vulnerability of Puerto Rico's economy as well as important parts of its safety net are underlined by an increasingly hostile federal government, which it has fought over key priorities.
Puerto Rico will again need the federal government's help to avert drastic cuts to Medicaid, the health care program for the poor and disabled as well as the disbursement of billions in hurricane aid that has not yet turned to the island.
The island would not need Congress to step in to fund its food stamps and Medicaid programs if it were a state. For states, the federal government has committed itself to financing the needs of these programs, regardless of cost and without having to vote. But Puerto Rico instead finances its programs through a block contribution from the federal government that needs to be renewed regularly, and also gives food stamp benefits about 40 percent less than the states.
After declining to reject food stamp financing, President Trump has agreed the emergency inquiry to help Senate Republicans deliver a broader disaster relief package that can be voted this week.
But at an oval office meeting on February 22, Trump asked top advisors for ways to limit federal support from going to Puerto Rico, believing it takes money to go to the mainland, according to senior officials on condition of anonymity to share details of the President's private remarks.  The meeting – an afternoon session focusing on the Department of Housing and Urban Development Grants – ended suddenly, and Trump continues to question how much money the island will receive. Then Trump said he wanted the money only to fortify the electrical network there.
Trump has also privately signaled that he will not endorse further aid to Puerto Rico beyond the food stamp's money and set up a congressional assembly with Democrats who have pushed for more expansive aid to the island.
A senior officials with direct knowledge of the meeting described Trump's attitude: "He doesn't want another dollar on the island."
Trump's anger in Puerto Rico  Puerto Rico's government first began to reduce benefits to food freedom recipients by an average of 25 percent during the first week of March. Pr. On March 12, more than 670,000 people received reduced monthly food concreting payments. The cuts were in force for the entire program last Friday.
Congress legislators knew about the deadlines in months. In January, House Democrats approved $ 600 million in the Supplementary Food Stamp to fund the program until the fall, but the bill immediately prompted the Senate to release the Trump administration a letter calling the extra food bill help "excessive and unnecessary."
More Senate Republicans , led by Sen. David Perdue (R-Ga.), Has incorporated 600 million. $ For Puerto Rico in Legislation with the purpose of helping farmers in states such as Georgia, who have been hit by other storms in a call for wider support at their expense.
Senate Majority Leader Mitch McConnell (R-Ky.) Was smoked to consider a vote in mid-March on this package, which, if it had gone, could have saved about half of program beneficiaries on the island from cuts. Instead, Congress used the week that was consumed in a debate on a vote to reject Trump's emergency statement for a border wall. It was interrupted for an additional week without solving the emergency package.
Congress dealers also shared the exact contours of the finance bill, where Perdue's expense cost $ 13.5 billion. Dollars and Senate Democrats are seeking over $ 14 billion Dollars, including some additional measures to help Puerto Rico, the Senate Republicans do not expect Trump to support. Negotiations continued at the end of Friday, but lawmakers are expected to vote to begin the debate on the relief package this week, according to congressmen.
The site of death comes across a hardening opposition from the president to extend further assistance to Puerto Rico. Trump sees the island as fundamentally broken and has told advisers that no amount will ever solve its systemic problems.
He describes in meetings that much of the island never had power at first, and that it is "ridiculous" much money going to Puerto Rico in the food stamp, according to the senior official. He has sometimes asked how ungrateful political officials in Puerto Rico were to help the administration, the official said.
Trump also reads a October October Wall Street Journal report and was convinced that bondholders and others benefited from federal state aid – and grew furious . (The report describes the prices of Puerto Rico's bonds, which increase after the governing board has assumed that disaster financing would increase the island's overall economic health.) Since then, helpers have described a president who regularly raises the island to ensure that it doesn't get too much money. Current and former officials say Trump often complains about meetings that Puerto Rico doesn't even know how to spend the money the island has been awarded.
In addition, Trump Administration officials have defended the island – Tom Bossert, former home security advisor, and Pam Patenaude, the former deputy HUD secretary – are no longer in the administration. Mick Mulvaney, Trump's acting chief of staff, has also been critical of how the island has spent its money.
& # 39; We want to buy less and eat less & # 39;
The emergency approved by Congress after Maria gave Puerto Rican economy is an instant cash infusion, while the foreclosure of hurricane victims is rising from the rising cost of basic food and safe water.
The Agranel supermarket group, for example, has Occupy at least two employees – and often as many as seven – in each of their 37 stores since the hurricane, often in neighborhoods with very high levels of poverty and unemployment.
"It not only helps these poor communities but spreads the economy with money to start running. It helps the truck that moves the food, the guards who cleans the store, the guy who straightens the fridge where the food is stored," said Felix G. Aponte Lopez, a food supplier for Agranel. "It has had a very positive domino effect."
But now that the extra food stamp money has gone out, Puerto Ricans sees a confidential story of the federal aid's unreliability that they have no control over.
"The problems with Puerto Rico have a causal issue related to it: We do not have political power and are not treated as equal citizens," says Ricardo Rosselló, Puerto Rico's governor, noting that the island does not elect voting members for the congress (though it chooses a non-member member) or has a choice in US presidential matches. "Mary has crystallized and reinforced this feeling of powerlessness."
For Amadita Jimenez Gutierrez, 63, the food bill infusion meant an almost doubling of her income, to about $ 200 a month. Although she did not pay rent and fear expulsion, the higher food freedom benefit allowed her to cook in more healthy meals.
But this month, Gutierrez's diet-freedom allowance dropped to about $ 115, while a small cash supplement during the program was also cut from about $ 40 to about $ 20. As she goes through a time full of cooking items, Gutierrez, she wants to skip the purchase of rice and beans this month, as well as detergents and cleaning supplies.
"We want to buy less and eat less," she said. 19659040] Some residents of Puerto Rico on stamps will see a cash surcharge that comes as part of the food stamp, cut to levels lower than before the hurricane, partly because the island's government expanded the program's eligibility after Congress granted the relief without providing permanent funding. The cuts also come as Puerto Ricans continue to struggle with the fallout from the hurricane: Hundreds of thousands of people have moved to states, while others continue to spend their money on repairs and other damage caused by Mary.
Effects on the Vulnerable
Luz Rivera Morales works full time as a nurse at Auxilio Mutuo, one of the best hospitals in Puerto Rico. She has two daughters, 8 and 5, of whom the youngest requires expensive asthma medication.
This month's birth stamp wound reduced Rivera Morale's benefit from $ 420 a month to $ 218. She plans to stop or restrict her purchases for yogurt, meat and vegetables for her and her children.
"Everything goes up. Nothing goes down," said Rivera Morales, 33, in an interview from a San Juan office in the family department who manages the food stamp. "Yes, I'm very worried."
Across the room from Rivera Morales, Rafael Veles, 82, had already waited two hours to learn how serious his benefit would be. His 56-year-old wife has Alzheimer's disease, and Veles – her caretaker – fears that the cut will put the adult diapers he buys to $ 16 for each package outside their budget.
"It's too little for our expenses," Veles said. . "I have to change my diapers often, and the money is not enough to pay for Pampers. Sometimes I have to change her five times a day. That is not enough."
Cecilia Estrada, 88, saw her benefit to approx. $ 100 a month from about $ 200. Estrada said she would buy the cheapest things. She is particularly concerned about the price of milk at close to $ 5 a jar.
"I buy only a few things, try to make sure I don't spend more than I have," Estrada said while mixing through a Loiza supermarket in San Juan.
Of Puerto Ricans on the food stamp in February 2018, about 55 percent are children, elderly or disabled, according to the preliminary results of a forthcoming research paper by Hector Cordero-Guzman, a professor at Baruch College, part of the City University of New York.
Out of the remaining 45 percent, around 42 percent searched for work; 15 percent worked and 17 percent were in school or had a family-related reason not to work, according to Cordero-Guzman's research.
In 2018, more than 200,000 Puerto Rico residents with disabilities were on food labels each month, according to Cordero-Guzman's research. Among them were the 11 men at the Casa Ismael HIV clinic in Toa Baja.
Izquierdo's parents founded Casa Ismael after their son – Izquierdo's brother – died of HIV in Puerto Rico. Izquierdo, a professional accounting consultant, decided to help her mother after her father's death in 2016.
Izquierdo is attempting to divide the monotony of home life with special meals on Fridays, including occasional lasagne or homemade pizza. She will sometimes use food-stamped money to buy a birthday cake. On special occasions, she tries to keep picnics outside, at least for the men who can take their wheelchairs down a rickety red ramp to the small backyard, which is still full of hurricane waste.
But the food stamp is reduced her budget by more than $ 1,000 every month. Earlier this month, Izquierdo went to Walgreens and imposed three packages of Pampers on his credit card because they were completely out.
Izquierdo said she will continue to cook and fire a birthday party, regardless of the food stamp. She has no idea how she will pay for them.
"We just need to find a way," she said.
Dawsey reported from Washington. Erica Werner in Washington contributed to this report.