Disparate Treatment of Puerto Rico Residents with 

Disabilities in Federal Programs and Benefits

National Council on Disability

May 25, 2022
National Council on Disability (NCD)

1331 F Street, NW, Suite 850

Washington, DC 20004

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 

and Benefits

National Council on Disability, May 25, 2022

Celebrating 38 years as an independent federal agency

This report is also available in alternative formats. Please visit the National Council on Disability 

(NCD) website (www.ncd.gov) or contact NCD to request an alternative format using the following 

information:

ncd@ncd.gov Email

202-272-2004 Voice

202-272-2022 Fax

The views contained in this report do not necessarily represent those of the Administration, as this and 

all NCD documents are not subject to the A-19 Executive Branch review process.
National Council on Disability

An independent federal agency making recommendations to the President and Congress 

to enhance the quality of life for all Americans with disabilities and their families.

Letter of Transmittal

May 25, 2022

President Joseph R. Biden Jr.

The White House

1600 Pennsylvania Avenue NW

Washington DC 20500

Dear Mr. President:

For a community of over 687,000 people with disabilities we have reneged on the federal promise 

to bring them into the economic and social mainstream simply because of where they reside. The 

conditions which drove the enactment the Americans with Disabilities Act (ADA), over 31 years ago, 

remain starkly present for this community of people who are much poorer, have far less education 

and have less social and community life than other Americans living elsewhere regularly enjoy, simply 

because they live on the beautiful island of Puerto Rico. 

In this report, Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs and 

Services, the National Council on Disability (NCD) highlights the disparate treatment of this community 

of people with disabilities in federal programs and services. The absence of specific safety net 

programs available to eligible people with disabilities residing in any jurisdiction on the mainland or in 

certain of the other territories, and the inadequate or nonexistent funding of other disability programs 

and services for residents with disabilities in Puerto Rico creates devastating economic hardship on 

Puerto Rican residents with disabilities, the most vulnerable group of people residing on the island.

Puerto Rico’s poverty rate is a staggering 44.1%, double the poverty rate of Mississippi, the most 

impoverished U.S. state. 22% of Puerto Rican residents of all ages have a disability, slightly under the 

26% prevalence rate for all of the United States. The highest prevalence of disability among Puerto 

Rican residents is mobility disability with the prevalence rate of 12.6%, almost double the prevalence 

rate of those residing in the states; and the incidence of low vision or blindness in Puerto Rico is 

four times the rate of those in the states. These statistics are especially troubling given the disparate 

treatment of residents with disabilities there under the federal safety net programs for people with 

disabilities and given the broader economic crisis affecting Puerto Rico overall. 

The report examines failing federal public policies, programs, and practices in Puerto Rico across the 

areas of education, employment, financial assistance and incentives, health care, long-term services 

and supports, transportation, housing, as well as disaster relief – each different segments of society 

that the promise enshrined in the ADA was deliberately intended to address.

1331 F Street, NW ■ Suite 850 ■ Washington, DC 20004

202-272-2004 Voice ■ 202-272-2074 TTY ■ 202-272-2022 Fax ■ www.ncd.gov

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 1
Safety net programs such as Puerto Rico’s nutritional assistance program and Medicaid, are funded 

by block grants, resulting in financial constraints given the island’s economic condition, which require 

the Commonwealth to limit program eligibility and services. A Puerto Rican resident with a disability 

is not eligible for Supplemental Security Income and the breadth of Medicare coverage is not equal to 

that offered to its enrollees in the states. Moreover, because of the maritime transportation restrictions 

of the Jones Act, durable medical equipment (DME) and replacement parts for DME are more 

expensive on the island and difficult to attain. Federal funding for education, employment, housing, 

and transportation services in Puerto Rico are allocated by the same funding formula as is used for the 

states. However, the current formula factors do not take into consideration the high level of poverty, 

incidence of disability, and the island’s financial constraints. Moreover, four years post-hurricane Maria, 

71% of disaster relief and recovery operations funds still have not reached communities on the island 

and thousands of houses are still covered with blue tarps.

Puerto Rican residents are U.S. citizens. The promise of the ADA was never conditioned on zip code. 

For the over 687,000 people with disabilities residing on the island (a community that is larger than the 

total population of residents in Wyoming or Vermont), we must end this disparate treatment.

We look forward to the opportunity to brief you and your Administration on these findings and our 

recommendations.

Most respectfully,

Andrés J. Gallegos

Chairman

(The same letter of transmittal was sent to the President Pro Tempore of the U.S. Senate and the Speaker of the 

U.S. House of Representatives.)

2 National Council on Disability
National Council on Disability Members and Staff 

Members

Andrés J. Gallegos, Chairman

Jim Brett, Vice Chair

Jim Baldwin

David D’Arcangelo

Munr Kazmir, M.D.

Rick Rader, M.D.

Neil Romano

Daniel C. Schreck

Mary G. Vought

Staff

Anne C. Sommers McIntosh, Executive Director

Joan M. Durocher, General Counsel & Director of Policy

Lisa Grubb, Director of Administration, Finance, and Operations

Stacey S. Brown, Staff Assistant

Kimie Eacobacci, Legislative Affairs Specialist

Netterie Lewis, Administrative Support Specialist

Amy Nicholas, Senior Attorney Advisor

Nick Sabula, Public Affairs Specialist

Amged Soliman, Senior Attorney Advisor

Ana Torres-Davis, Senior Attorney Advisor

Keith Woods, Financial Management Analyst

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 3
4 National Council on Disability
Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Acronym Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Puerto Rico Brief History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Demographic Data of Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Challenges of People with Disabilities in Puerto Rico . . . . . . . . . . . . . . . .  2

Chapter 1: Methodology and Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Methodology and Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Limitations of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Chapter 2: Jones Act / Inventory Taxes / Other Taxes . . . . . . . . . . . . . . . . . . . . . . . . . .  2

The Jones Act in Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Inventory Tax and Other Taxes Paid in Puerto Rico That Affect 

People with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Chapter 3: Health: Medicaid and Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3

Chapter 4: Income Assistance Benefits and Programs . . . . . . . . . . . . . . . . . . . . . . . . .  4

Supplemental Security Income (SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

Challenging Disparate Treatment: United States v

Vaello-Madero US Supreme Court . . . . . . . . . . . . . . . . . . . . . . . . . .  4

Social Security Disability Insurance (SSDI) . . . . . . . . . . . . . . . . . . . . . . . . .  4

Federal Nutrition Assistance Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

NAP Eligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 5
Chapter 5: Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Education Services in Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Chapter 6: Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Federal Employment Programs and Services in Puerto Rico, the 

United States, and U.S. Territories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Department of Labor and Human Resources . . . . . . . . . . . . . . . . . . . . . . .  6

Vocational Rehabilitation Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Supported Employment (SE) for Individuals with Significant 

Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Transition Services Under VRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Stakeholders’ Views on VRA Services . . . . . . . . . . . . . . . . . . . . . . . . .  6

Social Security Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Tax Incentives to Employers...

Chapter 7: Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

HUD Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Housing in Puerto Rico, the United States, and U.S. Territories . . . . . . . . 

Chapter 8: Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Transportation in Puerto Rico, the United States, and the 

U.S. Territories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Chapter 9: Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8

Emergency Response for Hurricanes Harvey and Irma . . . . . . . . . . . . . . .  8

Response Efforts Hurricane Harvey, Houston, TX, August 2017 . . . . .  8

Florida Recovery from Hurricane Irma; September 2017 . . . . . . . . . .  8

Chapter 10: Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8

Appendix A: Town Hall Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

National Council on Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Town Hall Meeting in Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Topics Discussed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Political Status of the Island . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Emergency Preparedness for PWD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

6 National Council on Disability
Compliance of Accessibility Guides in the Americans with 

Disabilities Act (ADA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Home Ownership Issues and FEMA Support on the Island . . . . . . . .  9

Appendix B: Comparison of the percentage of adults with select types of 

functional disability between the United States’ unincorporated organized 

territories and the states. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Appendix C: Tables of Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Appendix D: Comparison of the number of school-age students served 

under IDEA, Part B, in 2019–2020, in U.S unincorporated organized territorie

Note: table shows a comparison of the number of school-age students served 

under IDEA, Part B, in 2019–2020, in U.S. unincorporated organized territories . . . . 1

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 7
8 National Council on Disability
Acknowledgements

The National Council on Disability expresses its deep appreciation to the Movimiento para el Alcance 

de Vida Independiente (MAVI) Independent Living Center and its Executive Director Betzaida Ramos 

Charriez, Project Lead Nellyber Correa, Program Director Mildred de la Torre, Administrative Assistant 

and Student Intern Charlie Colon; The University Center of Excellence in Development Disabilities 

(UCEDD) Executive Director Dr. Carol Salas, who served as Principal Investigator, Research and 

Evaluation Coordinator Ilia Torres, and Student Research Interns Valeria S. Delgado-Rodriguez, Jonathan 

A. Pitre-Gonzalez, Jessica M. Naredo-Rojas, Adian N. Rodríguez-Lorenzo, Yoseline Mercado-Santiago, 

Paola A. Manrique-Pizarro, Karina M. Gómez-Torres; B/Adaptable founder Carmen Ramos-Watson, who 

served as Strategic Advisor with her consultant advisors, Jeffrey Watson and William Ramos.

A deep appreciation to all stakeholders who shared personal experiences, observations, and 

insights. Special thanks to Javier Balmaceda of the Center for Budget and Policy Priorities, Rosanna 

Torres of the Center for New Economy, and Cari Palerm from HUD for their invaluable contributions. 

Many thanks to the amazing team that dedicated countless hours to ensure that the voice of people 

with disabilities on the Island of Puerto Rico received the attention it deserves.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 9
10 National Council on Disability
Executive Summary

T

he Commonwealth of Puerto Rico is a U.S. 

territory and Puerto Rican residents are 

American citizens. However, Puerto Rican 

residents with disabilities are not treated equally 

as compared to their counterparts residing in 

the United States and in 

certain other territories 

in terms of access to, 

participation in, and 

benefits received under 

federal programs. This 

disparate treatment is 

evident when benefits 

are compared for people 

with disabilities (PWD) 

living in Puerto Rico 

and PWDs living on the 

mainland and other U.S. territories. While some 

of the same federal programs are available to 

residents of Puerto Rico with disabilities, the 

amount of appropriated funds for the federal 

safety net programs per person is considerably 

lower when compared to the funds provided for 

the same programs on the mainland and other 

U.S. territories.

In response to the funding disparity, it has 

been argued that Puerto Rican residents do not 

pay federal income tax, therefore they should 

not be eligible for safety net programs. While it 

is true, Puerto Rican residents do not pay federal 

income taxes, Puerto Rican residents do pay 

federal payroll taxes, and Puerto Rican residents 

working for federal agencies must submit 

federal income tax returns. In fact, Puerto 

Rican taxpayers contribute more to the federal 

treasury than taxpayers 

in six states and the 

Northern Mariana 

Islands.1

 Regardless, 

Puerto Rican residents 

are American citizens 

and should have access 

to the same benefits as 

any American citizen, 

regardless of their zip 

code.

This report examines 

the disparate treatment of Puerto Rican 

residents with disabilities in federal programs. 

NCD examines the disparity between residents 

with disabilities in the states with the highest 

population of Puerto Ricans, namely, Florida, 

New York, Pennsylvania, New Jersey, and 

Massachusetts, as well as other U.S. territories. 

The federal programs analyzed in this report are 

those that combined, create a safety net for 

people with disabilities: Medicaid, Medicare, 

Social Security Disability Insurance (SSDI), 

Supplemental Security Income (SSI), and 

Supplemental Nutrition Assistance Program 

Puerto Rican residents with 

disabilities are not treated equally 

as compared to their counterparts 

residing in the United States and 

in certain other territories in terms 

of access to, participation in, and 

benefits received under federal 

programs

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 11
(SNAP)/Nutritional Assistance Program (NAP). 

In addition, this report examines disparities 

in the cost and availability of durable medical 

equipment (DME), how Puerto Rican residents 

with disabilities fair in employment, and 

the availability of accessible housing and 

transportation. This report also examines 

disparities in the federal response to natural 

disasters in Puerto Rico compared to those in 

the states.

NCD found funding and coverage disparities 

in the following federal programs: Medicare, 

Medicaid, SSI and SNAP/NAP. Significant 

disparities were found in access to and prices 

of DME. NCD is concerned over the adverse 

consequences to people 

with disabilities due 

to delayed access to 

federal aid from recent 

emergencies. Before 

Puerto Rico was given 

access to appropriated 

emergency funds, 

additional restrictions and 

requirements were placed on the territory prior to 

disbursement. This furthered the delay of muchneeded resources and negatively impacted an 

already beleaguered island.

NCD report findings and recommendations 

were determined by data collection via literature 

review, interviews of stakeholders including 

persons with disabilities, and interviews with 

state and federal agencies.

Some of the findings and recommendations 

garnered from the report are:

■ NCD recommends all federal and state 

agencies, as well as public and private 

universities, include data on Puerto Ricans 

with disabilities living on the island and 

other territories in data collection to 

improve accountability so as to ensure 

that appropriate resources are provided 

to ensure equity to programs that allow 

PWDs the opportunity to achieve economic 

independence (for example, data collection 

initiatives collected by the Census Bureau, 

National Health Interview Survey, and State 

of the States).

■ NCD recommends Congress repeal 

the provision within the Jones Act, that 

restricts coastwise trade on U.S. flagged 

vessels, for durable medical equipment 

covered under Medicare Part B (such as 

manual wheelchairs, 

power wheelchairs 

and components and 

replacement parts, 

scooter and component 

parts and replacement 

parts, patient lift and 

transfer equipment, 

patient ventilators, portable oxygen, 

foam, gel, innerspring and air mattresses, 

continuous positive airway pressure (CPAP) 

devices, shower chairs and commode 

chairs, and suction pumps).

■ NCD recommends Congress amend the 

Social Security Act to replace the Medicaid 

block grant program in Puerto Rico and 

other U.S. territories with an uncapped 

federal matching system, equivalent to 

the Medicaid program provided to U.S. 

residents.

■ NCD recommends Congress amend Title 

XVI of the Social Security Act to require 

SSI benefits be provided to all eligible U.S. 

Before Puerto Rico was given 

access to appropriated emergency 

funds, additional restrictions and 

requirements were placed on the 

territory prior to disbursement

12 National Council on Disability
citizens, to include residents of Puerto Rico 

and U.S. territories.

■ NCD recommends Congress amend the 

Food Stamp Act to include Puerto Rico, the 

Northern Mariana Islands and American 

Samoa in the SNAP program, as has been 

done for Guam and the U.S. Virgin Islands 

(USVI).

■ NCD recommends Congress mandate 

federal agencies that use funding formulas 

recalculate their formulas to mitigate 

the impact of high poverty rates and 

hence a lower tax base which impacts 

the grantee’s ability to utilize the funds 

for programs and services as intended. 

Equitable redistribution of funds to grantees 

will mitigate the unintended disparate 

impact of the current method by providing 

the appropriate funding to all states and 

territories to ensure programs and services 

are adequately funded and provide similar 

benefits to all U.S. citizens.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 13
14 National Council on Disability
Acronym Glossary

AABD Aid to the Aged, Blind and Disabled

AAPD American Association of People with Disabilities

ABD Aged, Blind and Disabled Program

ABLE Achieving a Better Life Experience Act

ACA Affordable Care Act

ADSEF Family Socioeconomic Development Administration (ADSEF for its acronym in Spanish)

AIVR American Indian Vocational Rehabilitation

AJC American Job Centers

AMA Metropolitan Bus Authority

AMSI Alianza Municipal de Servicios Integrados

ASORE Puerto Rico Restaurants Association (ASORE for its Spanish acronym)

AT Assistive Technology

ATI Puerto Rico Integrated Transportation Authority (ATI for its Spanish acronym)

ATM Maritime Transport

BRFSS Behavioral Risk Factor Surveillance System

CCPA Puerto Rico Society of CPAs (CCPA for its Spanish acronym)

CDBG Community Development Block Grant

CDBG DR Community Development Block Grant Disaster Recovery

CDC Centers for Disease Control and Prevention

CEDD State Council on Developmental Disabilities (CEDD for its Spanish acronym)

CIL Center for Independent Living

CPD Community Planning and Development

CMS Centers for Medicare and Medicaid Services

CUD United Retailers Association (CUD for its Spanish acronym)

DDA Developmental Disabilities Agencies

DLRH Department of Labor and Human Services

DME Durable Medical Equipment

DOH Department of Housing

DOL Department of Labor

DOT Department of Transportation

DPI Puerto Rico Protection and Advocacy Service, Ombudsman for PWD 

(DPI for its Spanish acronym)

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 15
DTOP Puerto Rico Department of Transportation and Public Works

ED U.S. Department of Education

ELIL Extremely Low-Income Limit

EN Employment Network

ESSA Every Student Succeeds Act

ESSER Elementary and Secondary School Emergency Relief Fund

FCO Federal Coordination Office

FHWA Federal Highway Administration

FMAP Federal Matching Assistance Percentage

FNS Food and Nutrition Service

FPL federal poverty level

FTA Federal Transit Administration

GAO Government Accountability Office

GEER Governor’s Emergency Education Relief Fund

HHS U.S. Department of Health and Human Services

HUD U.S. Department of Housing and Urban Development

IDD Intellectual and developmental disabilities

IDEA Individuals with Disabilities Education Act

IEP Individualized Educational Plan

LEA Local Education Agencies

LIL Low Income Limit

LIS Low Income Subsidy program

MA Medicare Advantage

MAP-21 Moving America Plan-21

MAVI Movement for Achieving Independent Living (MAVI for its Spanish acronym)

META-PR Measurement and Evaluation for Educational Transformation Test

MIDA Industry and Food Distribution (MIDA for its Spanish acronym)

N-CATT National Center for Applied Transit Technology

NCHS National Center for Health Statistics (NCHS)

NHIS National Health Interview Survey (NHIS)

NHTS National Household Travel Survey

NSCH National Study of Children’s Health (NSCH)

OSEP Office of Special Education Programs

PAN Nutritional Assistance Program (PAN for its Spanish acronym)

PCBI Public Corporation for the Blind

PDL Preferred Drug List

PHA Puerto Rico Public Housing Administration

PRATP Puerto Rico Assistive Technology Program

PRDCRN Puerto Rico Disability Community Relief Network

16 National Council on Disability
PRDE Puerto Rico Department of Education

PRHTA Puerto Rico Highways and Transportation Authority

PROMESA Federal Oversight and Management Board

PRP Provisional Remedy Program

PR-PHA Public Housing Administration in Puerto Rico

PR UCEDD Puerto Rico University Center for Excellence in Developmental Disabilities

PWD People with Disabilities

PYMES Small to mid-size businesses (PYMES for its Spanish acronym)

RESTART Immediate Aid to Restart School Operations Program

RFP Request for Proposal

RSA Rehabilitation Service Administration

RSVFP Randolph Sheppard Vending Facilities Program

SAEE Secretaría Auxiliar Educación Especial (Special Education Assistant Secretary)

SDOH Social Determinants of Health

SE Supported Employment Program

SLTT State and Local Tribes and Territories

SNAP Supplemental Nutrition Assistant Program

SPP Strategic Plan or State Performance Plan

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

STIP Statewide Transportation Improvement Program

SVRA State Vocational Rehabilitation Administration

TPFA Third-Party Fiduciary Agent

TTW Ticket to Work, Employment Network

TU Urban Train (TU for its Spanish acronym)

USDA U.S. Department of Agriculture

USVI U.S. Virgin Islands

VR Vocational rehabilitation

VRA Vocational Rehabilitation Administration

VLIL Very Low-Income Limit

WHO World Health Organization

WIB Workforce Investment Boards

WIOA Workforce Innovation and Opportunity Act

WIPA Work Incentives Planning and Assistance Program

WOTC Work Opportunity Tax Credit

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 17
Given Puerto Rico’s high prevalence of 

poverty and disability, the disparate funding 

for essential safety net programs does not 

allow Puerto Rico to provide its residents 

with disabilities much needed services and 

supports

18 National Council on Disability
Introduction

Puerto Rico Brief History

On December 10, 1898, Puerto Rico became 

a U.S. territory under the “Treaty of Paris.” The 

Jones-Shafroth Act of 1917 (1917 Jones Act) 

granted U.S. citizenship to persons born on 

the Island and established the framework for 

the Puerto Rican government. The 1917 Jones 

Act also created the Bill of Rights for Puerto 

Rico and established the office of the Resident 

Commissioner in 

Congress for four-year 

terms. This position 

allows participation 

in the House of 

Representatives in 

Congress, without voting 

rights. Puerto Rico 

officially became a U.S. 

commonwealth in 1952, 

which allowed the island 

to create its own constitution.2

Puerto Rico’s economy is impacted by the 

various federal regulations and policies aimed 

to propel U.S. economic growth. The results 

garnered from these policies and regulations 

have not always benefited the residents 

of Puerto Rico. For instance, The Internal 

Revenue Code (IRC), Section 931, enacted in 

the 1920s, granted U.S. corporations tax-free 

exemptions for their overseas operations until 

they repatriated their earnings to the United 

States. In 1976, IRC Section 931 was repealed 

and replaced by IRC Section 936, designed to 

incentivize subsidiaries of U.S. corporations to 

settle on the Island and to repatriate their profits 

to their parent companies without paying federal 

taxes. This resulted in a boom to the Puerto Rico 

economy. Section 936 was repealed in August of 

1996, companies were 

granted a 10-year grace 

period for companies that 

remained on the island.3,4

The repercussions 

from the repeal of IRC 

Section 936 are still 

visible on the island. 

Once these tax credits 

were eliminated, Puerto 

Rico’s economic growth 

slowed, and its national 

debt rapidly increased. In 2015, Puerto Rico’s 

governor, Alejandro García Padilla, announced 

that the commonwealth could no longer meet 

its sizable debt, a debt of almost $70 billion.5

Public Law 114-187, the Puerto Rico Oversight 

Management and Economic Stability Act 

(PROMESA), was passed by Congress on June 

30, 2016. PROMESA created a structure to 

Puerto Rico’s economy is 

impacted by the various federal 

regulations and policies aimed 

to propel U.S. economic grow

The results garnered from these 

policies and regulations have not 

always benefited the residents of 

Puerto Rico

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 19
exercise federal oversight over the fiscal affairs 

of Puerto Rico, and potentially Guam, American 

Samoa, the Commonwealth of the Northern 

Mariana Islands, and the U.S. Virgin Islands 

(USVI).6 It established an Oversight Board 

which has broad financial control over Puerto 

Rico, created procedures for adjusting debts 

accumulated by the Puerto Rican government 

and its instrumentalities, and for debts of other 

territories and expedited approvals of key 

energy projects and other “critical projects” 

in Puerto Rico.7

In September 2017, Puerto Rico’s economic 

troubles were compounded when Hurricane 

Maria made landfall on 

the island and decimated 

its infrastructure. In 

Maria’s aftermath, some 

3.4 million American 

citizens found themselves 

in a humanitarian crisis, 

facing a destroyed 

infrastructure, power 

outages for over six 

months, shortages of 

water, food, fuel, and an uncertain future.8 And 

then, in January 2020, Puerto Rico suffered 

a 6.4 magnitude earthquake and continuing 

aftershocks in the Southwestern part of the Island, 

which destroyed homes and businesses further 

weakening an already dire economy and creating 

significant impact to the health and wellbeing of 

the residents of Puerto Rico. Later, in March 2020, 

Puerto Rico, as was the rest of the world, was 

hit with the COVID-19 pandemic. The pandemic 

brought business restrictions and placed a 

further strain on health and medical systems. The 

government took early precautions by shuttering 

everything except essential services. These 

restrictions, though necessary, saddled the island 

with further economic burdens, leaving thousands 

unemployed resulting in increased poverty rates 

further widening the gap to accessible services for 

PWDs.

As a result of these conditions and threats, 

the island has experienced an exodus of Puerto 

Rican residents to the United States. In 2011 and 

2012, approximately 55,000 Puerto Ricans per 

year emigrated from Puerto Rico to the United 

States. In 2018, 64 percent of Puerto Ricans 

lived within the United States and 36 percent 

resided on the island. Although Puerto Ricans 

have emigrated to the United States for several 

generations, the number 

of departures from 2000 

to 2010 (300,000) is the 

largest wave of migration 

since the 1950s, when 

nearly half a million 

people emigrated to 

the Continental United 

States over the decade.

Puerto Ricans 

represent nine percent of 

the Latin American population in the United States 

and 1.5 percent of the total population of North 

America. Although the 2010 Census of the United 

States puts the number of Puerto Ricans living in 

the United States at about 4.6 million, estimates 

from 2012 show that the population grew to an 

estimated 5.6 million in 2017, almost double the 

amount residing on the island.9 Migration has 

become an intrinsic component of Puerto Rican 

culture. As a result of this migration, there has 

been a substantial exodus of professionals that 

have left the island to search for job opportunities 

and better financial conditions, further depressing 

economic activity by leaving fewer taxpayers, 

In 2011 and 2012, approximately 

55,000 Puerto Ricans per year 

emigrated from Puerto Rico to the 

United States. In 2018, 64 percent

of Puerto Ricans lived within the 

United States and 36 percent 

resided on the island

20 National Council on Disability
thus placing the island in a precarious financial 

situation. There is a shortage in the supply of 

medical doctors, educators, and professionals 

that form the brain trust of the island, further 

exacerbating availability of services for PWDs.

Demographic Data of Puerto Rico

In 2019, Puerto Rico’s population was 3,193,694. 

Approximately 687,000 people, which makes 

up 21.7 percent of 

Puerto Rico’s residents, 

have a disability.10 In 

2018, 22.2 percent of 

females of all ages and 

21.0 percent of males of 

all ages in Puerto Rico 

reported a disability.11

On September 16, 

2020, the CDC published 

the Disability & Health 

U.S. Profile Data for 

Puerto Rico (adults over 

18 years of age). The 

following table illustrates the differing disabilities 

and the prevalence between the U.S. mainland 

and Puerto Rico.12 The data clearly demonstrates 

Puerto Rico residents have a higher percentage 

and prevalence for all types of disabilities than 

those living on the mainland.

Attaining education and employment for 

people with disabilities in Puerto Rico is bleak. 

PWDs in Puerto Rico with a high school diploma 

or equivalent is 29.8 percent, 26.5 percent 

have some college or an associate degree and 

only 18.2 percent have a bachelor’s degree or 

higher.13 Puerto Ricans 

with disabilities have 

an employment rate of 

23.5 percent compared 

to 58.5 percent for those 

without disabilities.14,15

In 2018, the percentage 

of working age people 

with disabilities in 

Puerto Rico who were 

unemployed but actively 

looking for work was 

7.5 percent, whereas 

those without disabilities 

was 22.6 percent.16 In the United States, 

the unemployment rate of people with 

disabilities was 12.6 percent in 2020, compared 

As a result of this migration, there 

has been a substantial exodus of 

professionals ..., further depressi

economic activity by leaving fewer 

taxpayers ... There is a shorta

in the supply of medical doctors, 

educators, and professionals that 

form the brain trust of the island, 

further exacerbating availability of 

services for PWDs

Table I.1: Types of Disabilities: U.S. Mainland Vs. Puerto Rico

Type of Disability

(Adults 18 years of age and older)

United 

States

Puerto 

Rico

Mobility: Serious difficulty walking or climbing stairs. 12.9% 21

Cognition: Serious difficulty concentrating, remembering, or making 

decisions

11.4% 15.

Independent living: Difficulty doing errands alone, such as visiting a 

doctor’s office or shopping

7.0% 12.

Hearing: Deafness or serious difficulty hearing. 5.6% 7

Vision: Blind or serious difficulty seeing, even when wearing glasses. 4.7% 16

Self-care: Difficulty dressing or bathing. 3.8% 7

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 21
to 7.9 percent unemployment for people 

without disabilities.17 The general population 

unemployment rate in Puerto Rico for December 

2020 was 9.2 percent.18

Mississippi is the poorest U.S. state with a 

poverty level of 19.6 percent19 whereas Puerto 

Rico’s poverty rate is a staggering 43.5 percent,20

making the island the most impoverished state 

or territory in the United States. The poverty level 

of PWDs in Puerto Rico in 2018 was 48 percent, 

compared to 38 percent of people without 

disabilities.21 “Approximately 44.1 percent of the 

population live in poverty 

with over 36 of the 

78 municipalities having 

more than 50 percent of 

their population living in 

poverty.”22

Challenges of 

People with 

Disabilities in 

Puerto Rico

The 687,000 PWDs living in Puerto Rico 

face additional challenges that their disabled 

counterparts living in the states likely do not 

encounter. The social conditions in which 

residents of Puerto Rico with disabilities live 

make it difficult or impossible for them to 

achieve autonomy and economic independence. 

Educational support for PWDs on the island is 

challenged due to lack of funding and human 

capital, Puerto Rico’s fiscal status, the impact 

of natural disasters, and the pandemic. All of 

these factors interfere with the free, public 

education that is indispensable for all students 

but especially for PWDs.

Essential needs like healthcare, access 

to affordable durable medical equipment 

(DME), employment opportunities, accessible 

transportation, and accessible housing are 

scarce or not available at all. Puerto Rican 

residents with disabilities are eligible for 

federal programs. However, funding for many 

of the government safety net programs for 

PWDs fall well below those provided in the 

states. Given Puerto Rico’s high prevalence of 

poverty and disability, 

the disparate funding 

for essential safety net 

programs does not allow 

Puerto Rico to provide 

its residents with 

disabilities much needed 

services and supports.

PWDs residing in 

Puerto Rico experience 

disparate treatment 

in federal benefits. Congress generally 

determines whether Puerto Rico is eligible for 

federal programs on a case-by-case basis and 

defines the disparate treatment in law.23 For 

example, some funds appropriated for federal 

programs in Puerto Rico are subject to eligibility 

restrictions, not imposed upon persons with 

disabilities in the states or in certain other 

territories.24 This report identifies the factors 

that contribute to the disparity of federal 

programs for residents of Puerto Rico with 

disabilities and their impact.

Given Puerto Rico’s high prevalence 

of poverty and disability, the 

disparate funding for essential 

safety net programs does not allow 

Puerto Rico to provide its residents 

with disabilities much needed 

services and supports

22 National Council on Disability
Chapter 1: Methodology and Data Collection

Summary

The methodology and data collection identified disparate treatment of Puerto Rican residents 

with disabilities in certain federal programs and examined the living conditions of Puerto 

Rican residents with disabilities.

Methodology and Research Design

The research design consisted of a qualitative 

study through document analysis and in- depth 

interviews. The literature review identified the 

five states with the highest percentage of 

population of Puerto Ricans in order to compare 

federal benefits available to Puerto Ricans living 

on the mainland versus those who live on the 

Island. A comparative technique was used to 

analyze relevant information and statistical data 

from programs in the United States that impact 

services to PWDs. Information was identified 

based on the results of questions that were used 

in the key informant interviews and validated by 

surveys of the National Center for Health Statistics 

(NCHS), the National Health Interview Survey 

(NHIS), the National Study of Children’s Health 

(NSCH), the Medical Expenditure Panel Survey, 

the Current Population Survey, ACS-Puerto Rico, 

the CDC Behavioral Risk Factor Surveillance 

System (BRFSS), and the U.S. Census. A 

document analysis on current public policy was 

conducted with regard to Puerto Rico, the United 

States, and the U.S. territories (Sociodemographic 

and National Survey Statistical Data, Social 

Security Policies, Medicaid, Health Coverage, 

Housing, Food Assistance, Transportation, 

Independent Life). The qualitative study examined 

whether there is disparate treatment to Puerto 

Rico residents in federal programs, the impact 

of the disparate treatment of Puerto Rico under 

the Jones Act, and how the application of federal 

health, educational, and social programs may 

impact the services provided to PWDs and their 

families residing in Puerto Rico.

Limitations of the Study

Data is crucial in every stage of research and 

service provisions. At the time of this report, 

there is no study that collects information 

on PWDs in Puerto Rico. There are limited 

data sets that include the health outcomes 

in Puerto Rico. There is a lack of concrete, 

coordinated, comparable data for Puerto Rico 

and the territories that made federal benefit 

comparisons among the mainland and the 

territories cumbersome. Nevertheless, sufficient 

legal, anecdotal, and empirical evidence exists to 

support our recommendations.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 23
24 National Council on Disability
Chapter 2: Jones Act / Inventory Taxes / Other Taxes

Impact of Taxes on DME

The Jones Act, Puerto Rico’s inventory tax, and Puerto Rico’s tax structure increase prices 

and availability of crucial durable medical equipment for residents of Puerto Rico with 

disabilities. The Jones Act, which puts limitations on the type of vessels that can transport 

American goods to the island, results in increased prices. Puerto Rico’s inventory tax 

penalizes businesses for retaining inventory and the federal tax structure on the island 

precludes Puerto Ricans with disabilities from receiving certain federal benefits. NCD 

recommends Congress repeal the provision within the Jones Act that restricts 

coastwise trade on U.S. flagged vessels, for durable medical equipment covered under 

Medicare Part B (such as manual wheelchairs, power wheelchairs and components 

and replacement parts, scooters and component parts and replacement parts, 

patient lift and transfer equipment, patient ventilators, portable oxygen, foam, gel, 

innerspring and air mattresses, continuous positive airway pressure (CPAP) devices, 

shower chairs and commode chairs, and suction pumps).

Additionally, NCD recommends the legislative assembly of Puerto Rico waive the 

inventory tax on DME.

The Merchant Marine Act of 1920, 

commonly known as the “Jones Act,” 

is a federal law originally intended to 

improve national security by having a strong 

merchant marine that would facilitate maritime 

commerce, be available in times of war or 

national emergencies, and support industrial 

shipyards.25 This law was meant to regulate the 

transportation of goods by water between U.S. 

ports. The Jones Act requires that:26 vessels be 

constructed in the United States, vessels must 

be registered in the United States and man a U.S. 

flag, American ownership and control of vessels 

must be at least 75 percent, and the crew of the 

ship must be American citizens.

The Jones Act in Puerto Rico

The Jones Act originally applied to every United 

States territory.27 However, the USVI, American 

Samoa, and the Northern Mariana Islands, all U.S. 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 25
territories, were exempted from the Jones Act 

in 1922. To compare, shipping costs to the USVI, 

a mere 179 miles from Puerto Rico, is about half 

that of shipping costs to Puerto Rico.28

The Jones Act’s prescriptive requirements are 

detrimental to Puerto Rican residents,29 especially 

Puerto Rican residents 

with disabilities who 

are more likely to live in 

poverty. The monopoly 

these American 

vessels have over the 

shipping routes in the 

Caribbean enable them 

to charge higher rates 

for shipping.30 The annual 

costs of transporting 

goods to Puerto Rico are 

$568.9 million higher because of the Jones Act.31

The cost of the Jones Act for Puerto Rico on 

food and beverage alone is approximately $367 

million per year,32 thus impacting the labor force 

in 13,250 fewer jobs, 

with $337.3 million lost 

in wages. Ultimately, the 

Jones Act burdens an 

individual Puerto Rican 

resident $375 a year.33

These circumstances 

exacerbate the living 

conditions on the island, 

where the cost of living 

is 13 percent higher than 325 geographical areas 

in the United States, with an annual per capita 

income of $12,914,34 which is less than the 

poorest state in the nation (Mississippi).35 Puerto 

Rico’s food supply is dependent on imports that 

are subjected to the Jones Act, which results in 

higher food prices on the island.36

PWDs stated that durable medical equipment 

was more expensive on the island. To verify these 

assertions, NCD conducted its own search of 

prices for DME most often purchased by PWDs. 

We compared prices in Puerto Rico, in the 

states, and the other U.S. territories. In Puerto 

Rico, we found only 

23 DME suppliers—

an underwhelming 

number of suppliers to 

service the needs of 

approximately 21 percent 

of the population of 

PWDs on the Island. 

The majority of DME 

suppliers are located 

in the metropolitan 

area, leaving the rural 

municipalities void of sufficient suppliers to 

satisfy the need of PWDs who live outside of the 

metropolitan area. The other U.S. territories, the 

USVI, Guam, American Samoa, and the Northern 

Mariana Islands only 

have a total of 12 DME 

suppliers, whereas there 

were 193 DME suppliers 

in Florida alone, 10 times 

the amount available in 

Puerto Rico.

When conducting 

the cost analysis of 

DME, price quotes were 

obtained from medical equipment providers in 

Puerto Rico versus providers in the states. When 

looking at basic DME, like manual wheelchairs, 

walkers, walking canes, grab bars, commodes, 

rollators, and bath chairs, we found no significant 

cost difference between Puerto Rico and the 

states. However, when comparing the costs of 

[T]he USVI, American Samoa, and 

the Northern Mariana Islands, all 

U.S. territories, were exempte

from the Jones Act in 1922. To

compare, shipping costs to the 

USVI, a mere 179 miles from Puerto 

Rico, is about half that of shipping 

costs to Puerto Rico

[T]he cost of living [in Puerto Rico] 

is 13 percent higher than 325 

geographical areas in the United 

States, with an annual per capita 

income of $18,000, which is less 

than the poorest state in the nation 

(Mississippi)

26 National Council on Disability
more specialized equipment such as evacuation 

chairs, CPAP machines, bath lifts, wheelchair 

lifts, and motorized wheelchairs, the increase 

in cost differential for goods in Puerto Rico was 

significant (Table 2.1). When comparing the 

equipment, the same equipment was quoted 

to ensure price variances were not due to 

differences in product specifications.

NCD found that the cost of specialized DME 

was 11 to 58 percent higher in Puerto Rico versus 

the mainland, showing a possible correlation that 

the Jones Act does increase the price of goods. 

Interestingly, NCD found one DME item’s list 

price that was considerably lower than that in 

the states. Specifically, a Permobil F5, a complex 

power wheelchair. The 

Permobil list price in 

Puerto Rico was $15,000 

less than the same 

wheelchair in the states. 

Upon further review, 

NCD found that power 

wheelchairs do cost more because of shipping 

and taxes in Puerto Rico. However, the DME 

dealers interviewed stated that they drastically 

reduced the price of the Permobil and other 

complex power wheelchairs so that they are 

more accessible and affordable to PWDs on the 

island.

The cost of a complex power wheelchair 

for residents of the USVI was not available. A 

DME dealer in the USVI, interviewed for this 

report, stated that highly specialized equipment 

is normally not available. Thus, PWDs residing 

in USVI with private health insurance order 

through distributors from Florida, while veterans 

with disabilities residing in USVI obtain their 

DME directly from the Veterans Administration 

(VA) out of Puerto Rico.

The price disparity for more complex and 

specialized DME are due to shipping costs and 

insurance co-pays between Puerto Rico and the 

states. Those factors feed into the vicious cycle 

of Puerto Rican residents with disabilities inability 

to achieve equality in 

education, employment, 

and attain independence.

DME, including but 

not limited to wheelchair 

parts, is subject to the 

island’s inventory tax. 

When looking at the availability of repair services 

and parts for power wheelchairs in Puerto Rico, 

most suppliers interviewed stated that they 

normally have an inventory of wheelchair tires, 

batteries, armrest, etc. However, specialized 

parts such as joy sticks, for example, need 

to be ordered by the manufacturer and may 

NCD found that the cost of 

specialized DME was 11 to 58 percent 

higher in Puerto Rico versus the 

mainland 

Table 2.1: Price Comparisons of Specialized Durable Medical Equipment

Puerto Rico United States Percent of Cost 

Difference

Emergency Evacuation Chair $2,441.07 $1,495.00 3

CPAP Machine $645.00 $399.00 3

Bath Lift $895.00 $371.99 5

Power Wheelchair Lift $3,475.00 $3,099.00 1

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 27
take between one to two weeks to arrive in 

Puerto Rico, leaving a person with a disability 

who is dependent on their chair, immobile and 

vulnerable until the part arrives. NCD found that 

the Commonwealth of Puerto Rico’s inventory 

state tax has a direct impact on the amount of 

inventory a DME dealer is willing to stock.

This evident disparity in the cost of DME 

and availability of replacement parts is further 

complicated when 

disasters strike, where 

shortages of goods are 

common. Congress 

usually reacts in these 

moments by waiving 

the Jones Act to allow 

for speedier access to 

goods. Pausing the Jones 

Act restrictions during 

natural disasters begs 

the question whether 

the Jones Act serves its original purpose. One of 

the rationales behind the enactment of the Jones 

Act was the ability to rapidly respond to national 

security threats.37 Natural 

disasters are a threat 

to national security. The 

Jones Act has been 

temporarily lifted three 

times. After Hurricane 

Katrina in 2006, Hurricane Sandy in 2012, and 

Hurricane María in 2017.38 In all these instances, 

the disaster caused a deficit in resources (fuel, 

food, water, etc.), which American ships did not 

have the capacity to supply. Had the Jones Act 

not existed, disaster response and relief would 

have been quicker and more efficient.

The 2019 Disaster Relief Act, Public Law 

116-20, provided an additional $600 million in 

food aid and $300 million in construction aid to 

Puerto Rico to aid in recovery after Hurricane 

Maria. However, because of the Jones Act, 

and the additional shipping costs, the total aid 

was reduced by 200 and 100 million, between 

10 percent and 20 percent of the total aid 

amount.39 This adversely affects an island already 

impoverished where 50 percent of the population 

rely on nutritional assistance for food security.

The Jones Act is a 

101-year-old law that 

continues to drive 

up costs and hamper 

economic growth 

in Puerto Rico and 

disparately impacts 

Puerto Ricans living on 

the island. The Jones 

Act has widespread 

economic impact on the 

cost of goods on the 

island and especially impacts the availability 

and cost of complex DME. In addition, 

availability of DME and replacement parts on 

the island due to local 

inventory taxes causes 

a shortage of goods in 

emergency situations 

and more expensive 

equipment yearround. NCD recommends Congress repeal 

the provision within the Jones Act that 

restricts coastwise trade on U.S. flagged 

vessels, for durable medical equipment 

covered under Medicare Part B (such as 

manual wheelchairs, power wheelchairs 

and components and replacement parts, 

scooters and component parts and 

replacement parts, patient lift and transfer 

Pausing the Jones Act restrictions 

during natural disasters begs the 

question whether the Jones Act 

serves its original purpose. One of

the rationales behind the enactment 

of the Jones Act was the ability to 

rapidly respond to national security 

threats

... 50 percent of the populati

rely on nutritional assistance for 

food security

28 National Council on Disability
equipment, patient ventilators, portable

oxygen, foam, gel, innerspring and air 

mattresses, continuous positive airway 

pressure (CPAP) devices, shower chairs and 

commode chairs, and suction pumps).

Inventory Tax and Other Taxes Paid 

in Puerto Rico That Affect People 

with Disabilities

Puerto Ricans, like citizens in the states, pay 

a variety of taxes that include income taxes, 

sales taxes, and inventory taxes among 

others. Puerto Rico has established income 

tax rates that are 

typically comparable 

with national republics.40

Puerto Rico’s income 

tax rates range from 

7 percent for an annual 

income starting at 

$9,001 to 33 percent 

for individuals whose 

annual income exceeds 

$61,500 (plus an 

additional fixed amount 

of $8,430).41 Puerto 

Rico’s sales tax is 10 

percent, plus an additional 1.5 percent (which is 

distributed to the municipal governments) for a 

total of an 11.5 percent tax rate. This contrasts 

with the tax rates of 42 states, which range 

from 4 to 6.9 percent.42

In addition to these taxes, Puerto Rico has 

an inventory tax requirement on all products 

purchased and kept in a warehouse or business 

facility. The inventory tax requires that any item 

that has been in inventory (materials, supplies, 

furniture, fixtures, machinery, equipment, or 

cash), as of January 1st of any given year, for 

business or trade purposes, must pay personal 

property tax in the municipality where this 

inventory is housed.

This tax mainly affects small to mid-size 

businesses (Pequeñas y Medianas Empressas 

(or PYMES for its Spanish acronym), since they 

may not have the cash flow to incur the additional 

expense. Larger businesses may have access to 

federal funding under designated foreign trade 

zones, access that is not extended to PYMES. 

These additional operating costs are eventually 

added on to the retail price of a product, and 

consequently to Puerto Rican consumers. This 

tax is a revenue for each 

of the 78 municipalities 

on the Island, and each 

municipality has full 

autonomy to decide the 

percentage of inventory 

tax to charge, usually 

between 6.33 percent to 

10.33 percent.43

These municipal 

inventory taxes impact 

the supply and demand 

chain. Business owners 

will purchase less 

merchandise to ensure no excess inventory 

is maintained. Lower quantities purchased 

represent higher costs per item because prices 

are less expensive when purchased in bulk. 

When added on to the Jones Act added costs, 

the result is products on the island are usually 

more expensive than the same products in 

the states. The need to decrease inventory 

levels to avoid taxation causes shortages 

when emergency situations occur, as was the 

case after Hurricane Maria. The island faced 

a shortage of groceries, medication, basic 

The 2019 Disaster Relief Act, 

Public Law 116-20, provided an 

additional $600 million in food aid 

and $300 million in construction 

aid to Puerto Rico to aid in 

recovery after Hurricane Maria

However, because of the Jones Act, 

and the additional shipping costs, 

the total aid was reduced by 200 

and 100 million

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 29
emergency supplies, 

and assistive equipment, 

among other items. 

NCD recommends 

Puerto Rico waive the 

inventory tax for the 

purchase of DME to 

improve availability of DME for PWDs.

In addition to the local state taxes imposed 

by the Commonwealth, Puerto Ricans also pay a 

series of federal taxes, 

although Puerto Rican 

residents do not pay 

federal taxes on income 

generated from Puerto 

Rican sources. Puerto 

Rican residents pay 

federal payroll taxes to 

finance Social Security 

and Medicare and 

federal unemployment 

taxes. Puerto Rican 

residents working for 

federal agencies also 

submit federal income 

tax returns. People 

who receive income 

(dividends, capital gains) from U.S. investments 

must also pay federal taxes. In Fiscal Year 2019, 

Puerto Rico paid $3,528,739,000 in federal 

taxes.44 In the United 

States versus José Luis 

Vaello-Madero, the First 

Circuit Court stated that 

Puerto Rican taxpayers 

contributed more to the 

federal treasury than 

taxpayers in six states 

and the Northern Mariana 

Islands.45

The need to decrease inventory 

levels to avoid taxation causes 

shortages when emergency 

situations occur, as was the case 

after Hurricane Maria

In the United States versus José 

Luis Vaello-Madero, the First Circuit 

Court stated that Puerto Rican 

taxpayers contributed more to the 

federal treasury than taxpayers in 

six states and the Northern Mariana 

Islands

30 National Council on Disability
Chapter 3: Health: Medicaid and Medicare

Disparities in Medicaid and Medicare

Medicaid in Puerto Rico is funded by a block grant that is capped and varies by year based 

on Congressional appropriations, which provides a prescribed amount of money for funding 

the program, unlike the Medicaid program in the states, which matches state expenditures. 

This funding gap has contributed to Puerto Rico’s debt crisis. NCD recommends Congress 

amend the Social Security Act to replace the Medicaid block grant program in Puerto 

Rico and other U.S. territories with an uncapped federal matching system, equivalent 

to the Medicaid program provided to U.S. residents. NCD’s research team found disparity 

in Puerto Rico’s Medicare plan as well. Over 50 percent of Puerto Rican residents receive 

their healthcare benefits through Medicaid or Medicare. The disparate disbursement of these 

program benefits between the states and Puerto Rico contribute to a lower standard of care, 

service, and quality of life for Puerto Rican residents with disabilities. NCD recommends 

Congress amend the Social Security Act to require Medicare benefits to residents of 

Puerto Rico and other U.S. territories be equal to those benefits provided to residents 

living in the United States.

Medicaid

Medicaid is managed by the state or territory 

and provides health 

coverage for some lowincome people, families 

with children, pregnant 

women, the elderly, and 

people with disabilities. 

In some states, the 

program covers all low-income adults below a 

certain income level. Medicaid provides health 

insurance coverage to more people than any 

other single program in the United States. It 

provides coverage for 

low-income children, 

adults, seniors, and 

those with disabilities.46

As of March 2017, there 

were 74 million Medicaid 

and Children’s Health 

Insurance Program (CHIP) enrollees. Nearly 

36 million were enrolled in CHIP or had children 

Over 50 percent of Puerto Rican 

residents receive their healthcare 

benefits through Medicaid or 

Medicare

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 31
enrolled in Medicaid, according to the Center for 

Medicaid and CHIP Services.47

Medicaid is a lifeline for people with 

disabilities48 who are less likely to have access to 

employer-sponsored health coverage, are more 

likely to have low incomes and may not be able 

to cover their healthcare costs independently.49

Even with private insurance, PWDs may not 

be able to get the care they need since private 

plans typically do not cover the range of services 

available through 

Medicaid.50 PWDs 

receiving Medicaid have 

the same access to a 

doctor as people with 

Medicare or private 

insurance.51

Medicaid provides a 

full range of coverage 

for PWDs, including preventive services, primary 

and specialty care, prescription drugs, medical 

equipment, and long-term services and supports. 

“About 40 percent of 

Medicaid beneficiaries 

with disabilities are also 

enrolled in Medicare, 

with Medicaid covering 

many of the services 

that Medicare does 

not, including long-term services and supports, 

and depending on the state, dental, vision and 

hearing services.”52 This kind of care is not 

usually available through private insurance and 

far too expensive for most people to fund out of 

pocket.53,54

In the United States and U.S. territories,55

26 percent56 of all adults have some type of 

disability. More than 10 million children and 

adults with disabilities rely on Medicaid.57,58

People with disabilities comprise about 

15 percent of all Medicaid beneficiaries. An 

agency representative from the PR Health 

Department stated that in Puerto Rico, as of 

May 2021, approximately 108,961 people are 

enrolled in Medicaid because of a disability. 

This represents 7.1 percent of all Medicaid 

beneficiaries on the island. Puerto Rico currently 

provides only 10 of Medicaid’s 17 mandatory 

benefits, citing insufficient funding and lack of 

infrastructure.59 Some of 

the mandatory benefits 

not covered are home 

health services for those 

entitled to nursing facility 

services, nonemergency 

transportation for 

medical care, certified 

pediatric and family 

nurse practitioner services, and nursing facility 

services for individuals 21 or over. Table 3.1 

illustrates the 17 mandatory benefits and those 

currently provided by 

the Medicaid program in 

Puerto Rico.60

Guam is the only 

territory that covers 

all 17 mandatory 

Medicaid benefits, 

while American Samoa, like Puerto Rico covers 

10 of 17. The reason some territories do not 

provide all 17 mandatory benefits is varied. 

Some of the reasons include limited funding, a 

lack of infrastructure, and in some cases, their 

right to exercise flexibility to exclude certain 

benefits.62 In American Samoa, for example, 

federal Medicaid and CHIP funds pay for care 

to the Lyndon B. Johnson Tropical Medical 

Center. This medical center is the only provider 

[I]n Puerto Rico, as of May 2021, 

approximately 108,961 people are 

enrolled in Medicaid because of a 

disability. This represents 7.1 percen

of all Medicaid beneficiaries on the 

island

Puerto Rico currently provides only 

10 of Medicaid’s 17 mandatory 

benefits, citing insufficient funding 

and lack of infrastructure

32 National Council on Disability
Table 3.1: Mandatory Benefits provided by the Medicaid Program in Puerto Rico61

Mandatory Medicaid Benefit Puerto Rico

Early and periodic screening diagnostic in treatment services X

Inpatient hospital services X

Laboratory X-ray services X

Medical or surgical services by dentist X

Outpatient hospital services X

Physician services X

Tobacco goes back home cessations for pregnant woman X

Family planning services X

Federally qualified health center services X

Home health services for those entitled to nursing facility services Not covered

Non-emergency transportation for medical care Not covered

Certified pediatric and family nurse practitioner services Not covered

Nurse midwife services Not covered

Nursing facility services for individuals 21 and over Not covered

Rural health clinic services X

Emergency services for certain legalized aliens and undocumented aliens Not covered

Freestanding birth center services Not covered

for healthcare services in the territory at little 

or no out-of-pocket cost.63 A 2015 GAO report 

found uniform and profound differences in 

the implementation of 

the Medicaid program 

across all five territories, 

with Medicaid per capita 

funding by the Federal 

Government at only 1/10 

of that in the states.64

One of many 

disparities within the 

Medicaid program 

within the states versus U.S. territories is the 

Medicaid demonstration grant, Money Follows 

the Person. The grant provides funds to states to 

transition people with disabilities out of nursing 

homes and back into the community. Since 2005, 

over 100,000 people have been moved into 

the community. MFP 

grants are not available 

to American citizens 

residing in Puerto Rico 

or other U.S. territories. 

NCD recommends 

Congress amend the 

Deficit Protection Act of 

2005, Public Law 109-

171 (2006) to extend 

the Money Follows the Person Demonstration 

Grant Funding to Medicaid recipients residing 

in U.S. territories.

A 2015 GAO report found uniform 

and profound differences in the 

implementation of the Medicaid 

program across all five territories, 

with Medicaid per capita funding by 

the Federal Government at only 1/10 

of that in the states

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 33
Thirty-nine percent of all Puerto Ricans living 

on the Island receive health insurance through 

the Medicaid program compared to 10 percent 

in the states.65 Yet, Puerto Rico receives less 

federal funding than any state. As a result, 

Puerto Rico on average spends significantly 

less on its Medicaid beneficiaries ($1,980 in 

Puerto Rico compared to $6,060 in the United 

States in 2014).66

Distinct from Medicaid funding for the 

50 states and the District 

of Columbia, federal 

funding for Puerto Rico’s 

Medicaid program is 

through a block grant 

rather than federal cost 

sharing.67 For each state, 

the amount of funding 

is determined by the 

state’s per capita income 

relative to the nation’s per capita income. This 

Federal Medical Assistance Percentage (FMAP) 

is the federal Medicaid reimbursement rate that 

traditionally provides 

higher rates to poorer 

states. However, the U.S. 

territories are assigned 

a permanent FMAP of 

50 percent, which was 

subsequently increased 

to 55 percent with the Patient Protection and 

Affordable Care Act (ACA).

Unlike the 50 states and the District of 

Columbia, where the Federal Government 

will match all Medicaid expenditures at the 

established FMAP rate for that state, in Puerto 

Rico, the FMAP is applied until the Medicaid 

ceiling funds and the ACA funds are exhausted.68

If Medicaid coverage in Puerto Rico was the 

same as in the states, its FMAP rate would be 

87 percent. Meaning, the Federal Government 

will pay 87 percent of Puerto Rico’s Medicaid 

expenditures.69 Instead, Puerto Rico generally 

exhausts all its ACA funds before the end of a 

given year, shifting the burden to Puerto Rico to 

fund the remaining expenditures. The Puerto Rico 

block grant for Fiscal Year 2019 was $367 million, 

while Puerto Rico’s total Medicaid expenditures 

were projected to be almost $2.8 billion. The 

block grant only provided 

enough funds to cover 

13 percent of the 

projected expenditures, 

leaving 87 percent of the 

projected expenditures 

not covered by the 

block grant.70 Federal 

funding for Puerto Rico’s 

Medicaid program 

increased through ACA. However, despite this 

increase, the match rate of 55 percent is still 

noticeably lower than that received in the United 

States.71 The disparity 

in which Medicaid is 

funded between the 

states and Puerto Rico is 

a detriment to the health 

status of Puerto Ricans 

with disabilities.

The structural inequity of Medicaid funding 

in Puerto Rico creates an enormous fiscal strain 

on the healthcare system on the Island and 

severely limits its ability to provide much needed 

care for its most vulnerable population. In 2013, 

NCD examined the history of federal block grant 

programs and summarized findings from studies 

examining the potential impact of current and 

past Medicaid block grant proposals.72 In its 

Thirty-nine percent of all Puerto 

Ricans living on the Island receive 

health insurance through the 

Medicaid program compared to 

10 percent in the states. Yet, Puerto

Rico receives less federal funding 

than any state

Federal funding for Puerto Rico’s 

Medicaid program is through a 

block grant rather than federal cost 

sharing

34 National Council on Disability
A Medicaid Block Grant Program: Implications for 

People with Disabilities report, NCD found PWDs 

frequently lack health insurance or coverage 

for necessary services such as specialty care, 

long-term care, care coordination, prescription 

medications, DME, and assistive technologies; 

they also experience a higher prevalence of 

secondary conditions and use preventive services 

at a lower rate than others. PWDs are affected 

disproportionately by barriers to care.73

Additionally, NCD asserted that converting the 

current U.S. Medicaid program to a state block 

grant would result in a lack of fiscal resources 

to replace lost federal 

assistance by states and 

slice benefits or trim 

eligibility. Instead of the 

Federal Government 

picking up half to threequarters of the cost 

of future recessions, 

epidemics, and the 

introduction of new, 

high-cost pharmaceutical 

treatments, states would 

be left on their own 

coping with the financial 

uncertainties caused by the block grant. NCD’s 

report indicated that block grant funding would 

place states and program beneficiaries in a far 

more vulnerable financial position, especially 

PWDs who would be at special risk.74 The 

concerns articulated by NCD in our 2013 report 

borne true in Puerto Rico.

There is a clear correlation between the health 

status of a person with a disability and Medicaid 

funding in Puerto Rico.75 Studies evaluating 

Medicaid expansion after the Affordable Care 

Act have found evidence to support that 

Medicaid expansion has a positive effect on 

health outcomes, including health outcomes for 

PWDs.76

Additionally, stakeholders interviewed for 

this report mentioned that Medicaid eligibility 

thresholds in Puerto Rico discourage PWDs 

from seeking employment. Many residents 

struggle to choose whether they should quit 

their job in order to qualify for the state funded 

health insurance, Plan Vital, or keep their job and 

receive a low coverage private plan provided 

by their employer. In addition, they pointed out 

that Medicaid providers receive a low fee per 

service percentage, 

which represents 60 

percent of the national 

average when compared 

to the other states. These 

issues are not unique to 

Puerto Rico’s Medicaid 

program, as residents in 

the United States have 

expressed the same 

concerns but coupled 

with the extreme 

poverty and extreme 

rates of unemployment 

for people with disabilities, it places the health 

and well-being of Puerto Rican residents with 

disabilities in great peril.

As NCD predicted, the block grant for 

Puerto Rico’s Medicaid program has taken its 

toll on PWDs. Puerto Rico’s Medicaid block 

grant funding has led to expansive Medicaid 

funding shortfalls and contributes to Puerto 

Rico’s fiscal and debt crisis.77 The disparate 

treatment of Puerto Rico’s Medicaid program, 

when compared with the states, is the most 

significant and primary reason for the problems 

The Puerto Rico block grant for 

fiscal year 2019 was $367 million, 

while Puerto Rico’s total Medicaid 

expenditures were projected to be 

almost $2.8 billion. The block gran

only provided enough funds to 

cover 13 percent of the projected 

expenditures, leaving 87 percent 

of the projected expenditures not 

covered by the block grant

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 35
faced by Puerto Rico’s healthcare system. 

It has left the island in a vulnerable financial 

position; especially PWDs who are at special 

risk who already faced disparities in access 

to healthcare. NCD recommends Congress 

amend the Social Security Act to replace the 

Medicaid block grant program in Puerto Rico 

and other U.S. territories with an uncapped 

federal matching system, equivalent to 

the Medicaid program provided to U.S. 

residents.

Medicare

Medicare is a federally funded health insurance 

program for individuals ages 65 and over and 

PWDs who receive Social Security Disability 

Insurance (SSDI) or 

Supplemental Security 

Income (SSI). Medicare 

provides hospital 

coverage (Part A) and 

supplementary medical 

insurance (Part B). The 

Federal Government 

also contracts with private health insurance 

companies to provide Medicare supplemental 

benefits (Part C or Medicare Advantage [MA]) 

and prescription drug expenditures (Part D) to 

Medicare beneficiaries. Providers are paid a per 

person monthly amount to provide all Medicare 

covered benefits (except hospice) to beneficiaries 

who enroll in an MA plan.78 Everyone is required 

to enroll in Medicare Part A once they begin 

receiving Social Security benefits. However, 

Medicare Parts B, C, and D are optional, so 

a beneficiary can opt out if they have other 

insurance coverage.

About 29.1 percent of Puerto Rican residents 

are covered by Medicare,79 compared to just 

15 percent of the U.S. population.80 In 2014, 

16 percent of Puerto Ricans who received publicly 

funded health insurance were beneficiaries of 

Puerto Rico’s Medicare Advantage Plan, 6 percent 

were beneficiaries of traditional Medicare 

programs,81 58 percent of the general population 

had some type of publicly funded health insurance 

(Medicaid, Medicare or Veterans), 35 percent of 

the general population had some type of private 

health insurance, and an average of 7 percent 

had no health insurance.82 Puerto Rico ranked last 

among all states and the District of Columbia on 

average performance across 22 Medicare quality 

indicators.83 The quality indicators measure or 

quantify healthcare processes, outcomes, patient 

perceptions, and organizational structure that 

are associated with the 

ability to provide highquality healthcare.84

The goals include 

providing effective, 

safe, efficient, patientcentered, equitable, and 

timely care.85

In Fiscal Year 2019, the Federal Government 

spent nearly $1.2 trillion on healthcare.86

Medicare accounted for roughly $644 billion with 

Medicaid and the Children’s Health Insurance 

Program (CHIP) accounting for $427 billion. The 

growth of these numbers is impacted in part 

by the increased cost of disability-associated 

healthcare expenditures stemming from the high 

prevalence of disability among an ever-growing 

adult population.

Stakeholders interviewed for this report 

identified the greatest disparity between the 

states and Puerto Rico with regard to the 

Medicare program is the 75 percent Medicare 

cap. The Inpatient Prospective Payment 

Puerto Rico’s Medicaid block grant 

funding has led to expansive 

Medicaid funding shortfalls and 

contributes to Puerto Rico’s fiscal 

and debt crisis

36 National Council on Disability
System (IPPS) excluded Puerto Rico initially, 

which was Medicare payments under a costbased reimbursement system for hospital 

systems that were operated primarily under 

local government administration. Eventually, 

Puerto Rico’s hospitals were included by 

Congress in the 

IPPS but at a lower 

percentage. The 

national cost-based 

formula was applied 

to only 25 percent of 

the payment, whereas 

in the states it is applied to 100 percent. For 

the remainder, Congress enacted a special 

Puerto Rico based IPPS, which perpetuated 

the depressed local pricing levels within the 

Medicare payment system.87

The majority (71 percent) of Puerto Rican 

resident Medicare beneficiaries receive services 

through a Medicare Advantage (MA) plan, 

compared to 34 percent in the states.88 CMS is 

responsible for establishing the reimbursement 

rate for services provided under an MA plan. As of 

2018, CMS established 

reimbursement was 

43 percent below the 

national average and 

26 percent below that 

of its neighbors in the 

U.S. Virgin Islands.89

This reimbursement rate has exacerbated the 

already crumbling healthcare infrastructure in 

Puerto Rico and has hastened the mass exodus of 

healthcare professionals to the mainland for higher 

reimbursement rates. Over 1,000 healthcare 

Puerto Rico ranked last among all 

states and the District of Columbia 

on average performance across 

22 Medicare quality indicators

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 37
professionals have migrated to the mainland over 

the last five years.90 This has left all Puerto Ricans, 

but especially Puerto Ricans with disabilities, 

with limited choice and access to much-needed 

specialty health services.

Another disparity within the Medicare 

program is the vast difference between the 

co-pay percentage for durable medical 

equipment. In the states, the Medicare co-pay 

for DME is 20 percent. whereas in Puerto Rico, 

the Medicare co-pay is 50 percent. Thus, for 

a Medicare beneficiary residing in the states, 

out-of-pocket expense for DME is 20 percent 

of the list price of the equipment. Whereas a 

beneficiary residing in Puerto Rico is required to 

pay 50 percent of the cost of the equipment.

Medicare beneficiaries on the island are already 

unduly burdened by a higher list price for DME 

because of the cost of shipping. When one factors 

in the co-pay amount for DME, it makes much 

needed DME unattainable for many people with 

disabilities. For example, in the states the list price 

for a Permobil F5 (a complex power wheelchair) 

is $60,000. Medicare recipients are subject to a 

20 percent co-pay, which would be $12,000. In 

Puerto Rico, a Permobil F5’s list price is $45,000. 

The actual cost of a Permobil F5 to Puerto Rican 

DME dealers is higher than in the states, so 

DME dealers drastically reduce the price to make 

the complex power wheelchair more accessible 

and affordable to Puerto Ricans with disabilities. 

Medicare recipients are subject to a 50 percent 

co-pay, which would be $22,500. The co-pay for 

a Puerto Rican beneficiary to acquire a power 

wheelchair is greater than Puerto Rico’s average 

annual per capita income ($12,914 in 2019).91

38 National Council on Disability
A PWD in need of a complex power chair should 

not be required to choose between food and rent 

or independence and mobility. The out-of-pocket 

expense required for DME under the Advantage 

Medicare program in Puerto Rico excludes, by 

design, Puerto Rican residents with disabilities 

access to desperately needed DME.

The enrollment process for Medicare is 

executed disparately as well. Puerto Rican 

residents are required 

to enroll in Medicare 

Part A and Part B and 

given a limited open 

enrollment window to do 

so. If a beneficiary opts 

out or misses the open 

enrollment window and 

wishes to opt in at any 

time, the beneficiary is assessed a penalty. That 

same penalty is also assessed to those on the 

mainland, but U.S. residents are automatically 

enrolled in both and must opt out of the program. 

The penalty is 10 percent of the monthly 

premium, and the penalty 

is assessed for the life of 

the policy.

NCD recommends 

Congress amend the 

Social Security Act 

to eliminate the late 

penalty enrollment provision placed on Puerto 

Rico and U.S. territory Medicare recipients. In 

the alternative, NCD recommends Congress 

pass HR 4666 (2019) to amend title XVIII of the 

Social Security Act to provide certain lowincome territorial residents with automatic 

eligibility for premium and cost-sharing 

subsidies under the Medicare program, and 

for other purposes.

There are four types of medical savings 

programs: the Qualified Medicare Beneficiary 

program, the Specified Low-Income Medicare 

Beneficiary program, the Qualified Individual 

program and the Qualified Disabled and 

Working Individuals program. The Omnibus 

Reconciliation Act of 1986 required states to pay 

for Medicare Part B premiums for beneficiaries 

up to 100 percent federal poverty level (FPL). 

The FPL is also known 

as the poverty line and 

defined as the amount 

of annualized income 

earned by a household, 

below which they would 

be eligible to receive 

certain welfare benefits, 

or to cover Part B 

benefits through other means. Subsequently, 

in 1990, the requirement was extended to 

beneficiaries up to 120 percent FPL. Puerto 

Rican residents are not eligible for any of these 

programs.92

Another program 

to assist low-income 

beneficiaries is the Low 

Income Subsidy (LIS) 

program. Premium and 

cost-sharing assistance 

is available for Part 

D enrollees with low incomes, and Medicare 

beneficiaries in the states and the District of 

Columbia are eligible for this program.93 Medicare 

beneficiaries residing in territories are not.

NCD found numerous examples of Puerto 

Ricans facing disparity in access to healthcare 

compared to those living in the United States. 

Two of the stakeholder groups that participated 

in this report were PWDs and parents of children 

The co-pay for a Puerto Rican 

beneficiary to acquire a power 

wheelchair is greater than Puerto 

Rico’s average annual per capita 

income ($12,914 in 2019)

A PWD in need of a complex power 

chair should not be required to 

choose between food and rent or 

independence and mobility

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 39
with disabilities. They moved from the states 

back to Puerto Rico and stated they had a wider 

array of benefits and greater access to needed 

health services when living in the United States 

and that the benefits and services promoted 

independent living and access to a wider array 

of services. Stakeholders acknowledged greater 

access to over-the-counter medications and 

hygiene supplies in the United States versus 

in Puerto Rico where 

access was not readily 

available. They also 

acknowledged that 

many of the products 

that were covered under 

Medicare in the states 

were not covered items 

in Puerto Rico, resulting in higher out-of-pocket 

expenses for supplies. Stakeholders also stated 

that even with Medicare, the price of healthcare 

is expensive. Some PWDs in Puerto Rico who 

are homeowners have had to place second 

mortgages on their homes to attain much-needed 

medical care.

Physical accessibility 

to medical offices and 

appropriate medical 

equipment is still a 

challenge in Puerto 

Rico as well as in the 

states, as was discussed 

in NCD’s 2021 report, Enforceable Accessible 

Medical Equipment Standards: A Necessary 

Means to Address the Health Care Needs of 

People with Mobility Disabilities. Additionally, 

some stakeholders reported that Puerto Rico’s 

healthcare system lacked proper information 

and orientation on how to best navigate the 

system to acquire services for their children 

and on transition services on the island. Some 

stakeholders explained that services in the 

states are often offered in “one stop centers” 

where PWDs get all the services needed in one 

place and that patients have greater flexibility 

and options when choosing their medical 

service providers. One interviewee stated that 

the disparity in healthcare services between 

Puerto Rico and the states makes one feel like a 

“second class citizen.”

PWDs in Puerto Rico 

are at greater risk of 

developing secondary, 

comorbid, and agerelated health conditions 

than the general 

population,94 and access 

to comprehensive, inclusive healthcare is a 

necessity. However, when Puerto Rican residents 

with disabilities attempt to access much-needed 

health services, they face barriers instead.

The loss of federal payments to Puerto 

Rico’s MA program; the limitations of Medicaid 

funding and the ensuing 

dearth of healthcare 

providers who have 

left the island; and 

already impoverished 

Puerto Ricans with few 

options for treatment all 

emphasize the urgent 

need for healthcare reform on the island that 

would benefit providers as much as patients.95

For these reasons, NCD recommends 

Congress amend the Social Security Act to 

allocate Medicare benefits for residents of 

Puerto Rico and other U.S. territories equal to 

those benefits provided to residents living in 

the United States.

[M]any of the products that were 

covered under Medicare in the 

states were not covered items in 

Puerto Rico, resulting in higher outof-pocket expenses for supplies

One interviewee stated that the 

disparity in health care services 

between Puerto Rico and the States 

makes one feel like a “second class 

citizen.

40 National Council on Disability
Chapter 4: Income Assistance Benefits and Programs

Disparities in Income Assistance and Benefits

Supplemental Security Income (SSI) is available to U.S. residents and the territory of the 

Northern Mariana Islands. SSI is not available to PWDs in Puerto Rico and the other U.S. 

territories. Eligible Puerto Rican residents with disabilities receive benefits through the 

Aged, Blind and Disabled Program (AABD). This entitlement program is not equal to SSI. 

Monthly benefits under AABD are only $75 compared to over $750 for an SSI recipient. This 

is a noticeable disparity that severely impacts Puerto Rican residents with disabilities ability 

to manage their most basic needs. NCD recommends Congress amend Title XVI of the 

Social Security Act to require SSI benefits be provided to all eligible U.S. citizens, to 

include residents of Puerto Rico and U.S. territories.

The United States federal Supplemental Nutrition Assistance Program (SNAP) is also not 

available to Puerto Rican residents. Instead, Puerto Rico’s food assistance program is a block 

grant program with limited funds, and unlike SNAP, does not adjust to the cost of living or 

to extreme situations caused by disasters. NCD recommends Congress amend the Food 

Stamp Act to include Puerto Rico, the Northern Mariana Islands, and American Samoa 

in the SNAP program, as has been done for Guam and the USVI.

Globally, an estimated 36 percent of 

people who are very poor have escaped 

poverty as a result of safety nets.96 This 

statistic alone demonstrates the critical and 

meaningful impact safety nets provide to improve 

standards of living. A safety net is not only a 

monetary benefit, though financial resources are 

at the core. A safety net is an interconnected 

web of services and benefits that together lift 

those living in poverty to a better quality of life. 

The U.S. social safety net is composed of a 

number of different programs that provide various 

kinds of help designed to protect those with low 

socioeconomic status from poverty and hardship. 

When at high levels of poverty, the goal becomes 

ensuring a minimum standard of living.97 In 

Puerto Rico, with its high level of poverty and 

percentage of residents with disabilities, a 

minimum standard of living seems elusive.98

Javier Balmaceda, Senior Policy Analyst on 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 41
Puerto Rico for the Center on Budget and Policy 

Priority reflects, “Nowhere is the need greater 

than in Puerto Rico, which unlike other parts of 

the country entered the pandemic following well 

over a decade of virtually uninterrupted economic 

decline coupled with devastating natural 

disasters.”99

Supplemental Security Income (SSI)

SSI is a federal program, administered by the 

Social Security Administration, which provides 

monthly cash payments to the aged, blind, and 

PWDs who lack the financial means to support 

themselves and that helps them meet basic 

needs of food, shelter, 

and clothing. It is perhaps 

the most important 

safety net program in the 

United States, a program 

of last resort, and a part 

of the safety net that 

protects citizens from 

abject poverty.

SSI, created by 

Congress in 1972, was 

made available to eligible U.S. citizens residing 

in all 50 states and the District of Columbia. SSI 

was not made available to American citizens 

residing in Puerto Rico or other U.S. territories. 

Under SSI, the Federal Government establishes 

eligibility standards, determines federal benefit 

amounts, and pays the total sum of those 

benefits and administrative expenses.100 In 

1976, Congress extended SSI to the Northern 

Mariana Islands as part of a commitment made 

by the United States to the island when it was 

established as a commonwealth. To date, the 

Northern Mariana Islands is the only U.S. territory 

that receives SSI. Puerto Rico, like the other 

territories, except for the Mariana Islands, grants 

federal assistance to the needy, aged, blind, and 

disabled individuals through AABD.

AABD emphasizes greater local control 

with less federal funding. As such, Puerto 

Rico establishes income benefit sums, set by 

Section 1108 of the Social Security Act and 

is not adjusted for inflation. AABD funding 

has not increased since the enactment of the 

Personal Responsibility and Work Opportunity 

Reconciliation Act of 1996 (P. L. 104-193).101

The Federal Government pays two-thirds of 

the benefits established by the government 

of Puerto Rico and half of the administrative 

costs, and the program 

is subject to a statutory 

total expenditures cap. 

The income limit, the 

maximum allowable 

income to qualify for 

benefits]and benefit 

amounts for AABD are 

dramatically lower than 

SSI.102 To be eligible for 

AABD, an individuals’ 

countable income must be less than $64 a 

month,103 whereas the income limit for SSI is 

$794.104 A Puerto Rican resident with a disability 

receives only $75 a month through AABD in 

comparison to a monthly maximum of $841 in 

SSI benefits.105 Puerto Ricans residing in the 

states receive a yearly benefit of approximately 

$9,500 under SSI compared to persons with 

disabilities residing on the island who receive 

only $900 per year under AABD (see Table 4.1).

The poverty level in Puerto Rico is greater than 

the poorest state on the mainland. The absence 

of SSI benefits exacerbates the percentage of 

Puerto Ricans with disabilities living in poverty 

“Nowhere is the need greater than 

in Puerto Rico, which unlike other 

parts of the country entered the 

pandemic following well over a 

decade of virtually uninterrupted 

economic decline coupled with 

devastating natural disasters.

42 National Council on Disability
Table 4.1: SSI/AABD Comparison of SSI/AABD Benefits of Puerto Ricans Living 

in the States Versus Puerto Rico

Puerto Rican’s living 

in the states

Puerto Rican residents 

living on the island

Total Households 1,873,440 1,192,654106

SSI/AABD Households 215,445 37,000107

Mean Yearly Income $9040 $900

and eliminates a PWD’s ability to financially 

care for oneself. One explanation given for the 

disparity is that SSI benefits are paid by revenues 

generated by federal 

income taxes and those 

in Puerto Rico or other 

territories generally do 

not pay federal income 

tax.108 A letter supporting 

extending SSI to Puerto Rico and the territories, 

by a group of Congressional members who 

introduced the Supplemental Security Income 

Equality Act in January 

2012 (most recently 

introduced as H.R. 537 

in the 117th Congress), 

reflected the following:109

It could be questioned 

whether extending 

SSI to Puerto Rico, 

Guam, the U.S. Virgin 

Island and American 

Samoa is justified 

given that SSI is 

funded by federal 

general revenues 

and residents of the 

territories are not required to pay federal 

income taxes on their local income. 

But we do not believe this argument 

withstands scrutiny for at least two 

reasons. First, as noted, eligible residents 

of one territory 

already receive SSI. 

Second, over 45% 

of all households in 

the 50 states do not 

earn enough to pay 

any federal taxes. And there is virtually no 

chance that an SSI recipient in the states 

pays federal income taxes, since SSI 

recipients generally 

cannot have assets 

that exceed $2,000 

($3,000 in case of 

beneficiary-couples). 

Thus, to exclude 

four territories from 

SSI because their 

residents are not 

required to pay 

federal taxes on their 

local income is clearly 

unfair.110

In addition, they 

emphasized that since 

1973, “delegates from the territories have 

introduced at least 35 bills that would extend SSI 

The poverty level in Puerto Rico is 

greater than the poorest state on 

the mainland

[O]ver 45% of all households in the 

50 states do not earn enough to pay 

any federal taxes. And there is virtually

no chance that an SSI recipient in 

the states pays federal income taxes, 

since SSI recipients generally cannot 

have assets that exceed $2,000 

Thus, to exclude four territories from 

SSI because their residents are not 

required to pay federal taxes on their 

local income is clearly unfair

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 43
to their constituents,” yet no House or Senate 

committee has ever held a hearing to examine 

the issue.111

In 2019, Puerto Rico paid over $3.5 billion to 

the Federal Treasury.112

Puerto Rico residents 

pay Social Security and 

are eligible for Social 

Security benefits upon 

retirement, yet they are 

excluded from the SSI 

program. Puerto Ricans 

on the Island also pay 

other taxes such as 

payroll, business, gift, 

and estate taxes. Those 

that are employed by the 

Federal Government must 

file a federal income tax 

return as must any resident who earns money 

from outside the territory. Pew Research Center 

found that in the United States, taxpayers earning 

less than $30,000 paid only “1.4 percent of all 

federal income tax, and two-thirds of the almost 

66 million returns filed by people in this lower 

income bracket owed no tax at all.”113 To compare, 

the annual household income in Puerto Rico is 

$20,539 with a per capita income of $12,914, 

indicating that even if Puerto Rican residents were 

required to pay federal income tax, the majority of 

them would be exempt.114

In a 2014 report, the Government 

Accountability Office (GAO) indicated that if 

Puerto Rico participated in the SSI program, 

beneficiaries would be eligible to receive 

between $1.5 billion and $1.8 billion each year, 

using Fiscal Year 2011 data.115 This contrasts 

with the $23.7 million for Fiscal Year 2017 of 

Puerto Rico’s AABD in federal costs for benefit 

payments and $1.3 million for administrative 

expenses.116

The Center for a New Economy conducted 

a review of the impact SSI eligibility for Puerto 

Rican residents would 

have on Puerto Rico and 

estimated the population 

eligible for SSI benefits 

in Puerto Rico based 

on the 2018 American 

Community Survey, as 

reflected in Table 4.2.117

Every territory pays 

federal taxes. In 2019, 

USVI paid federal taxes 

in the amount of $179 

million, while Guam 

paid $169 million, the 

Northern Mariana Islands 

paid $58.8 million, and American Samoa paid 

$22.7 million in taxes to the Federal Government. 

[GAO] indicated that if Puerto Rico 

participated in the SSI program, 

beneficiaries would be eligible to 

receive between $1.5 billion and

$1.8 billion each year, using Fiscal

Year 2011 data. This contrasts with

the $23.7 million for Fiscal Year

2017 of Puerto Rico’s AABD in 

federal costs for benefit payments 

and $1.3 million for administrative

expenses

Table 4.2: Populations Eligible for SSI 

Benefits118

Population by Age, Disability, 

and Poverty Status

(Income in the past 12 months 

below poverty level)

Puerto Rico

Under 5 years, with a disability 1,173

5 to 17 years, with a disability 25,235

18 to 34 years, with a disability 31,029

35-64 years, with a disability 128,868

65 to 74 years, with a disability 49,967

65 to 74 years, no disability 79,812

75 years and over, with a 

disability

77,770

75 years and over, no disability 42,032

TOTAL 435,886

44 National Council on Disability
From 1990–2009, Puerto Rico paid $73.7 billion 

to the U.S. Federal Government in taxes, greater 

than six other states: Wyoming ($51.3B), Vermont 

($54.7B), South Dakota ($64.7B), Alaska ($63.2), 

North Dakota ($53.9B), and Montana ($60.8B).119

Expanding SSI eligibility to all territories would 

provide a much-needed safety net and elevate the 

incomes of PWDs to a level that would provide 

an opportunity for them to be able to afford 

some of the basic needs required as a PWD. 

Approximately 24,000 Guam residents and 11,587 

American Samoa residents with disabilities would 

be eligible for SSI.120 The 2010 U.S. Census data 

for USVI reveals that over 10,000 residents are 

PWDs; one could infer that a high percentage of 

these would benefit from the program. However, 

it is important to note that data for PWDs in 

the territories is extremely limited and is not 

reported within U.S. statistical data gathering 

and reporting. Multiple federal agencies produce 

reports that collect data and report on outcomes 

and access to quality healthcare. The Agency for 

Healthcare Research and Quality has produced 

in the annual National Healthcare Quality and 

Disparities Report mandated by Congress to 

provide a comprehensive overview of the quality 

of healthcare received by the general U.S. 

population and disparities in care experienced by 

different racial and socioeconomic groups. Data 

from U.S. territories has never been included 

in the report. NCD recommends all federal 

and state agencies, as well as public and 

private universities, include data on people 

with disabilities living in Puerto Rico and 

other territories in data collection to improve 

accountability so that appropriate resources 

are provided to ensure equity to programs 

that allow PWDs the opportunity to achieve 

economic independence. (For example, data 

collection initiatives collected by the Census 

Bureau, National Health Interview Survey, and 

State of the States)

A stakeholder interviewed for this report 

stated, “We need SSI, we need supplemental 

assistance for young PWDs, we need the 

Vital Health Plan to include alternatives for 

this population, with professionals who have 

knowledge of the process to help this population 

at a health level.”

The consequences of denying SSI to U.S. 

citizens with disabilities residing in Puerto Rico 

has been and continues to be catastrophic. 

PWDs already experience higher rates of poverty 

than their nondisabled peers, and when one adds 

lower income benefits it places them in a cycle 

of extreme poverty they will likely never escape. 

This disparity negatively impacts the Puerto Rican 

economy, as it limits funds to stimulate economic 

development and financial activity. In addition, 

the implications for U.S. citizens who receive SSI 

on the mainland and move to Puerto Rico are 

punitive, as their SSI benefits are canceled once a 

PWD changes residency.

Challenging Disparate Treatment: 

United States v. Vaello-Madero US 

Supreme Court

Heretofore, NCD’s report has argued the policy 

reasons for addressing the disparate treatment 

of PWDs in Puerto Rico in federal program 

eligibility and benefits receipt; however, there 

are compelling legal arguments for these 

changes as well. The disparate treatment in 

the SSI program in particular was challenged in 

the federal district court of Puerto Rico in 2018 

in United States v. Vaello-Madero, 313 F.Supp. 

3d 370 (D.P.R. 2018),121 as a violation of the 

Constitution’s Fifth Amendment’s guarantees of 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 45
equal protection. In a February 2020 ruling issued 

by U.S. District Judge Gustavo Gelpi, he declared 

that the Federal Government’s policy of denying 

SSI benefits to U.S. citizens in the territories 

“impermissibly creates a group of secondclass citizens and violates the equal protection 

component of the Fifth Amendment.”122

This conclusion was affirmed by the U.S. 

Court of Appeals in Boston on April 2020, United 

States v. Vaello-Madero, 

956 F. 3d 12, 125 

A.F.T.R.2d 2020-1686 (1st 

Cir. 2020), cert. granted, 

2021 WL 769690, 2021 

Daily Journal D.A.R. 

1895 (U.S. Mar. 1, 2021) 

(Judge Juan Torruella, 

Judge O. Rogeriee Thompson, and Chief Judge 

Jeffrey Howard), where the court affirms:

The categorical exclusion of otherwise 

eligible Puerto Rico 

residents from SSI 

is not rationally 

related to a legitimate 

government interest. 

In addition to the 

record established 

by the parties, we 

have considered even 

conceivable theoretical 

reasons for the differential treatment 

conceded by the government. Having 

found no set of facts, nor Appellant having 

alleged any additional theory, establishing a 

rational basis for the exclusion of Puerto Rico 

residents from SSI coverage, such exclusion 

of the residents of Puerto Rico is declared 

invalid.123

The U.S. Court of Appeals states that the Fifth 

Amendment does not allow the United States 

to arbitrarily deny SSI benefits to individuals who 

qualify for the benefit but are deemed ineligible 

for the benefit due to their residency.124 Two 

reasons were presented by the U.S. Government 

for the exclusion of residents of Puerto Rico: 

Puerto Rico’s unique tax status and the expense 

of expanding the program to island residents. In 

its response, the court 

stated:

The residents of 

Puerto Rico not only 

make substantial 

contributions to the 

federal treasury, but 

in fact have consistently made them in 

higher amounts than taxpayers in at least 

six states, as well as the territory of the 

Northern Mariana Islands.125

The U.S. Supreme 

Court heard oral 

arguments in November 

2021. The question 

before the Court is 

whether Congress 

infringed the Equal 

Protection section of 

the Fifth Amendment’s 

Due Process Clause by refusing SSI benefits 

to Puerto Rican residents.126 At the time of this 

report publication, the Court had not rendered 

its ruling.

In addition to the case above, in 2018, nine 

plaintiffs filed suit against the U.S. Department 

of Health and Human Services (HHS) regarding 

the constitutionality of exclusion from SSI, SNAP, 

“The categorical exclusion of 

otherwise eligible Puerto Rico 

residents from SSI is not rationally 

related to a legitimate government 

interest.

District Court of Puerto Rico Federal 

Judge William G. Young ruled

that “the federal government’s 

exclusion of Puerto Rico residents 

from the three major social benefits 

programs is an unconstitutional 

violation of equal protection”

46 National Council on Disability
and Medicare Part D Low Income Subsidy (LIS) 

program in Pena-Martinez vs. US Health and 

Human Services.

127 District Court of Puerto Rico 

Federal Judge William G. Young ruled that “the 

federal government’s exclusion of Puerto Rico 

residents from the three major social benefits 

programs is an unconstitutional violation of equal 

protection,” ruling in favor of the nine plaintiffs 

who would qualify for these benefits if they did 

not live in Puerto Rico but 

instead in any of the 50 

states. The court issued 

an injunction covering 

potential beneficiaries 

across the island and 

provided a 60-day administrative stay for the 

Federal Government to implement its ruling, 

applying to the nine plaintiffs immediately.128,129

The Federal Government filed an appeal with 

the Court of Appeals for the First Circuit and is 

awaiting litigation.

The economic impact on PWDs living in 

Puerto Rico would be significant if the above 

decisions are upheld. It 

would provide billions of 

dollars to assist the lives 

of the most vulnerable 

U.S. citizens.

Without question, 

there is disparate 

treatment in which 

American citizens who 

live in Puerto Rico are 

denied access to SSI, 

the single most important safety net program the 

Federal Government makes available to citizens 

residing in the states and in the Northern Mariana 

Islands. The exclusion of SSI to Puerto Rican 

residents with disabilities also precludes Puerto 

Rican residents’ access to quality healthcare 

coverage. Recipients of SSI are automatically 

eligible for Medicare, a benefit not provided 

under AABD. NCD recommends Congress pass 

HR 537, the Supplemental Security Income 

Equality Act (117th Congress), which would 

provide SSI benefits to residents of Puerto 

Rico and U.S. territories. Alternatively, NCD 

recommends Congress amend Title XVI of the 

Social Security Act to 

extend SSI benefits 

to residents of Puerto 

Rico and U.S. territories.

Eligibility for SSI benefits 

should be identical 

to those afforded all U.S. citizens, regardless 

of zip code.

Social Security Disability Insurance 

(SSDI)

SSDI is an entitlement program that pays cash 

benefits to individuals who can’t work and 

have a medical condition that can last for at 

least one year or result 

in death.130,131 These 

benefits are calculated 

using the PWD’s 

previous earnings and 

are paid to the PWD and 

family dependents.

SSDI is administered 

under the Social Security 

Administration (SSA) and 

is available to individuals 

under 65 years of age who have a qualifying severe 

disability. SSA uses both non-medical and medical 

disability criteria when determining eligibility for 

SSDI. Individuals must provide documentation of 

a medical disability and meet two different earning 

Eligibility for SSI benefits should be 

identical to those afforded all U.

citizens, regardless of zip code

The exclusion of SSI to Puerto 

Rican residents with disabilities also 

precludes Puerto Rican residents’ 

access to quality healthcare 

coverage. Recipients of SSI are

automatically eligible for Medicare, 

a benefit not provided under AABD

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 47
tests, a “recent work test” and a “duration of work 

test.” Certain blind workers are only required to 

meet the duration of the work test.132

Certain family members can qualify for benefits 

of an eligible person’s work, such as a spouse 

if older than 62 years old, a divorced spouse if 

married for at least 10 years, unmarried children 

including adopted children younger than 18 or 19 

if still in high school, a child with a disability, or an 

adult child with a disability before age 22.133

SSA evaluates medical 

information provided 

by the applicant, their 

healthcare providers, 

and their own health 

professionals, who 

will give the applicant 

a medical exam. The 

process is lengthy with 

about 63 percent of applications being rejected. 

SSDI beneficiaries are eligible for Medicare after 

two years.

The application process for SSDI is the same 

in Puerto Rico as it is for PWDs residing in the 

states. Approximately 6 percent of Puerto Rican 

residents receive SSDI 

compared to an average 

of 4.4 percent in the 

states.134 The average 

monthly disability 

benefit is $1,037 in Puerto Rico compared to 

$1,195 in the states. Approximately 7 million 

people receive SSDI benefits in the states, 

accounting for 13.8 percent of total benefits.135

In December 2019, approximately 4,600 Puerto 

Rican and U.S. territory residents with disabilities 

received SSDI with an average monthly disability 

payment of $990 (American Samoa $883, Guam 

$1,080, Northern Mariana Islands $806, and 

USVI $1,191).136 NCD found no disparity in the 

distribution of SSDI benefits.

Federal Nutrition Assistance 

Programs

The Supplemental Nutrition Assistance Program 

(SNAP) provides eligible, low-income individuals 

and households in need of nutrition assistance.137

SNAP is the largest federal domestic nutrition 

assistance program administered by the Food and 

Nutrition Service (FNS) 

of the U.S. Department 

of Agriculture (USDA).138

SNAP benefits are an 

entitlement program.139 A 

person aged 60 or older 

is considered a senior for 

SNAP eligibility purposes. 

A person is considered 

to have a disability if they receive federal or state 

payment due to a disability, blindness, payments, 

or other disability benefits.

SNAP is not available in Puerto Rico, while 

residents of certain other territories, such as 

Guam and USVI, do qualify for SNAP benefits. 

Puerto Rican residents 

were removed from the 

SNAP program in 1981. 

As part of the Omnibus 

Budget Reconciliation 

Act of 1981, Puerto Rico was removed from 

the National Food Assistance Program, and a 

standalone nutrition assistance program was 

created for Puerto Rico (NAP, or PAN for its name 

in Spanish, Programa de Asistencia Nutricional). 

Permanently authorized in 1985, NAP continues 

to be the food assistance program in Puerto Rico, 

American Samoa, and the Mariana Islands, each 

with varying rules.

SNAP is not available in Puerto 

Rico, while residents of certain other 

territories, such as Guam and USVI, 

do qualify for SNAP benefits. Puerto

Rican residents were removed from 

the SNAP program in 1981

NCD found no disparity in the 

distribution of SSDI benefits

48 National Council on Disability
NAP is administered via a block grant, which 

means the funding for NAP is capped and 

eligibility and benefit levels are determined 

based on budget instead of an individual’s need. 

There is also no mechanism to supplement for 

rising food prices. The very design prevents 

the program from assisting all Puerto Rican 

residents who experience food insecurity. The 

structure of NAP as a block grant exacerbates 

food insecurity in Puerto Rico. SNAP, however, 

is an entitlement 

program that bases 

eligibility on poverty 

levels and the cost of 

food enabling benefits 

to adapt to changing 

socioeconomic 

conditions of 

recipients.140

NAP Eligibility 

Requirements

As in the United States, eligibility 

requirements for NAP in Puerto Rico are 

determined primarily 

by the level of income 

and resources of the 

participants with slight 

variations designed 

to simplify eligibility 

requirements. Most 

of the eligibility 

requirements are validated through the 

Automated Case Management System, 

which improves the efficacy of the eligibility 

determination process and reduces the 

percentage of errors and fraud.

To qualify for NAP,141 a person must live in 

Puerto Rico and:

■ Resources cannot exceed $2,000 (savings 

accounts, bank accounts, etc.); or

■ Resources cannot exceed $3,000 (savings 

accounts, bank accounts, etc.) and be a part of 

a household with a person aged 60 or older or 

totally disabled.

Puerto Rican residents must not exceed 

an income limit that varies by the number of 

people in the household. To calculate the net 

income, deductions of 

income type, type of 

household members, 

and certain allowable 

expenses are subtracted 

from the total amount 

of income from the 

household. Based on 

the eligibility criteria, for 

example, a household of 

three must not exceed a monthly NET income 

of $1,706 to qualify.142

Eligibility requirements for NAP did not change 

during the COVID-19 pandemic, but procedures to 

determine eligibility were 

modified. The agency 

designated to administer 

NAP and its local offices, 

transitioned to a digital 

and online presence. The 

rules for determining the 

eligibility of applicants 

and participants for NAP are currently under 

review to include the new requirements.

Puerto Rico has 751,369 households enrolled in 

NAP, for a total of 1,365,502 household members. 

There are 103,280 PWDs enrolled in NAP. NAP 

has no set gross income limits. The net income 

level is lower than SNAP, and benefits are lower. 

NAP is administered via a block 

grant, which means the funding for 

NAP is capped and eligibility and 

benefit levels are determined based 

on budget instead of an individual’s 

need. There is also no mechanism to

supplement for rising food prices

The maximum monthly food 

assistance benefits for Puerto Rican 

residents are roughly 60 percent 

of the maximum monthly benefits 

under SNAP

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 49
Nutrition Assistance during 

Disasters in Puerto Rico

NAP does not have an automatic mechanism 

to provide disaster benefits. After the 2017 

Hurricanes Irma and Maria, it took six 

months to receive approval of Puerto Rico’s 

request for additional NAP funds. In contrast, 

in the USVI, whose residents receive SNAP, 

disaster assistance funds were available 

within 47 days.

The maximum monthly food assistance benefits 

for Puerto Rican residents are roughly 60 percent 

of the maximum monthly benefits under SNAP. 

Additionally, NAP does 

not have an automatic 

mechanism to provide 

disaster benefits. This 

means that when Puerto 

Rico experiences a natural 

disaster or a recession, 

Puerto Rico is unable to 

provide relief benefits 

to all in need. As an example, after the 2017 

Hurricanes Irma and Maria, it took six months 

to receive approval of Puerto Rico’s request for 

additional NAP funds. Whereas in contrast, in the 

USVI, whose residents receive SNAP, disaster 

assistance funds were available within 47 days. 

The impact from the delayed funds for Puerto 

Rican residents reverberates throughout the 

island. Puerto Rican residents are unique in that 

they experience a compounded issue of increased 

food insecurity during disasters – one more dire 

than their Puerto Rican residents residing in the 

states.143 NCD recommends Congress amend 

the Food Stamp Act to provide expedited 

funding for food and nutrition benefits before, 

during, and after natural disasters for residents 

of Puerto Rico and U.S. territories, as is 

available in the states.

Repercussions from the delayed funding 

is alarming for Puerto Rican residents, given 

the high rates of poverty and limited federal 

programs available to help low-income families 

meet their basic needs. Individuals with 

disabilities on the Island are at a greater risk.

NAP is funded through a block grant and 

funding levels are static. This type of funding 

stream allows no consideration for exceptional 

circumstances such as natural disasters or 

inflation that drive up food costs. As such, those 

administering the NAP program must determine 

future benefits based on 

available funding versus 

need. Even when a 

resident meets eligibility 

requirements, Puerto 

Rico may be required to 

decrease participation 

or benefit levels to stay 

within the rigid funding 

stream. When approximately 66 percent of NAP 

eligible households report a monthly income at or 

below half of the federal poverty line, eliminating 

or reducing their ability to purchase food during a 

natural disaster is unconscionable.

Puerto Rico increased the income threshold 

limit following the obtention of additional NAP 

funding in response to Hurricanes Irma and 

Maria. The additional funds provided an increase 

in program participation of about 10 percent. 

However, the additional funding ended in 

March 2019.

NAP is funded through a block grant 

and funding levels are static.  ...

such, those administering the NAP 

program must determine future 

benefits based on available funding 

versus need

50 National Council on Disability
In the states, during Fiscal Year 2018, SNAP 

provided monthly benefits to approximately 

39.7 million people living in 19.7 million 

households across the 

United States.144 In Fiscal 

Year 2018, the total cost 

of the program to the 

Federal Government 

was $64.9 billion, of 

which $60.4 billion went 

to SNAP benefits and 

the balance to program 

administration. The 

average monthly SNAP benefit was $255 during 

Fiscal Year 2018 for participating households.

Almost 27 percent (26.6) of Puerto Rican 

households in the states receive SNAP or Food 

Stamp benefits or 498,335 citizens.

Table 4.3 reflects the income eligibility 

requirements for Puerto Rico and the states, 

which includes Guam, the USVI, and the 

Northern Mariana Islands.

Findings from this report show that Puerto 

Ricans who emigrated to the states receive 

almost double the monthly benefits than those 

who reside in Puerto Rico. For example, a 

resident of New Jersey receives a 15 percent 

higher monthly stipend 

than a resident of 

Puerto Rico. Disparity 

also exists between 

Puerto Rico and other 

U.S. territories. Monthly 

benefits for Puerto Rican 

residents are lower than 

those residents of the 

Mariana Islands. And the 

Mariana Islands food assistance program is also 

administered through NAP.

NAP funding is dependent solely on funds 

provided to Puerto Rico via a block grant, and 

during the pandemic, the temporary additional 

funds provided through the Cares Act. Benefit 

amounts have had to be adjusted as the 

percentage of eligible households has increased. 

Prior to COVID-19, over 700,000 families and 

1.3 million participants received benefits. 

The Family Socioeconomic Development 

When approximately 66 percent of 

NAP eligible households report a 

monthly income at or below half of 

the federal poverty line, eliminating 

or reducing their ability to purchase 

food during a natural disaster is 

unconscionable

Table 4.3: Net Monthly Income Eligibility Standards: NAP vs. SNAP

NAP

Net Monthly Income 

threshold

NAP

Net Monthly Income 

threshold

SNAP

Net Monthly Income 

threshold

Household 

Size

Puerto Rico

(March 2019)

Commonwealth Northern 

Mariana Islands

(FY2021)

48 States and DC145

USVI

Guam

(FY2021)

1 $619 $1,064 $1,064

2 $1,179 $1,437 $1,437

3 $1,706 $1,810 $1,810

4 $2,206 $2,184 $2,184

5 $2,666 $2,557 $2,557

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 51
Table 4.4: NAP/SNAP Maximum Benefit Fiscal Year 2021

NAP Maximum Monthly Benefit SNAP Maximum Monthly Benefit

After 

Adjustments 

March–June 

2019

FY 2021 FY 2021 FY 2021 FY 2021 FY 2021 FY 2021

Household 

Size Puerto Rico Saipan CNMITinian Rota 48 States and DC146 USVI Guam

1 $146 $300 $317 $365 $204 $262 $300

2 $274 $551 $582 $670 $374 $481 $551

3 $381 $789 $834 $960 $535 $688 $789

4 $493 $1,002 $1,059 $1,219 $680 $874 $1,002

5 $600 $1,190 $1,257 $1,448 $807 $1,038 $1,190

Administration (ADSEF) reports that for 2017 

there were about 1.5 million participants of which 

103,280 are PWDs who are currently enrolled in 

NAP.147

Block grant funds for NAP are 25 percent 

below the expenditures 

for a similarly situated 

program under SNAP. 

Allocations for NAP also 

do not include annual 

adjustments for inflation, 

creating a larger disparity 

between the two programs over time. Puerto 

Rican residents receive disparate treatment in 

the disbursement of SSI, Medicare, and Medicaid 

benefits. Leaving residents with little to no 

expendable income, it is of utmost importance 

that Puerto Rico’s food assistance program is 

able to provide residents of Puerto Rico with the 

basic needs of access to food and provide food 

security.148

According to a confidential interview with a 

Puerto Rico Family Department representative 

regarding the differences in food assistance 

benefits in Puerto Rico versus the states, the 

interviewee said:

“I could not give you specifics, but obviously 

the program is based on family income, and 

the number of relatives 

living in the house, and 

the specific needs of 

the family members. 

They are extremely 

restrictive. No, they 

do not promote the 

individual growth of a human being, because 

if you manage to improve your salary a little, 

then they take the benefit away from you. 

I’ve had the opportunity to assist, within our 

facilities, a participant with a disability who 

only received nutritional assistance of $60 

per month to live. She is a person who has 

a whole series of supply and support needs 

that no one provides in Puerto Rico, support 

that Medicaid and other benefit programs 

supply in the United States to the population 

with disabilities.”149

Allocations for NAP also do not 

include annual adjustments for 

inflation, creating a larger disparity 

between the two programs over time

52 National Council on Disability
Other stakeholders expressed that the process 

to qualify for benefits in the states was less 

complicated and more accessible. Preliminary 

assistance was provided 

by telephone, delivery 

of documents by fax, 

and determination of 

application received by 

postal mail. In contrast, in 

Puerto Rico, the process 

is lengthy and strictly 

face-to-face. This past 

year, since the pandemic, 

the program has been administered virtually. It is 

uncertain as to whether Puerto Rico will continue 

that practice once federal agencies are able to 

reopen.

Over the last two years, Puerto Rico was 

awarded supplemental funding through the 

Families First Coronavirus Response and CARES 

Act of March 2020, which allowed Puerto Rico to 

expand the capped benefits and serve more NAP 

participants for a limited period (May–July 2020) 

adding $300 million to the nutrition assistance 

block grants in Puerto Rico and other territories.150

In addition, short term 

assistance included a 15 

percent increase in the 

COVID-19 relief bill and 

recent American Rescue 

Plan Act, which added 

$1 billion in funding for 

nutrition assistance for the 

Island and other territories 

that receive NAP. While 

these increases filled a critical void, they were 

only for a limited time. So, when the funds ran out 

Puerto Rico once again was required to severely 

cut benefits by 40 percent for all households with 

the average benefit dropping from about $323 in 

July 2020 to about $188 by October 2020,151 thus 

lowering benefits when many were still reeling 

from the effects of the 

pandemic. This, coupled 

with the fact noted 

previously that most 

NAP participants receive 

lower benefits than if 

they received SNAP, and 

they are subjected to 

comparable if not higher 

food prices than in the 

states.152 The temporary funding did not address 

the systemic inadequacy and instability of NAP 

thus exacerbating food insecurity on the island and 

other territories.

The modest NAP benefits are insufficient to 

meet the basic nutritional needs of the island’s 

most vulnerable residents. In 2018, over two-fifths 

of all residents of Puerto Rico (43 percent) and 

over half of all children in Puerto Rico (57 percent) 

lived in poverty.153 Moreover, about one-third of the 

adult residents of Puerto Rico experienced food 

insecurity.154 Puerto Rican residents are disparately 

treated in the allocation of 

funds for food assistance 

programs. Because of 

the disparate funding, 

Puerto Rico is unable to 

provide much needed 

food assistance to all 

qualified families. NCD 

recommends Congress 

amend the Food Stamp 

Act to include Puerto Rico, the Northern 

Mariana Islands, and American Samoa in the 

SNAP program, as has been done for Guam 

and the USVI.

[W]hen the [COVID relief] funds 

ran out Puerto Rico once again was 

required to severely cut benefits by 

40 percent for all households with 

the average benefit dropping from 

about $323 in July 2020 to about 

$188 by October 2020 

In 2018, over two-fifths of all 

residents of Puerto Rico (43 percent) 

and over half of all children in 

Puerto Rico (57 percent) lived in 

poverty. Moreover, about one-third

of the adult residents of Puerto Rico 

experienced food insecurity

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 53
54 National Council on Disability
Chapter 5: Education

Factors Impacting Education

Multiple factors impact the quality of education provided to PWDs in Puerto Rico. They 

include lack of financial resources and the impact of natural disasters as well as mandated 

internal controls and monitoring plans to monitor the distribution of federal funds. The 

imposition of additional conditions prior to the release of funds significantly delayed the 

island’s recovery and directly impacted educational services for Puerto Rican students with 

disabilities during the COVID-19 pandemic. Federal funds are distributed via a formula to 

ensure equal distribution among the states and territories. However, those formularies do 

not factor in Puerto Rico’s extremely high poverty rate and increased cost for services on the 

island. NCD recommends Congress amend IDEA’s funding formula to mitigate the high 

incidence of poverty and the island’s increased cost to provide services to students 

with disabilities. Equitable redistribution of funds by considering the financial resources 

and cost of services for a region will mitigate the unintended disparate impact of the current 

formulas.

Students with disabilities are required 

by federal law to be provided a free, 

appropriate public education. The 

Individuals with Disabilities Education Act 

(IDEA) is a federal law designed to ensure 

that children with disabilities be granted a free 

and appropriate public education, in the least 

restrictive environment. The law applies to all 

U.S. territories, including Puerto Rico.

IDEA has four parts, Parts A, B, C and D. 

Part A covers the general provisions of the 

law;155 Part B is the largest part of IDEA and 

accounts for 95 percent of appropriations 

dedicated to state grants programs, preschool 

programs, and all children with disabilities.156

Children from two years old through high school 

(or age 21) can apply for early intervention and 

special education programs if they meet one 

of the 13 eligibility criteria from the following 

categories: specific learning disability (dyslexia, 

dyscalculia, dysgraphia, nonverbal learning 

disability, and auditory processing disorder); other 

health impairments; autism spectrum disorder; 

emotional disturbance; speech or language 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 55
impairment; visual impairment; deafness; 

hearing impairment; deaf-blindness; orthopedic 

impairment; intellectual disability; traumatic brain 

injury; and multiple disabilities.157 Part C funds 

offer early intervention services to infants and 

toddlers with disabilities, covering ages birth 

to 3 years old, and Part D includes competitive 

grants to improve state personnel development, 

personnel preparation and technical assistance, 

model demonstration projects, and support to 

improve results for children with disabilities.158

IDEA supports states and localities in their 

efforts to aid children and youth with disabilities, 

as well as their families, by protecting their rights, 

meeting their individual needs and improving 

their educational outcomes.159 An Individualized 

Educational Plan (IEP) under IDEA is federally 

mandated and requires the school system to 

implement and adopt their provisions. The IEP is 

a plan that ensures that a child with a disability 

receives adequate educational services that 

respond to their individual needs. For students 

who don’t require an IEP, schools can create a 

504 Plan for students with disabilities that are 

not eligible for services under IDEA. The 504 plan 

eliminates barriers and provides support services 

that allow equal access to educational services 

for students with disabilities.160

The Office of Special Education Programs 

(OSEP) oversees IDEA. OSEP leads the efforts to 

improve outcomes for children with disabilities, 

from birth through age 21, ensuring access 

to fair, equitable, and high-quality education 

and services.161 OSEP authorizes formula 

grants to states under Part B, formula grants 

to lead agencies for the infants and family’s 

program under Part C, and discretionary 

grants under Part D to support grants for state 

personnel development, technical assistance 

and dissemination, technology, personnel 

development, parent-training and information 

centers.162

Funds are allocated to the states in 

accordance with a variety of factors, as outlined 

in the funding formula under Section 611(d) 

of IDEA.163 At a minimum, state and territory 

regulations must provide all of the protections 

included under IDEA.164 IDEA allows the 

states and territories to interpret the rules 

and approve additional regulations related to 

special education.165 IDEA requires a minimum 

set of rules and regulations but beyond these 

minimums, states and territories can establish 

additional parameters that could benefit students 

with disabilities. Grants to state programs provide 

formula grants to assist the 50 states, the District 

of Columbia, Puerto Rico, and the territories. To 

be eligible for Part B funding, states must serve 

all children with disabilities between the ages of 

three through 21.166 Funds under this program are 

combined with state and local funds to provide 

fair, appropriate, public education to children with 

disabilities.167

Allowable expenditures for states and 

territories are the same. Expenditures include the 

salaries of special education teachers and costs 

associated with related services personnel, such 

as speech therapists and psychologists.168 States 

may use these federal funds reserved for other 

state-level activities for a variety of specified 

activities, including support and direct services; 

technical assistance and personnel preparation; 

assisting Local Education Agencies (LEAs) in 

providing positive behavioral intervention and 

support; and improving the use of technology in 

the classroom.

States and territories have faced challenges 

acquiring specialized services and personnel 

56 National Council on Disability
needed to comply with federal IDEA 

requirements.169 Many states and territories 

don’t have funding for these services and 

personnel costs.170 Unfunded federal mandates 

and are an economic burden to states and 

territories with insufficient resources.171

Education Services in Puerto Rico

Puerto Rico’s 2020 fiscal plan includes funding for 

the Puerto Rico Department of Education (PRDE), 

the territory’s largest 

government agency, 

which is responsible for 

providing education to 

approximately 289,000 

K-12 students throughout 

the island in 856 

schools.172 PRDE submits 

an application to the U.S. Department of Education 

(ED) to obtain federal funds under the Individuals 

with Disabilities Education Improvement Act.

PRDE is required to develop a Strategic Plan 

or State Performance Plan (SPP) in accordance 

with IDEA regulations 

and submit an annual 

performance plan. 

The SPP is presented 

annually to the public for 

comments and submitted 

to OSEP for review.

PRDE’s Special Education Program provides 

services to students with disabilities that impact 

their academic process. The program is offered 

to students with disabilities through services 

established according to individual needs. This 

program is regulated by IDEA and various local 

laws.173,174

Approximately 35 percent, 103,318 out of 

289,000, of students between the ages of three 

and 21 receive special education services in 

Puerto Rico.175 In the states, special education 

services account for 10 to 12 percent of the 

school population, whereas in Puerto Rico it’s 

32 to 33 percent. Stakeholders reported that 

according to the IDEA, funds are applied to 

Puerto Rico under the same formula as other 

states. Other stakeholders reported gross 

differences in service provisions between the 

United States and Puerto Rico in terms of 

access to services, 

specialists, transition 

services, employment, 

and post-secondary 

education opportunities. 

The formulary used 

to determine grant 

amounts to states and 

territories is codified in statute within the IDEA 

§1411(a)(2)(B)(i),(ii),(iii). The formulary factors 

the number of children with disabilities during 

the school year receiving special education and 

related services, and multiplies the average pupil 

expenditure in public 

elementary schools and 

secondary schools in the 

states by 40 percent. 

If additional funds are 

still available after other 

required allocations, part 

of the formulary does factor in a state’s relative 

population of children without disabilities living in 

poverty. The current formula does not equitably 

distribute education funds and disparately 

impacts states and territories experiencing high 

rates of poverty. NCD recommends Congress 

amend IDEA’s funding formula to mitigate 

the high incidence of poverty and the island’s 

increased cost to provide services to students 

Approximately 35 percent, 103,318 

out of 289,000, of students between 

the ages of three and 21 receive 

special education services in Puerto 

Rico

In the states, special education 

services account for 10 to 12 percent 

of the school population, whereas in 

Puerto Rico it’s 32 to 33 percent

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 57
with disabilities. Equitable redistribution of 

funds by considering the financial resources 

and cost of services for a region will mitigate 

the unintended disparate impact of the current 

formulas. Appendix D contains detailed data 

on students with disabilities aged 6 to 21 who 

receive special education services in Puerto Rico 

and other U.S. territories.

PRDE provides services through two 

programs. The first is the Special Education 

Program, known as the Special Education 

Auxiliary Secretary (SAEE for its Spanish 

acronym), which offers educational and 

therapeutic services to students, and the second 

is the Provisional Remedy Program (PRP), which 

only offers non-educational support services to 

students.176 Under IDEA, schools must identify, 

locate, and evaluate all children with disabilities 

regardless of the severity of that disability and 

provide them with an IEP tailored to each child’s 

needs.177 If PRDE does not provide the necessary 

services within 30 days of a request for services 

to SAEE and the writing of the IEP, the student 

may receive services through the alternate PRP.178

Stakeholders have stated that wait times for 

special services can far exceed the 30-day period.

Dispute resolution tools to challenge an IEP are 

the same in Puerto Rico as they are elsewhere 

(mediation, state complaint, and due process 

hearing). However, as a result of a class action 

lawsuit, El caso Rosa Lydia Vélez v. Departamento 

de Educación de Puerto Rico, the PRP was created 

in Puerto Rico.179 The ruling demands that PRDE 

offer therapeutic services to special education 

students, whose only obstacle to receiving regular 

services was the limitation of SAEE resources, 

once their eligibility is approved.180

During Fiscal Year 2020, approximately 11,000 

special education services were provided through 

PRP at four to five times the normal cost of 

services provided by SAEE.181 PRP accounts 

for only 6 percent of the therapy services 

provided to students, but accounts for almost 

30 percent of the total budget.182 The PRDE 

Special Education Program offers services for 

evaluations, therapies (occupational, educational, 

speech, language, physical), technological 

assistance, and transportation.183 Parents of 

children with disabilities expressed frustration in 

the responsiveness and timeliness of receiving 

required services.

In Fiscal Year 2019, PRDE provided 

transportation to approximately 18,000 students, 

equivalent to approximately 84 percent of those 

eligible under the minimum income and distance 

from school rule. Transportation is also provided 

to approximately 12,000 special education 

students, equivalent to 55 percent of students 

requiring transportation based on their IEP as of 

March 2020. These services were provided in a 

fragmented manner, with more than 250 vendors 

and 35 municipalities providing services. PRDE 

spent approximately $94 million on student 

transportation services, nearly all funded through 

general funds. Transportation accounts for 

approximately 11 percent ($94 million) of general 

funds spending. Approximately 60 percent of 

transportation expenditures ($56 million) supports 

transportation for special education students.184

The average annual transportation cost for 

a special education student in Puerto Rico is 

approximately $4,600, more than double the cost 

incurred to transport others who are not special 

education students.185 Federal IDEA funds can be 

used for transportation. However, ED prohibited 

PRDE from using IDEA funds for transportation 

services. ED stated the reason for the prohibition 

was SAEE’s noncompliance with certain 

58 National Council on Disability
provisions under IDEA. The noncompliance 

cited was improper payments, lack of internal 

controls, noncompliance with agency policies, 

and lack of adequate supervision regarding the 

issuance of payments for transportation services 

to students in the Special Education Program.186

Because of this prohibition, PRDE is required 

to fund transportation for special education 

students through Puerto Rico’s general fund 

until the special conditions, a third-party fiduciary 

agent (TPFA) and monitoring plans governing 

distribution of funds imposed by ED, are met.187

These restrictions have created additional 

financial stress on local governments and created 

a scenario in which the Commonwealth does 

not have the resources to transport all special 

education students. 

As of March 2020, 

approximately 9,800 

special education 

students did not have 

access to transportation, 

placing the burden on the 

parents to transport their 

children to school.188

Addressing special educational needs is a 

challenge and an indicator of the capacity of the 

system to offer the highest quality education 

possible. Limited or inappropriate resources 

are regarded as significant barriers to ensuring 

inclusive education for children receiving special 

education services.189 Inadequate training and 

support for teachers, as well as physical and 

technological barriers make it difficult for students 

with disabilities to participate. Year after year, the 

parents of students with special needs express 

dissatisfaction with educational services offered 

by PRDE. Parents interviewed as stakeholders 

for the purposes of this report agree that special 

education services provided for their children are 

not as robust as they could be.190

A lack of adequate funding to provide services 

and slow recovery from natural disasters and 

the pandemic create barriers to the provision 

of a free, appropriate public education that 

is accessible and inclusive to students 

with disabilities. PRDE and the Vocational 

Rehabilitation Administration (VRA) have 

attempted to adjust to their environment in the 

wake of Hurricanes Irma and Maria, the recent 

earthquakes, and COVID-19.

In 2017, Hurricanes Irma and Maria caused 

nearly $100 billion in damage and devastated core 

parts of Puerto Rico’s educational infrastructure.191

Consequently, Congress recognized Puerto Rico’s 

need and appropriated 

$589 million for K-12 

school recovery under 

the Immediate Aid 

to Restart School 

Operations (RESTART) 

program.192 Congress 

designated the Education 

Stabilization Fund within the CARES Act to 

provide resources to states and local educational 

agencies. ED established a set of internal 

controls for fund recipients, and required PRDE 

to abide by the same internal controls articulated 

in the RESTART program and additional internal 

controls and monitoring plans for oversight of the 

fund’s distribution.

As mentioned earlier in this chapter, in 2019, 

ED notified PRDE that specific conditions were 

being imposed based on information provided 

to ED by the PRDE Internal Audit Office.193 The 

special conditions required PRDE to retain a 

TPFA to perform the financial management 

duties required under federal regulation.194

In 2017, Hurricanes Irma and 

Maria caused nearly $100 billion 

in damage and devastated core 

parts of Puerto Rico’s educational 

infrastructure

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 59
PRDE posted a request for information in search 

of a TPFA in October 2019 and a TPFA was finally 

in place in the spring of 2021. In March 2021, 

U.S. Secretary of Education Miguel Cardona 

notified the Governor of the Commonwealth of 

Puerto Rico the Commonwealth had immediate 

access to federal education funds, which were 

not previously available 

because of the lack 

of a TPFA.195

The earthquakes 

in January 2020 and 

COVID-19 severely 

impacted the quality of 

education services for 

Puerto Rican children 

with disabilities and 

disparities in funding 

between the states 

and Puerto Rico were apparent. The CARES 

Act recognized that for education services 

to continue in the midst of COVID-19 and to 

guarantee the safety of our nation’s children, 

school districts would need to adapt systems 

and protocols, acquire technology and safety 

equipment, and hire staff and specialists 

needed to restart schools safely with low risk 

of transmission. To further this process along, 

the CARES Act created the Elementary and 

Secondary School Emergency Relief Fund 

(ESSER) and the Governor’s Emergency 

Education Relief Fund (GEER). PRDE and 

Puerto Rico’s Governor should have received 

$349,113,000 under 

the ESSER Fund, and 

$47,812,236 under the 

GEER Fund, respectively. 

However, the ED Risk 

Management Services 

informed PRDE that they 

would not be receiving 

the funds allocated 

to assist in reopening 

schools because the 

TPFA was not in place.196

No other states or territories were given 

these conditions for the release of funds, 

which delayed receipt of funds and drastically 

convoluted the funds’ original purpose, thus 

impeding Puerto Rican children from returning 

to school and receiving a free, appropriate public 

education.

[T]he ED Risk Management Services 

informed PRDE that they would not 

be receiving the funds allocated to 

assist in reopening schools because 

the TPFA was not in place. No other

states or territories were given 

these conditions for the release of 

funds 

60 National Council on Disability
Chapter 6: Employment

Employment Disparities

Only 23.7 percent of Puerto Rican residents with disabilities actively participate in the 

workforce, compared to 36 percent in the states and 44 percent in other U.S. territories. 

The lack of employment opportunities on the island exacerbates the poverty level, which 

is significantly higher than any of the states. Identical employment programs exist on the 

island as are in the states, and funding for those programs is distributed equally among 

states and territories. However, the funding provided for Puerto Rican residents with 

disabilities is not sufficient to address the unique unemployment needs of PWDs in Puerto 

Rico. NCD recommends Department of Education amend 34 CFR 361.60, the cost 

sharing requirement for state vocational rehabilitation services grants, to allot for an 

exemption to the cost sharing requirement if a state or territory can prove they are 

fiscally incapable of providing the cost share portion. Equitable distribution of funds to 

grantees will mitigate the unintended disparate impact of the current formula stipulations.

Therefore, a state or territory already in financial distress is not penalized or precluded 

from gaining access to federal funds solely because of its economic status.

NCD recommends the Commonwealth of Puerto Rico implement tax incentives for 

employers who hire persons with significant disabilities, similar to established state 

programs.

I

n 2018, the average employment rate for 

people with disabilities in the United States 

and Puerto Rico was 37.8 percent. The 

employment rate for people without disabilities 

was 80.0 percent.197 Puerto Rico’s employment 

rate for PWDs was much lower at 23.5 percent 

compared to 58.3 percent for those without 

disabilities.198 Unemployment rates for PWDs in 

Puerto Rico were much higher among people 

with a disability.199

Several factors contributing to the 

unemployment of people with disabilities 

are the island’s slow recovery from recent 

hurricanes and earthquakes, the mass exodus 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 61
of professionals who would otherwise be job 

creators on the island, and the pandemic. This 

results in a lack of opportunities and greater 

poverty, which further increases dependence 

on family members or government assistance. 

Puerto Rico has a poverty rate of 48 percent 

compared to the states (22.5 percent).200

Puerto Rico’s poverty rate is more than double 

that of Mississippi 

at 19.7 percent, 

and Mississippi had 

the highest poverty 

rate of any state in 

2018. As is true in 

the states, Puerto 

Rico’s metropolitan 

area offers better 

access to employment, community, and 

transportation.201

Federal Employment Programs and 

Services in Puerto Rico, the United 

States, and U.S. Territories

Employment support for people with 

disabilities comes from various agencies 

available to all prospective employees with 

disabilities in Puerto Rico as well as in the 

states and territories. 

Examples of these 

agencies are the State 

Vocational Rehabilitation 

Agencies (SVRAs), 

Employment Networks 

under the Social Security Ticket to Work 

Program (TTW), state or local Workforce 

Investment Boards (WIBs) and American Job 

Centers (AJCs), Developmental Disability 

Agencies (DDA), and Centers for Independent 

Living (CILS), among others.202

Department of Labor and Human 

Resources

In Puerto Rico, all coordinated employment 

services are managed under the Department 

of Labor and Human Resources (DTRH). The 

mission of the DTRH of Puerto Rico is: “[ . . .] the 

identification, training, and transformation of the 

workforce, ensuring labor rights, promoting the 

creation of more and 

better jobs, the security, 

social and economic 

well-being of workers, 

[ . . .]”.203 This includes 

protecting PWDs from 

discrimination and 

ensuring equal access 

to services and equal 

employment opportunities, rights that are 

covered under the ADA and Rehabilitation Act 

of 1973. DTRH has employment programs and 

services that support obtaining employment for 

PWDs.

Vocational Rehabilitation Programs

The Rehabilitation Services Administration 

(RSA) oversees four assistance programs that 

service PWDs to achieve 

successful employment 

outcomes. These are the 

Vocational Rehabilitation 

Service Program (VR) 

and the Supported 

Employment Service (SE), both being state 

formula grant programs; the American Indian 

Vocational Rehabilitation Service Program (AIVR); 

and the Demonstration and Training programs, 

which are discretionary grant programs with up 

to five years of competitive awards. Additionally, 

Only 23.7 percent of Puerto Rican

residents with disabilities actively 

participate in the workforce, 

compared to 36 percent in the 

states and 44 percent in other U.

territories

Puerto Rico has a poverty rate of 

48 percent compared to the states 

(22.5 percent

62 National Council on Disability
federal agencies are required to comply with 

the Randolph-Shepperd Act, which prioritizes 

blind vendors on federal or other properties 

with program compliance overseen by RSA. 

The funds to support blind vendors are provided 

by VR program funds and authorized by SVRA 

programs.204 In the United States, most of 

the RSA and VR agencies are overseen by 

the Department of Education (ED), however, 

in Puerto Rico, this program falls under the 

Department of Labor (DOL).

The Vocational Rehabilitation Administration 

(VRA) is the primary agency that provides 

employment services for PWDs in Puerto 

Rico. Among the different federal programs 

and benefits offered 

by VRA, related to 

employment, are the 

Sustained Employment 

Program (SE), the Public 

Corporation for the 

Blind Industry (PCBI), 

the Self-Employment 

Program, the Subsidized 

Employment Program (SEP), and the 

Independent Living Program (IL).205

The SE program, administered by the VRA, 

offers PWDs assistance in job training and 

job placement services. The program offers 

skill evaluation, skill development training, job 

training, and placement, with the assistance 

of a job trainer.206 In addition, it administers 

the Public Corporation for the Blind, which 

manufactures mops and exclusively hires 

people who are blind paying a minimum wage 

of $7.25 per hour.207 SEP provides PWDs with 

training and funds to acquire the necessary 

equipment to set up their own business. SEP 

offers employers an incentive, or subsidy, to 

provide PWDs employment opportunities. 

These subsidies are temporary and usually 

phase out after a pre-agreed term among 

VRA and the employers. VRA also funds CILs 

and IL service providers who offer services 

to PWDs interested in pursuing and achieving 

independent living goals.

VRA also provides support services to PWDs 

by providing assistance through educational 

and vocational programs. Examples of some 

services are readers for the blind, orientation 

and mobility training, Braille training, sign 

language interpreters, personal assistant 

services, medical services, or related services 

for rehabilitation, food stipends, payment of 

professional licenses, 

transition services, 

tuition payment for 

educational institutions, 

rehabilitation counseling, 

and career exploration 

services.

For a PWD to be 

determined eligible for 

vocational rehabilitation services, they must 

meet the two criteria identified in Section 102(a)

(1) of the Rehabilitation Act.208 The first criteria 

is that the person has a disability as specified 

in Section 7(8)(A) of the Rehabilitation Act. 

This definition has two elements: (1) having 

a physical or mental impairment that, for that 

person, constitutes or results in a substantial 

impediment to employment, and (2) the person 

can benefit from vocational rehabilitation 

services in terms of an employment 

outcome.209 The second criteria for eligibility 

is that the PWD must require VR services to 

prepare for, enter, engage in, or retain gainful 

employment.210

In the United States, most of the 

RSA and VR agencies are overseen 

by the Department of Education 

(ED), however, in Puerto Rico, this 

program falls under the Department 

of Labor (DOL)

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 63
Each state and territory has at least one 

VR program that serves all individuals with 

disabilities. In some states, a Commission 

for the Blind is also available through federal 

funding. In Puerto Rico and the other U.S. 

territories, this program falls under VRA. Federal 

funds for VRA are 

based on the statutory 

formula that takes into 

account population and 

per capita income in 

determining the amount 

made available to each 

grantee for VR program 

purposes.211

In its 2017–2020 

government transition report, the Puerto Rico 

VRA noted that 78.7 percent of the funds 

allocated to the agency are federal funds with the 

remaining 21.3 percent from state funds.212 The 

annual budget for 2017 was $56,762,321; for 2018 

it was $68,027,392; for 

2019, it was $44,857,077; 

and for 2020 it was 

$44,664,306.213

VR funds are allotted 

to state agencies via 

a formula. Federal 

statute requires each 

year’s appropriation be 

equal to the prior year’s 

appropriation plus an increase equal to inflation.214

Puerto Rico receives the maximum percentage 

of funds available to any state or territory, set at 

75 percent.215 Each state is required to match a 

portion of its federal grant.216 The cost sharing 

percentage for all states and territories is 21.3 

percent of the total program cost.217 If a grantee 

is not able to provide its cost share obligation, 

the unmatched funds must be returned and are 

made available to other states.218 In 2018, Puerto 

Rico received $68,027,392 in grant funding. In 

2021, they received $68,469,627 but relinquished 

$19,292,383. In 2020, Puerto Rico was awarded 

$67,570,718 and relinquished $22,906,512, 

presumptively because 

of the island’s financial 

constraints and inability 

to provide the matching 

funds.

A stakeholder 

indicated that, because 

of Puerto Rico’s 

economic status, the 

Federal Government’s 

requirement to match funds often leaves federal 

funds unused because of Puerto Rico’s inability 

to procure funds for the match. This further 

impedes and limits the services provided to 

PWDs.

NCD recommends 

Department of 

Education amend 

34 CFR 361.60, the cost 

sharing requirement 

for state vocational 

rehabilitation services 

grants, to allot for an 

exemption to the cost 

sharing requirement if 

a state or territory can prove they are fiscally 

incapable of providing the cost share portion.

Supported Employment (SE) 

for Individuals with Significant 

Disabilities

Supported Employment (SE) is a service that 

supports people with significant disabilities to 

In 2020, Puerto Rico was awarded 

$67,570,718 [in VR funds] and 

relinquished $22,906,512, 

presumptively because of the 

island’s financial constraints and 

inability to provide the matching 

funds

In its 2017–2020 government 

transition report, the Puerto Rico 

VRA noted that 78.7 percent of the

funds allocated to the agency are 

federal funds with the remaining 

21.3 percent from state fund

64 National Council on Disability
obtain, maintain, and retain competitive and 

continuous employment. In Puerto Rico, these 

services are provided by sub-contractors. Puerto 

Rico’s Office of Support and Employment 

Modalities indicated that for the year 2020, 

319 PWDs were provided services under the 

sustained employment mode.219

Transition Services Under VRA

Transition Services under VRA provide youth 

with disabilities education and training to attain 

adequate skills and empowerment that will allow 

them to compete successfully in the job market. 

The primary agency responsible for providing these 

transition services is vocational rehabilitation, both 

in Puerto Rico, the states, and the territories.

The Workforce Innovation and Opportunity 

Act (WIOA) amends the Rehabilitation 

Act of 1973 and now requires vocational 

rehabilitation agencies to set aside at least 

15 percent of their federal funds to provide 

“pre-employment transition services” to 

“students with disabilities who are eligible 

or potentially eligible for VR services.”220

The transition services in the states and 

territories are mandated by the IDEA and WIOA. 

Under IDEA a student with disabilities in the 

transition program is focused on independent 

living skills that include vocational education.221

Meanwhile, WIOA services focus on students 

with disabilities under the age of 21, and the 

transition required for job counseling, workbased learning experience, counseling on 

comprehensive transition and post-secondary 

educational programs, training for development 

of independent living and social skills, and 

introduction to self-advocacy.222

In Puerto Rico, transition services are provided 

by VRA subcontracted agencies. These agencies 

are required to provide trainings that support 

youth in transition by increasing their knowledge 

in subjects regarding their rights, self-defense, 

workforce, and independent living skills. They 

must also administer vocational interest tests, 

offer job fairs, and provide career counseling to 

youth with significant disabilities receiving special 

education services or with a Section 504 plan. 

In Puerto Rico, VRA subcontracted agencies’ 

provided services to 59,775 people from 2017 

to 2020. They had 5,900 new applicants; with 

4,675 referrals to transition (14–21 years).223

The Agency also reports (2017–2020) that 

under Law 51 of the Puerto Rico Department 

of Education, a total of 14,329 parents, 4,969 

teachers, and 15,110 students in transition 

services attended workshops.224

Stakeholders’ Views on VRA Services

Stakeholders with disabilities stated some of 

the challenges faced when requesting services 

at the Puerto Rico VRA is that counselors 

discourage people with significant disabilities 

from seeking services. Counselors underestimate 

the capabilities of people with significant 

disabilities and limit their access to programs and 

opportunities. When services are sought there’s 

often a long evaluation process with many delays 

in provided services. Once a PWD is 21 years of 

age or older, CILs provide services to PWDs after 

they conclude services with the ED. However, 

in Puerto Rico there are only two agencies who 

manage the five CILs available in Puerto Rico. 

These centers do not service all the municipalities 

on the island and the majority are underfunded.

Some stakeholders that had previously resided 

in the states, said that “in the United States, they 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 65
are able to find jobs for PWDs and that employers 

take the time to help. There might be nonprofit 

organizations that help, but in Puerto Rico, it’s 

more limited.”

Social Security Administration

The Social Security Administration (SSA) also 

administers employment programs through the 

Work Incentives Improvement Act of 1999. One 

of the programs currently available in Puerto 

Rico is the Employment Network (EN) Ticket to 

Work (TTW) program, which provides support 

to beneficiaries of SSA disability programs and 

SSDI, with job search 

and placement efforts to 

those who want to return 

to the workforce.225

Currently, only two 

active ENs exist in 

Puerto Rico, Movimiento 

para el Alcance de Vida 

Independiente (MAVI) 

and Alianza Municipal de 

Servicios Integrados (AMSI). The other program 

available (that is not an EN) is the Work Incentives 

Planning and Assistance Program (WIPA) whose 

goal is to support beneficiaries with disabilities 

with information on work incentives for a 

successful transition to work.226 Between 2014 

and 2020, the WIPA program in Puerto Rico has 

assisted approximately 500 SSDI beneficiaries 

per Fiscal Year to reenter the workforce.

Tax Incentives to Employers

In Puerto Rico, the Internal Revenue Code of 

Puerto Rico offers a tax deduction for employers 

that hire people with significant disabilities who 

participated in VR services, a deduction of $400 

dollars per person with disabilities and a right to 

claim a maximum of 5 PWDs. Each employee 

must work a minimum of 20 hours per week.227

In the states, employers that provide PWDs 

employment opportunities receive IRS tax credits 

such as the Disabled Access Credit, the Barrier 

Removal Tax Reduction, and the Work Opportunity 

Tax Credit. The differences among the states and 

territories are due to differences in tax structures.

NCD has documented that increased 

employment for PWDs benefits PWDs by 

increasing their 

economic stability and 

independence and 

benefits the overall 

economy. It also 

decreases government 

dependence and 

increases diversity 

in the workforce. 

Therefore, employment 

for PWDs is not a “them” issue, but one that 

impacts us all.228

Research conducted in 2018 found that 

81 percent of employers interviewed on the 

island understood that PWDs have the skills 

and knowledge to apply for a competitive job 

opportunity.229 Perhaps if provided greater tax 

incentives these employers would be willing to 

extend even greater job opportunities to PWDs. 

NCD recommends the Commonwealth of Puerto 

Rico implement tax incentives for employers 

who hire persons with significant disabilities, 

similar to established state programs.

[Puerto Rico VRA] counselors 

discourage people with significant 

disabilities from seeking services

Counselors underestimate the 

capabilities of people with significant 

disabilities and limit their access to 

programs and opportunities

66 National Council on Disability
Chapter 7: Housing

Housing Disparities

Accessible homes in Puerto Rico are limited and directly impact the ability of a person with 

a disability to live independently. The impact of natural disasters on the island has critically 

weakened housing stock and impacted Puerto Rico’s infrastructure, contributing to the 

extremely limited affordable accessible housing on the island. This, coupled with untenable 

waiting lists for accessible and affordable housing and numerous systemic and longstanding 

accessibility issues,[1] makes acquiring housing challenging. NCD recommends the U.S. 

Department of Housing and Urban Development (HUD) require that all federally 

assisted housing units follow universal design principles and ensure that accessible 

housing units reflect the percentage of people with disabilities in need of federal 

housing assistance.

Affordable and accessible housing is 

a necessity for PWD’s to achieve 

independence. In Puerto Rico,230

PWDs face multiple social disadvantages 

that preclude them from that status such as 

high poverty levels, low employment rates, 

low educational attainment,231,232 and the 

overwhelming challenge to attain affordable and 

accessible housing. Federal funding is available 

for housing service assistance throughout 

different federal programs. However, gaining 

access to these programs can prove elusive. 

These programs are available across the states 

and all the territories for which formulas and 

methodologies are similar in the application 

for the determination of funding amounts to 

the SLTTs.

Discretionary funds are awarded by HUD 

through 20 grant programs that support all HUD 

initiatives.233 Funding for HUD programs comes 

from discretionary appropriations provided each 

year in the annual appropriations acts, typically 

as a part of the Transportation, HUD, and Related 

Agencies Appropriations Bill.234

HUD Programs

Available HUD programs include: the TenantBased Rental Assistance (housing choice 

vouchers); Project-Based Rental Assistance; 

Public Housing; Housing for the Elderly 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 67
(Section 202); and Housing for People with 

Disabilities (Section 811). “HUD programs are 

designed to assist residents with very low 

incomes or other special housing needs.”235 Three 

rental assistance programs: Section 8 tenantbased rental assistance (which funds Section 8 

Housing Choice Vouchers); Section 8 projectbased rental assistance; and Public Housing, 

account for the majority of the department’s 

funding (nearly 80 percent of total HUD 

appropriations in Fiscal Year 2017).236 In addition, 

two flexible block grant programs, HOME and the 

Community Development Block Grant (CDBG) 

program, help communities finance a variety of 

housing and community development activities 

designed to serve low- and moderate-income 

families.237

HUD sets eligibility requirements for their 

programs. The local Public Housing Agencies 

(PHAs) determine eligibility based on annual 

gross income, whether the person is a senior 

citizen, PWD or family member, a U.S. citizen 

or eligible immigrant, and other local factors.238

These other local factors vary by state. HUD 

sets income limits that determine eligibility 

for assisted housing programs and develops 

income limits based on a multitude of factors. 

The income limits are determined by HUD 

where the low-income limit is 80 percent of the 

median county income, and the very low-income 

limit is 50 percent of the median income for 

the county.239,240 The income levels for Puerto 

Rico and the five states chosen for comparison 

purposes in this report demonstrate that the 

income level eligibility criteria are different for 

Puerto Rico when compared to the states. 

Table 7.1 presents Puerto Rico’s income level 

eligibility for 2021.

Housing in Puerto Rico, the United 

States, and U.S. Territories

Housing is a major challenge for Puerto Ricans 

with disabilities, as is the case for other 

territories, specifically due to natural disasters 

like hurricanes and earthquakes, which have 

destroyed properties and infrastructure that 

will impact the territories for years to come.242

On the Island, HUD provides housing through 

Section 8 and public housing programs. There are 

20 housing facilities subsidized by federal funds; 

however, they are mainly for people aged 62 or 

older.243 In terms of funding, the Department of 

Housing (DOH) in Puerto Rico has a budget of 

$477,965,000 for Fiscal Year 2021.244

Table 7.1: Fiscal Year 2021 Income Limits for Puerto Rico Adjusted by 4-Person 

Federal Poverty Guidelines (Prepared: April 1, 2021)241

Adjusted Income Limits 1-Person 2-Person 3-Person 4-Person

30% Income Limits $11,150 $12,750 $14,350 $15,900

50% Income Limits $18,550 $21,200 $23,850 $26,500

80% Income Limits $29,700 $33,950 $38,200 $42,400

100% Income Limits $37,100 $42,400 $47,700 $53,000

120% Income Limits $44,550 $50,900 $57,250 $63,600

Note: The rounded 4-person income limit is adjusted for person sizes and then rounded up $50.

68 National Council on Disability
The DOH of Puerto Rico has three branches: 

the Housing Department, the Puerto Rico 

Housing Finance Corporation, and the Puerto 

Rico Public Housing Administration (PHA). The 

Housing Department oversees the following 

divisions: the Information System division, 

Human Resources division, Subsidy and 

Community Development division, Acquisition 

and Sale of Properties division, Project 

Management and Development division, and 

the Strategic Planning division. Its mission is to 

increase the housing inventory, manage existing 

public housing projects, and offer subsidy 

programs to low- and middle-income individuals 

and families to provide a safe and proper home 

that contributes to improving their quality of life 

and self-sufficiency.

The Housing Finance Corporation’s main 

mission is to promote the development of 

affordable housing and provide financing facilities, 

subsidies, and incentives so that people can 

purchase or rent an appropriate home.245 The 

Public Housing Administration in Puerto Rico was 

created by Law 66 of 1989, and its vision is to 

improve the quality of life of residents in public, 

residential projects by fostering community 

activity and personal and family development of 

its residents. The agency receives funding from 

the Federal Housing Act of 1938 that provides 

100 percent of funding for the Puerto RicoPHA. These funds can be used for providing 

transportation to PWDs and making accessibility 

modifications to housing units. Those funds 

are insured annually in the budget granted by 

Congress to the federal agency.

Federal fair housing laws are the Fair Housing 

Act, ADA, and Section 504 of the Rehabilitation 

Act. The Fair Housing Act accessibility standards 

require that a minimum of 5 percent of the total 

public housing dwelling units be accessible for 

individuals with a mobility disability.246 Puerto 

Rico has more than 5 percent with a total 

of 53,000 housing units of which 4,100 are 

accessible, representing 8 percent of accessible 

units. The Puerto Rico-PHA operational funds are 

100 percent from federal funds and therefore 

require no state matching.

Puerto Rico has the second largest housing 

project in the United States, second only to New 

York City.247 Yet it is important to note that this 

does not equate to greater housing opportunities 

for PWD’s. In 2016, HUD reached a $65 million 

settlement with Puerto Rico PHA to improve 

accessibility for residents with disabilities. The 

goal was to address “longstanding accessibility 

issues affecting PWDs.”248

PHA was required to retrofit 2,560 housing 

units by December 31, 2021, to ensure 

accessibility. This five-year agreement required 

PHA to set aside $3.6 million each year to retrofit 

1,489 additional units, to create 1,209 units in 

184 existing housing projects, to make accessible 

units in 25 project sites, and to produce 1,024 

sensory-accessible units by 2017.249,250

It is important to emphasize that construction 

materials used for housing in Puerto Rico differ 

from those used in the states as well as the 

construction codes due to the geographical 

location of the island and its propensity to natural 

disasters such as hurricanes and earthquakes.251

These materials are more expensive, which, in turn, 

lead to higher costs per unit resulting in a limited 

amount of housing compared to the demand on 

the island. Before Hurricane Maria, there were only 

2,500 public housing units available, and 25,000 

people were on the waiting list.252

As of 2021, the PHA has approximately 

4,100 public housing units certified for PWDs 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 69
and 360 projects around the island, with 

an approximate Fiscal Year 2021 funding of 

$477,965,000.253 HUD publicly announced in May 

2020, the assignment of $241,205 to Puerto 

Rico, as part of nearly $77 million nationwide 

assignment in a fourth 

wave of CARES Act 

funding supporting 

up to 8,300 additional 

vouchers through HUD’s 

Section 811 Mainstream 

Housing Choice Voucher 

Program. This initiative 

includes affordable 

housing to people who 

are aging and/or disabled.254 The Puerto Rico DOH 

indicated at its transition hearing that a request 

for proposal (RFP) is expected to be published 

for these funds to subsidize construction of new 

projects intended for older adults and PWDs, 

which will provide support services such as 

nursing, home assistance, or transportation.255,256

Stakeholders have found that houses are 

not constructed with 

universal designs that 

adapt to the needs of 

people who are aging 

or PWDs.257 Some 

HUD housing projects 

have limits as to how 

many PWDs are able to 

reside in one location. 

Independent living 

housing complexes only 

allow a small percent of 

PWDs if younger than 55 years old.

People that need support services find them 

only available to people living in assisted living 

or institutions and not available to those living 

independently.258 In Puerto Rico, the majority 

of support services for people with disabilities 

cease once a person reaches the age of 21. 

Because of the lack of support services, a PWD 

is often destined to remain at home with her 

parents and/or respite 

programs.

Assisted living 

programs could benefit 

PWDs in Puerto Rico. 

Program requirements 

are that you must be 

over the age of 21, have 

a professional diagnosis 

of an intellectual disability 

through a psychometric test, and have the basic 

skills of independent living, low income, and no 

property or economic means. Under assistive 

housing, support services are not provided. 

Stakeholders suggested that the government 

of Puerto Rico fund assisted living programs. 

Additionally, what assisted living programs 

do exist are limited and difficult to access, 

especially outside of 

the metropolitan area. 

Another important 

aspect relevant to 

assisted living is the 

lack of transportation 

programs on the island. 

Many PWDs need these 

services in order to live 

independently.

Puerto Rico has 

20 residential complexes 

that are subsidized by federal funds and 

are available to senior citizens aged 62 or 

older as well as the housing units available 

under Section 8. NCD recommends the 

[C]onstruction materials used for 

housing in Puerto Rico .. are mo

expensive, which, in turn, lead 

to higher costs per unit resulting 

in a limited amount of housing 

compared to the demand on the 

island

In Puerto Rico, the majority of 

support services for people with 

disabilities cease once a person 

reaches the age of 21. Because of

the lack of support services, a PWD 

is often destined to remain at home 

with her parents and/or respite 

programs

70 National Council on Disability
U.S. Department of Housing and Urban 

Development (HUD) require all federally 

assisted housing units follow universal 

design principles and ensure that accessible 

housing units reflect the percentage of people 

with disabilities in need of federal housing 

assistance.

In February 2020, the U.S. Department 

of Justice settled a disability-based housing 

discrimination lawsuit with owners and 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 71
developers of 11 apartment complexes in 

Puerto Rico. The lawsuit required the owners 

and developers to resolve violations of the Fair 

Housing Act and the ADA.259 The companies 

are required to retrofit and remove accessibility 

barriers, which may require things such as 

replacing sloped sidewalks, installing curb 

ramps and walkways, installing wheelchair 

accessible bathrooms and kitchen cabinets, and 

removing public and common area accessibility 

barriers.260 NCD recommends PRHD ensure 

that all construction projects destined for 

the island with CDBG-DR funds comply not 

only with the minimum design requirements 

of the ADA but also with universal design 

recommendations to ensure accessibility 

for PWDs.

Stakeholders interviewed emphasized the 

limited number of programs across the island 

dedicated to serving the adult population with 

intellectual disabilities. Additional support services 

identified by stakeholders as necessary to achieve 

independent living (besides the accessible 

housing), were accessible transportation, 

housekeeping services, PAS, and a respite 

program, among others. Scarcity, in terms of 

assistive housing funds, low incomes, and 

insufficient service support programs and 

resources limit PWDs ability to be self-sufficient 

and live independently.

72 National Council on Disability
Chapter 8: Transportation

Transportation Disparities

Accessible transportation is a necessity for many PWD’s to attain employment, education, 

access to the community, and healthcare. Puerto Rico’s transportation system is fraught 

with issues. Recurring natural disasters have severely damaged the infrastructure, and the 

disparity in transportation services for people with disabilities in Puerto Rico is apparent. This 

disparity exists despite DOT’s equal distribution of transportation funds to the states and the 

territories. DOT’s funding formula considers the high poverty rate on the island resulting in 

reduced tax revenue, beleaguered infrastructure with an economy dependent on imports, 

and because of the Jones Act, higher prices. Because of these unique circumstances, the 

transportation funds equally provided to Puerto Rico are not sufficient to provide the most 

basic transportation needs for people with disabilities on the island. NCD recommends 

Congress amend DOT legislative formula for formula grants so that funds are equitably 

distributed. NCD recommends Congress amend Department of Transportation’s 

legislative formula to allot for an exemption to the cost sharing requirement if a state 

or territory can prove they are fiscally incapable of fulfilling the cost share requirement.

Therefore, a state or territory already in financial distress is not penalized and precluded 

from gaining access to federal funds solely because of its economic status.

NCD recommends that the Puerto Rico Commonwealth prioritize and strategize 

efforts to match all federal matching funds when fiscally possible so that all federal 

funds are utilized to improve transportation on the island for PWDs. NCD recommends 

that Puerto Rico create a unified systemic integration and capacity building among the 

transportation providers to PWDs on the island and the territories to improve access 

and coverage for PWDs.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 73
Transportation in Puerto Rico, the 

United States, and the U.S. Territories

Accessible transportation options in Puerto Rico 

are extremely limited and leave many PWDs 

limited options to engage in their community. 

The American with Disabilities Act (ADA) of 

1990 includes the right to accessible and equal 

access to transportation. It requires public transit 

entities to provide complementary paratransit 

along with its bus or rail fixed route service.261

Few transportation options exist when no 

public transportation is 

available, such as in rural 

areas. Many PWDs in 

Puerto Rico simply never 

leave home.

The U.S. Department of Transportation (DOT) 

administers formula-based programs and grants 

available to the states and territories. The Federal 

Transit Administration (FTA) is the agency that 

has oversight and enforcement capabilities to 

ensure that transportation is provided to PWDs 

in public transportation systems. Federal benefits 

and support include transportation formula 

grants for the transportation of disadvantaged 

populations such as PWDs and seniors with 

disabilities. They are provided through the states 

to organizations who provide transportation 

services to PWDs. Organizations providing these 

services face constraints as a result of growing 

need and the limited, often strained, budgets. 

This is the case in the states and U.S. territories. 

While there are services available, the demand 

exceeds the capacity to serve all those that need 

transportation.262

Puerto Rico Department of Transportation 

and Public Works (DTOP) created the Puerto 

Rico Integrated Transportation Authority in 2014 

(ATI for its abbreviation in Spanish), to manage 

and integrate the different transit modes on the 

Island.”263 Currently it serves the metropolitan 

area of San Juan’s heavy rail and bus service 

with 102 buses with an average of 11 years 

of service and 54 vehicles with an average 

5 years in service. Along with the Metropolitan 

Bus Authority (AMA), the Urban Train (TU), TU 

Connectors and Maritime Transport (ATM), the 

collective transportation concentration of these 

services is available in eight municipalities of the 

metropolitan urban area 

of San Juan (Bayamon, 

Carolina, Cataño, 

Guaynabo, Loíza, San 

Juan, Trujillo Alto, and 

Toa Baja) and the two smaller islands of Vieques 

and Culebra. AMA manages the fixed route bus 

system with 17 routes and with a fleet of 108 

buses. Puerto Rico’s paratransit system, “Llame 

y Viaje” (Call and Travel—public service) and 

“Transcita” (Private Service) are available for 

PWDs. However, most of these services are only 

available during the week.

Not unlike the rural areas in the states, 

accessible public transportation is extremely 

limited outside of the metropolitan area. 

Unfortunately, the fiscal restraints experienced 

by most municipalities on the island restrict its 

ability to provide desperately needed accessible 

transportation. Currently, municipalities who 

are not part of the Metropolitan area, must 

develop their own transportation options and 

request funding from Puerto Rico Highways and 

Transportation Authority (PRHTA) to establish 

their own paratransit system. Transportation 

agencies have tried to unify the public 

transportation options, yet there is great variation 

Many PWDs in Puerto Rico simply 

never leave home

74 National Council on Disability
in available services. Municipalities were already 

strained fiscally before the wave of natural 

disasters over the last several years. As of 

April 2021, Puerto Rico was still waiting on the 

disbursement of disaster relief funds to assist in 

recovery efforts including transportation. Most 

of the municipalities have limited transportation 

alternatives. If accessible transportation is 

provided, it usually is only provided for medical 

appointments.

The fiscal crisis, outbound migration, and the 

severity of natural disasters has reduced ridership 

and investment in public transportation. This has 

resulted in increased automobile dependency and 

vehicular traffic in the Metropolitan areas.264

AMA has been cited for infringements 

numerous times by the Protection and Advocacy 

System regarding bus driver attitudes, buses not 

stopping for passengers, non-working ramps 

or seat belts for wheelchairs, lack of space 

for boarding, and accessibility of sidewalks. 

Training has been conducted to assist bus drivers 

to develop an understanding of the law and 

sensitivity in providing the appropriate service to 

passengers with a disability. All buses are ADA 

Compliant and must comply with Buy America. 

An agency representative stated that AMA buses 

are mainly diesel-dependent buses and break 

down frequently. They also mentioned that FTA 

requires that buses operate for 14 years before 

they can be replaced. As a result, the transit 

agency must invest in costly and recurrent repairs 

fixing deteriorated buses. FTA considers Puerto 

Rico’s terrain and geography, the salty air, and the 

density of the Sahara dust that reaches shores, 

which all cause additional wear and tear and 

impact the durability and lifespan of the buses. 

A 10-year life span for buses is most appropriate 

and for paratransit five years is ideal. This same 

stakeholder asserted that it is a critical factor that 

influences having an adequate supply of buses 

for the demand of services.

NCD recommends that DOT reduce the life 

span for buses to 10 years and for paratransit 

vehicles to five years.

The TU is a limited route train in the 

metropolitan area with 16 stops and provides 

transportation to only three municipalities, 

Bayamon, Guaynabo, and San Juan. It is 

accessible for PWD by escalators, elevators, 

and visual and auditory messaging and meets 

the minimum ADA requirements. Most of the 

difficulties in accessibility occur when elevators 

and escalators break down, and there is a delay 

in repairs due to fiscal constraints brought upon 

by the island’s fiscal crisis.

Maritime Transport uses a ferry system to 

provide transportation to and from the islands of 

Vieques and Culebra. This system does not meet 

the transportation needs of PWDs who travel to 

and from the Islands of Vieques and Culebra for 

health and other specialized services. Complaints 

of erratic schedules, faulty machinery, and 

inconsistent availability are consistent. This limits 

PWD mobility because the only other options 

(small commuter planes) are costly and do not 

work for all PWD’s mobility needs. Accessible 

transportation on the smaller islands and to and 

from other islands is extremely limited and for 

many unattainable.

The Puerto Rico Highway and Transportation 

Authority (PRHTA) is the entity responsible for 

receiving and administering FTA funds to the 

Island of Urbanized and non-urbanized areas. 

Within this agency, the Federal Coordination 

Office (FCO) administers the funds and 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 75
collaborates with FTA, the Metropolitan Planning 

Organization, local governments, and transit 

providers to develop and maintain a network 

of transportation services available to the 

public on the island. DTOP the policy making 

umbrella agency for transportation on the island 

serves as the operative arm for the Puerto 

Rico Metropolitan Planning Organization for all 

urbanized areas and has created policy/board 

committees to assure cooperative decision 

making.

The Puerto Rico Strategic Transportation 

Improvement Plan (STIP)265 reflects the 

different regions of the island and their 

categories for program benefits and funding 

from FTA and managed by FCO. Funds 

apportioned to Puerto 

Rico are calculated 

based on legislative 

formulas factoring 

population and 

population density 

statistics. It is noted 

that while transportation 

programs in Puerto 

Rico are funded utilizing 

the same formula for 

the states and other territories, the depth 

of the need, socioeconomic conditions, and 

natural disasters are far more dire and have 

increased the financial needs for Puerto Rico 

to provide the unmet benefits and services to 

PWDs. NCD recommends Congress amend 

DOT legislative formulas so that funds are 

equitably distributed. Equitable distribution 

as opposed to equal distribution will lessen the 

disparity of access to services and programs 

caused by the high levels of poverty and 

economic distress experienced by PWDs in 

Puerto Rico and other territories.

Section 5307 - 

Urbanized Area 

Formula Grants

2020

Apportionment:266

Provides grants 

to support public 

transportation in 

urbanized areas through 

transit capital and 

operating assistance

SJUA: 

$26,901,585

AUA: $2,641,752

UZA: $17,033,736

In the STIP, examples of Section 5307 

Urbanized Area Formula Grant projects awarded 

to the SJUA include:

■ Operation and administrative equipment 

office of the paratransit / territorial planning 

programs in the 

municipality (Bayamon, 

Vega Alta, Vega Baja);

■ Replacement of 

paratransit vehicles 

(4-Bayamon, 

3-Guaynabo 4-Toa 

Baja);

■ Contracting on 

the non-fixed ADA 

paratransit services 

(Carolina);

■ Construction or rehabilitation of sidewalks 

and access around the bus shelter (Carolina, 

Toa Baja);

■ Design and construction of sidewalks along 

shelters and stops, Elderly Center, City Hall, 

and Dos Bocas (Corozal);

■ Operational assistance for ADA paratransit 

(Corozal, Guaynabo, Gurabo);

Equitable distribution as opposed 

to equal distribution will lessen the 

disparity of access to services and 

programs caused by the high levels 

of poverty and economic distress 

experienced by PWDs in Puerto Rico 

and other territories

76 National Council on Disability
■ Provision for paratransit services (Gurabo, 

Humacao, Juncos, Manati, San Lorenzo, Toa 

Baja); and

■ Preventive maintenance for paratransit 

activities (Vega Alta).

Section 5310 - 

Enhanced Mobility 

for Seniors and PWD

Apportionment 

2020267

Provides formula funding 

to increase seniors and 

PWD’s mobility “when 

public transportation is 

insufficient, inappropriate, 

or unavailable” and 

projects that improve 

access to fixed-route 

service and decrease 

reliance by PWDs on 

paratransit, or alternative 

to public transportation.

SJUA: 

$2,558,984

AJUA: $396,353

UZA: $2,021,589

NUA: $233,391

For PWDs, Section 5310 is critical and may 

be used to purchase vehicles, support existing 

services, increase service hours, expand options, 

spread awareness about eligibility, and/or how 

to access transportation services, and create 

mobility management or travel training, among 

other uses.268

A stakeholder interviewed mentioned that 

transportation services are indispensable for 

PWDs. However, in their health insurance 

policy, where transportation is included, major 

restrictions apply. If provided, transportation 

is limited to 13 round trips per year, which are 

usually used for medical appointments. For 

other trips, to the supermarket for example, 

the caregiver or trip companion is required to 

pay a $20 fee per trip. A $20 fee for someone 

who receives AABD benefits and receives 

only $75 a month is an exorbitant expense. 

When consulting with health plan providers, 

they confirmed that the main requirement to 

receive the transportation service is being 

a beneficiary of Medicare and Vital. Even 

then, transportation is mostly provided only 

for medical appointments and depends on 

insurance coverage.

A confidential interview with a family 

member of a person with a disability compared 

experiences in the states versus the island and 

noted that in the United States:

Residents of assisted living programs are 

picked up by city transit vehicles to take 

them to their jobs and returned to their 

home in the afternoon. In other words, 

there is an organized system, where 

adequate transportation needs for PWDs 

are prioritized. We have not reached that 

point in Puerto Rico. We are very far from 

creating awareness about the fact that 

people, even with intellectual disabilities, 

cannot drive a vehicle, but could perhaps 

have a job and a better quality of life, if they 

had adequate transit programs in all the 

towns.269

Several transportation grants require 

Puerto Rico to match funds for eligibility. For 

instance, match requirements for Section 5310 

vary by project. For Capital projects (funds 

to purchase vehicles) a 20 percent match is 

required. Projects to fund program operations 

must provide a 50 percent match. The match 

may be derived from other federal funds.270

Funding apportioned to states is allocated 

by population. The formula is 60 percent for 

urbanized populations with over 200,000, 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 77
20 percent for population over 50,000 but 

less than 200,000, and 20 percent in rural 

areas with a population under 50,000.271 NCD 

recommends Congress amend Department 

of Transportation’s legislative formulas to 

allot for an exemption to the cost sharing 

requirement if a state or territory can prove 

they are fiscally incapable of fulfilling the 

cost share requirement.

Funding reduction observed in Fiscal Year 21 

and Fiscal Year 22 are due to decreases in usage 

during the pandemic. Additional funding from 

CARES Act and CRRSA are now available to offset 

the difference. Examples of projects being funded 

in Puerto Rico under Section 5310 include:

■ Municipality of Barranquitas acquired one 

paratransit van, 10 passenger vans, one 

minibus, and 16 passenger vehicles;

■ Municipality of Cayey acquired three 

paratransit vehicles with a 10-passenger 

capacity;

■ Altergarten I, Las Teresas, Combined Building 

& Housing Consultants, Inc. (San Juan), 

acquired one minibus for 16 passengers with 

a handicap access (lift);

■ Hogar Juan Ruiz Velez, Asc. Jubilados de la 

AEE, Inc., Combined Building and Housing 

Consultant, acquired a passenger bus with 

handicap access (lift);

■ Corporación Servicios de Salud Primaria y 

Desarrollo Socioeconómico El Otoao-Cossao 

(Utuado) acquired one paratransit with a 

10-passenger capacity and two vans; and

■ Municipality of Ponce acquired six buses 

(four paratransit vans and two minibuses) 

and constructed or rehabilitated 20 

sidewalks and/or ramps, all ADA compliant.

Section 5311 - 

Non-Urbanized Area 

Formula Grants and 

Rural Transportation 

Assistance Programs

2020

Apportionment

These grants provide 

operating assistance and 

preventive maintenance 

for transportation in the 

selected municipalities

NUA: $2,265,122

Subrecipients receiving FTA 5311 funds and 

operating a fixed route service are required to 

provide separate ADA Complementary Paratransit 

service for PWDs unable to use the fixed 

route system. Prior to the start of a fixed route 

service, subrecipients submit to PRHTA their 

complementary paratransit plan with compliance 

written documentation.

The public transportation system or 

PUBLICOS throughout the island is privately 

owned and operated and is regulated by the 

Public Safety Commission. Fares are regulated 

by route and special insurance requirements 

are imposed. This mode of transport has 

had a significant decrease in demand and 

ridership from 2010–2016272 with an over 50 

percent drop in trips as measured by the 

National Transportation Database.273 From 

Fiscal Year 2012 through Fiscal Year 2016 the 

PUBLICO system has lost 23 percent of its 

routes and 31 percent of its available vehicles. 

Unfortunately, most have disappeared, and the 

majority are not accessible.

When looking at transportation options in 

the states and specifically those states with the 

highest Puerto Rican population, we found a 

variety of options exist for mobility and transport 

(including trains, buses, paratransit, rural, and 

maritime transportation) options. Interestingly, 

78 National Council on Disability
the same issues persist and require attention: 

inadequate enforcement of ADA laws, physical 

obstacles to all forms of public transit, and lack 

of transportation options in rural areas across the 

island (although these are currently expanding).274

All of these federal benefit programs identified 

are available in the states under the Department 

of Transportation (DOT) who provides formula 

grant funding to each state and additional 

recipient and subrecipients that can include 

non-profit organizations designed to facilitate 

transportation options for PWD. Fiscal Year 2020 

funding for U.S. urbanized areas with a population 

over 200,000 is $172,893,544, urbanized areas 

with a population between 50,000 and 199,000 

and non-urbanized areas total $57,631,182 each.

The Moving America Plan-21 (MAP-21) of 2012 

created a streamlined and performance based 

surface transportation program that imposed 

requirements to FTA funded human services 

programs that support transportation services 

for PWDs, older adults and persons with low 

incomes.275 When looking at transportation 

options in the territories, each is eligible for 

formula based grants and funding options that 

include the Territorial Highway Program, which 

was created for constructing and improving the 

highways and inter-island connectors (including 

ferry boats, terminal facilities and approaches) 

in the USVI, Guam, American Samoa, and 

the Commonwealth of the Northern Mariana 

Islands.276 In 2014, under MAP-21277 funding for 

Territorial Highway Programs was $40 million 

and was allocated to the four territories by an 

administrative formula set at 40 percent each for 

Guam and the USVI and 10 percent for American 

Samoa and the Northern Marina Islands. In terms 

of public transportation under MAP-21, there are 

four formula grants including, as in Puerto Rico, 

the urbanized area formula program of which the 

USVI was apportioned $183,266 for the Transit for 

Elderly and Disabled Individuals Program, the Bus 

and Bus Facilities Program, and the Non-Urbanized 

Area Formula Grant. Non-urbanized area grants 

for populations under 50,000 in 2020 included 

$9,552 for the Northern Marina Islands, $45,768 

for Guam, and $12,089 for American Samoa.

The Cornell University 2018 Disability Report 

for Puerto Rico reflects that 17.3 percent of the 

population with disabilities indicated that they 

had a disability that made it difficult for them 

to move, walk, or climb stairs.278 As we enter 

2021, the transportation needs for the disability 

community continue to be acute. The lag in 

supply versus demand is so great that current 

funding streams, albeit equally distributed, still 

do not meet the needs and demand for services 

for PWDs in Puerto Rico, which is compounded 

by the significant poverty, delays in funding 

accessibility, and the island’s fiscal crisis.

NCD recommends that the Puerto Rico 

Commonwealth prioritize and strategize 

efforts to match all federal matching funds 

when fiscally possible so that all federal funds 

are utilized to improve transportation on 

the island for PWDs. NCD recommends that 

Puerto Rico create a unified system and build 

capacity among the transportation providers 

to PWDs on the island and the territories to 

improve access and coverage for PWDs.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 79
80 National Council on Disability
Chapter 9: Emergency Preparedness

Impact of Natural Disasters

Natural disasters and emergencies occur across the globe, and the impact is felt by all. 

However, PWDs have an increased risk to extreme weather events and coastal flooding. 

PWDs face multiple obstacles with messaging and sheltering during natural disasters such 

as: ineffective notification and lack of communication services for the deaf, hard of hearing, 

and the blind; poor or nonexistent transportation for evacuations; and/or inaccessible 

shelters. Expedient access to federal funds to mitigate the impact of natural disasters as a 

community is imperative immediately following a disaster. The rebuild should ensure that 

communities are rebuilt to be inclusive and accessible to all.

The World Health Organization (WHO) 

reported that “globally, the number of 

weather-related natural disasters has 

more than tripled since the 1960s.”279 In 2017, 

the United States had a devastating hurricane 

season, making it one of the costliest in our 

history with simultaneous wildfires in the 

west burning thousands of acres, followed by 

mudslides in Southern California.

PWDs are especially affected as a 

consequence of these natural disasters resulting 

in higher rates of injury and even death. 

PWDs face multiple barriers during natural 

disasters such as: ineffective notification and 

communication alternatives for the deaf, the hard 

of hearing, and the blind, poor transportation 

alternatives for the evacuation of PWDs with 

physical limitations; inaccessible shelters; 

inadequate food alternatives; loss of support 

networks; lack of preparedness skills; and 

nonexistent inclusive emergency plans to ensure 

accommodations are met.

PWDs are identified as an increased risk to 

extreme weather events and coastal flooding 

because of their “specific access and functional 

needs.”280 Reasons for the vulnerability are 

dependence on caregivers and others for 

assistance, potential reliance on medical 

equipment that could be damaged or inoperable 

during power outages, difficulty following or 

accessing evacuation orders, or inability to 

understand warnings or communicate needs.

In NCD’s 2019 report, Preserving our Freedom: 

Preventing Institutionalization of People with 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 81
Disabilities Before, During, and After Disasters,281

NCD found multiple instances in which PWDs 

became institutionalized due to lack of planning 

by state and local tribes and territories (SLTT’s). 

Systemic deficiencies in inclusive emergency 

planning cause PWDs to be institutionalized 

due to lack of power, lack of durable medical 

equipment, lack of medications, and oxygen.282

On September 20, 

2017, thousands of 

PWDs in Puerto Rico 

endured Hurricane Maria, 

a Category 4 hurricane 

with sustained winds of 

up to 155 miles per hour. 

Maria wiped out Puerto 

Rico’s infrastructure: 

there was no electricity, water, telephones, or 

communication systems. A traumatic experience 

for all Puerto Ricans on the island, but especially 

traumatic to PWDs. Motivated by their desire 

to move into action and assist PWDs, a work 

group comprised of six public and private 

disability service organizations united to provide 

response efforts and 

called themselves the 

Puerto Rico Disability 

Community Relief 

Network (PRDCRN). This 

work group was made up 

of the independent living center; the Movement 

for Achieving Independent Living (MAVI for its 

Spanish acronym); the University of Puerto Rico 

Center for Educational Excellence (PR UCEDD); 

the Puerto Rico Protection and Advocacy Service, 

Ombudsman for PWD (DPI for its Spanish 

acronym); the State Council on Developmental 

Disabilities (CEDD for its Spanish acronym); the 

Puerto Rico Assistive Technology Program (PRATP 

for its Spanish acronym); and B/Adaptable. In the 

months following Hurricane María, the PRDCRN 

provided many testimonials on federal, state, 

and international forums describing the negative 

impacts sustained by the disability community in 

Puerto Rico in the aftermath of the hurricane.

If Puerto Ricans had been adequately shielded 

against the social and environmental risks of 

the impact, lives could 

have been saved.283 It 

took Puerto Rico six 

months after Maria’s 

landfall to enter into its 

recovery phase. The 

Puerto Rican government 

failed to take the lead 

in restoring power and 

telecommunication systems to the island. The 

magnitude of the hurricane and Puerto Rico’s 

financial crisis, plus a decimated infrastructure, 

severely diminished Puerto Rico’s response 

capacity, and the slow federal response and 

assistance that did arrive was not adequate 

to address the issues. Former FEMA officials 

and disaster response 

experts have affirmed 

that the slow response 

is evidence that FEMA 

underestimated the force 

of the hurricane and did 

not assertively position their assets in preparation 

of the storm.

Table 9.1 summarizes the disparities in aid 

received by Puerto Rico when compared to 

Hurricane Harvey that struck Texas in 2017.

Stakeholders interviewed stated that FEMA 

assistance to the island was delayed and that 

accessing FEMA relief funds was more difficult 

in Puerto Rico than in the states. Years after the 

Systemic deficiencies in inclusive 

emergency planning cause PWDs 

to be institutionalized due to lack 

of power, lack of durable medical 

equipment, lack of medications, 

and oxygen

It took Puerto Rico six months after 

Maria’s landfall to enter into its 

recovery phase

82 National Council on Disability
Table 9.1: Comparative Data on Disaster Response for Hurricane Harvey and 

Hurricane Maria284

Comparison Item Harvey Maria

Official in charge Specialist in disaster 

response, stayed in Houston 

after it was stabilized

Local Director, Executive Office 

& Senior Policy Advisor, no 

disaster response experience

Specialist in disaster response 

deployed to Puerto Rico 3 weeks 

after hurricane

U.S. Army and Marine Corps Deployed immediately Not us

U.S. Northern Command Deployed 73 helicopters wit

aid six days after disaster

Deployed 70 helicopters with aid 

3 weeks after disaster

FEMA Individual Assistance Approved $141.8 million Approved $6.2 milli

FEMA provisions supplies 

during the first nine days

Provided 5.1 million meals,

4.5 million liters of water, and

over 20,000 tarps

Provided 1.6 million meals,

2.8 million liters of water and

roughly 5,000 tarps

Federal Government 

Personnel

30,000 personnel 10,000 personnel

Permanent Disaster Work 

approval

10 days 43 days

Federal applications 

approved 78 days after 

hurricanes

39% of applications 28% of applications

Permanent repair project 

funding

In process with established 

funding source

Experimental funding

Funding was contingent on an 

experimental funding formula in 

which Puerto Rico is responsible 

for overrun cost

USS Abraham Lincoln Positioned itself in FL two 

days prior to Hurricane Irma

Was never requested

USNS Comfort, a hospital 

ship

Did not embark until two weeks 

after the hurricane

First responders assigned FEMA had filled only 1,258 of 

2,250 beds allotted for its first 

responders at the convention 

center and aboard two training 

vessels from the U.S. Maritim

Service

Blue roof tarps Blue roofs were not requested 

in TX but given temporary 

housing relief

In FL, 25 days after Irma 1,600 

blue roofs installed out of 

15,000 or 10.7

25 days after the storm; only 260 

of 60,000 requested had been 

installed or 0.4

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 83
disaster people with disabilities are still living 

with blue tarps and leaks in their homes.

FEMA provided considerably less aid to Puerto 

Rico than to other states affected by hurricanes. 

FEMA rejected over half of FEMA applications for 

assistance made by Puerto Ricans.285 Thousands 

of Puerto Ricans were forced to leave the island 

and moved to the southeastern United States 

in search of better living conditions. However, 

Puerto Ricans with disabilities on Medicaid were 

confronted with no insurance coverage when 

they relocated to the states. Medicaid is a staterun insurance program and is not portable. The 

lack of insurance placed PWDs at a high risk of 

worsening health conditions, with the greater 

risk of institutionalization.286 NCD recommends 

that Congress require CMS to establish a 

process for Medicaid 

portability among 

states and territories 

during disasters to 

ensure uninterrupted 

health maintenance 

and medical care in the least restrictive 

environment for Medicaid recipients.

Programs and policies were created to assist 

families who wished to emigrate to the states. 

The programs and policies were flawed, which 

resulted in warnings that temporary housing 

would be terminated for those who relocated.287

For the almost 160,000 Puerto Ricans that moved 

to the states since Maria, these situations have 

demonstrated there are limits to citizenship for 

people from underserved populations in the 

wake of disaster. “Citizenship on paper does 

not automatically confer rights nor a sense of 

belonging.”288

Congress approved funding for Puerto Rico’s 

recovery through CDBG-DR programs and 

CDBG-MIT programs. There were four block 

grants approved: two for unmet needs in disaster 

recovery (one for $1.5 billion and the other for 

$8.2 billion); one for mitigation programs (CDBGMIT- $8.3 billion); and one for the improvement of 

Puerto Rico’s electrical grid ($1.9 billion).289 HUD’s 

OIG office concluded that Puerto Rico signed 

it’s grant agreement with HUD for the second 

block of funds for unmet needs on February 21, 

2020: 178 days after Texas signed, 150 days after 

Florida signed, and even several days after the 

USVI signed for their funding.290 The third block 

of funds, the $8.3 billion destined for mitigation 

work, was published by HUD in the Federal 

Register Notice 145 days past the established 

statutory deadline (two years after appropriation), 

when other notices for other grantees (including 

the USVI) were published 

approximately 139 days 

earlier. The report 

cites many reasons 

by HUD and OMB for 

the delayed release 

of funds, including additional requirements 

imposed exclusively to Puerto Rico due to 

concerns regarding alleged corruption and fiscal 

mismanagement that led to the imposition 

of a Federal Fiscal Monitor, an extra layer of 

disbursement verification by the PROMESA 

Board, as well as obligating Puerto Rico to 

fix its property tax system in order to receive 

mitigation funds.

The estimated aid needed for Puerto Rico 

after the 2017 hurricanes was $91 billion.291 As 

of May 2021, The Housing Department, the 

Federal Emergency Management Agency, and 

other agencies have only released a fraction of 

these funds leaving the island’s infrastructure 

and homes unstable.

292 Puerto Rico established 

FEMA rejected over half of FEMA 

applications for assistance made 

by Puerto Ricans

84 National Council on Disability
an oversight office to review federal recovery 

funds and ensure better management and 

accountability of the funds. In the interim, FEMA 

instituted a process, where they would review 

each reimbursement request before providing 

public assistance funds, in an effort to ensure 

accountability and decrease risk.293

Recently, the Biden administration announced 

the lifting of these excessive restrictions,294 but 

the fact is that millions of American citizens 

residing on the island, in addition to suffering the 

onslaught of the worst disaster in their history, 

have gone without the lifesaving funds needed 

to hasten recovery for over three years. The 

funding delay was also felt by survivors in the 

form of national flood insurance payouts and SBA 

loans. Nine days after the hurricane, only $6.2 

million had been approved by FEMA for hurricane 

victims and permanent disaster work.

FEMA’s Public Assistance Program provides 

response and recovery funding to SLTTs to assist 

during disasters or emergencies.295 Puerto Rico’s 

Department of Housing, the Puerto Rico Electric 

Power Authority, the Puerto Rico Aqueduct and 

Sewer Authority, and its 78 municipalities are 

eligible to apply for public assistance. President 

Trump’s Disaster Declaration was amended to 

require additional conditions that required Puerto 

Rico to establish a third-party approved oversight 

authority.296 This oversight authority will receive all 

Public Assistance and Hazard Mitigation Funding 

and guarantee adequate project management 

and a centralized oversight over FEMA funds. 

In October 2017, a Puerto Rico government 

office, COR3 was established to guide and 

oversee recovery efforts, including FEMA Public 

Assistance Program funds.297

Damage to the island by the January 2020 

earthquakes required additional emergency aid 

to facilitate the region’s recovery. Therefore, 

both the federal and state government had the 

immense challenge of having to oversee and 

administer two disaster recovery programs 

simultaneously.298

After the earthquake, HUD announced the 

approval of a disaster package, but it also issued 

additional guidelines and restrictions in the use 

of these funds because of their concern over 

the mismanagement of funds by the Puerto 

Rican government. One restriction was the 

appointment of a federal monitor for the CDBG 

DR funds received on the island. In addition, the 

approved funded projects had to be approved 

by the Federal Oversight and Management 

Board (FOMB-PROMESA). Governor Vázquez 

issued an Executive Order on February 3, 2020, 

creating an advisory council for the oversight 

of CDBG disaster recovery funds authorized 

for Puerto Rico. The council’s task is to work 

with the Puerto Rico Housing Department to 

create an integrated work plan for the efficient, 

transparent, and correct use of these funds. 

The council is an important step in Puerto 

Rico’s ongoing efforts to combat corruption 

in government contracting and to restore the 

Government of Puerto Rico’s credibility with the 

Federal Government.299

Disaster scholars affirm that disasters do not 

create the inequities but reaffirm and deepen 

structural problems that already exist.300 Since 

September 2017, “Puerto Rico has experienced 

a perfect storm caused by the natural disaster 

of Hurricane María and a human made financial 

crisis.”301

Puerto Rican diaspora was a vital and 

appropriate response to the hurricane. There are 

many more Puerto Ricans living in the states 

than on the island. Thanks to their efforts, the 

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 85
humanitarian crisis experienced in Puerto Rico 

was visible and public and promoted a sustained 

public discussion. This same diaspora continues 

to be a watchdog and an advocate for Puerto 

Rico’s recovery.

Emergency Response for Hurricanes 

Harvey and Irma

Response Efforts Hurricane Harvey, 

Houston, TX, August 2017

In contrast to the Puerto Rican relief efforts 

discussed above, within six days of Hurricane 

Harvey, U.S. Northern Command had deployed 

73 helicopters over 

Houston, critical for 

saving victims and 

delivering emergency 

supplies. FEMA had 

approved $141.8 million 

in individual assistance to 

Harvey victims just nine 

days after the hurricane. 

FEMA provided 5.1 

million meals, 4.5 million 

liters of water, and over 

20,000 tarps to Houston 

during the first nine 

days after Hurricane Harvey. Nine days after the 

hurricane, the Federal Government deployed 

30,000 personnel in the Houston region. 

Permanent disaster work for Texas was approved 

after just 10 days. Within 78 days after Hurricane 

Harvey, 39 percent of federal applications for 

relief were approved. A $15.25 billion disaster 

relief package was approved resulting in $7.4 

billion for FEMA; an additional $450 million was 

approved for the Small Business Administration 

(SBA) disaster loan program; and an additional 

$7.4 billion was allocated to HUD for housing 

assistance. Texans also had access to $5.5 billion 

in tax relief to alleviate the impact created by 

Hurricane Harvey. President Trump also signed 

a bill authorizing a tax deduction for property 

damage costs and allowed penalty-free access 

to retirement savings. A second disaster aid 

package ($36.5 billion) was approved for relief 

for Texans and those impacted by wildfires in 

the western United States. The third disaster aid 

package of $89.3 billion was allocated for areas 

hit by natural disasters, including Harvey; and the 

U.S. Army Corps of Engineers provided close to 

$5 billion for disaster recovery projects in Texas 

and $16 million for Texans 

on projects that would 

protect against future 

natural disasters.

Florida Recovery 

from Hurricane Irma; 

September 2017

Hurricane Irma hit 

Southern Florida as a 

category three hurricane 

in September 2017. 

Immediately, Florida 

communities began 

rebuilding with $5.8 billion in federal grants, 

loans, and flood insurance payments.302 The 

response received included:

$1.02 billion in grants from FEMA for 

individuals and households; $1.4 billion in 

low-interest loans from SBA; $979 million in 

payments to policyholders by the National Flood 

Insurance Program; $20 million for Palm Beach 

County to combat erosion and help restore Juno 

Beach restoration; $17.5 million to restoration of 

the City of Miami’s Dinner Key Marina; a grant 

of $25 million to replace the seawalls of City of 

Post disaster recovery and 

mitigation funds for Puerto Rico 

were delayed when compared 

to those same funds in response 

to Hurricane Harvey in Texas 

and Hurricane Irma in Florida

This delay resulted in unhealthy 

living conditions for people with 

disabilities and all Puerto Rican 

residents

86 National Council on Disability
Punta Gorda; $208 million awarded by FEMA’s 

Hazard Mitigation Grant Program to reduce 

damage from future storms; $10.3 million for 

Disaster Unemployment Assistance; $21.7 

million for Disaster Case Management; $421,569 

for the Crisis Counseling Immediate Services 

Program, $1 million for the Crisis; FEMAs Public 

Assistance Program was awarded $2.06 billion in 

grants to the State of Florida to reimburse local 

governments and eligible nonprofit organizations.

Post disaster recovery and mitigation funds 

for Puerto Rico were delayed when compared to 

those same funds in response to Hurricane Harvey 

in Texas and Hurricane Irma in Florida. This delay 

resulted in unhealthy living conditions for people 

with disabilities and all Puerto Rican residents.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 87
88 National Council on Disability
Chapter 10: Conclusion and Recommendations

Conclusion

Puerto Rican residents and residents of U.S. 

territories who have disabilities experience 

disparate treatment in federal programs. 

Coverage and funding disparities in Medicare, 

Medicaid, SSI, and SNAP/NAP exist, and 

significant disparities were also found in the 

price of specialized DME. NCD also found a 

lack of meaningful systemic data on PWDs in 

Puerto Rico and the territories and untoward 

consequences because of the delay in 

distribution of funds because of the additional 

stipulations placed on Puerto Rico to access 

much-needed emergency relief funds.

Puerto Rico’s poverty rate is twice that of 

the highest state’s poverty rate in the United 

States. Even though Puerto Rican residents are 

U.S. citizens, they are not afforded the same 

access to benefits and services of the citizens 

residing in the United States. Thirty-six percent of 

U.S. residents who are very poor have escaped 

poverty as a result of safety nets.303 This statistic 

alone demonstrates the critical and meaningful 

impact it has on improving living standards. The 

safety net programs discussed in this report are 

SSI, Medicaid, and SNAP. A safety net is not only 

a monetary benefit, though financial resources 

are at the core. A safety net is an interconnected 

web of services and benefits that together lift 

those living in poverty to a better quality of 

life. The U.S. social safety net is composed of 

a number of different programs that provide 

various kinds of help designed to protect those 

with low socioeconomic status from poverty 

and hardship. When at high levels of poverty, 

the goal becomes ensuring a minimum standard 

of living.304 In Puerto Rico, with its high level 

of poverty and percentage of residents with 

disabilities, even a minimum standard of living 

seems elusive. “Nowhere is the need greater 

than in Puerto Rico, which unlike other parts of 

the country, entered the pandemic following well 

over a decade of virtually uninterrupted economic 

decline coupled with devastating natural 

disasters.”305 NCD recommends the availability 

of these key safety net programs described 

within this report be made available to 

citizens of Puerto Rico and U.S. territories. The 

integration should occur simultaneously with 

each other so that vulnerable populations do 

not fall through the gaps.

This report found funding for federal programs 

and services such as housing, employment, 

education, and transportation were allocated 

equally among states and U.S. territories. It also 

found, equal distribution of funding did not equate 

to equitable access to programs and services for 

residents of Puerto Rico with disabilities.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 89
The recommendations below strive to provide 

the appropriate remedies that will afford U.S. 

citizens with disabilities living in U.S. territories 

the same federal programs and benefits as their 

U.S. counterparts and remove the disparate 

treatment of federal programs simply based on a 

PWDs zip code.

Recommendations by Chapter

Chapter 2: Jones Act/Inventory Taxes/Other Taxes

1. NCD recommends Congress repeal the provision within the Jones Act that restricts 

coastwise trade on U.S. flagged vessels, for durable medical equipment covered under 

Medicare Part B (such as manual wheelchairs, power wheelchairs and components and 

replacement parts, scooters and component and replacement parts, patient lift and 

transfer equipment, patient ventilators, portable oxygen, foam, gel, innerspring and air 

mattresses, continuous positive airway pressure (CPAP) devices, shower and commode 

chairs, and suction pumps).

2. NCD recommends Puerto Rico’s legislative assembly waive the inventory tax for the 

purchase of DME.

Chapter 3: Health: Medicaid and Medicare

3. NCD recommends Congress amend the Social Security Act to replace the Medicaid block 

grant program in Puerto Rico and other U.S. territories with an uncapped federal matching 

system, equivalent to the Medicaid program provided to U.S. residents.

4. NCD recommends Congress amend the Social Security Act to eliminate the late 

penalty enrollment provision placed on Puerto Rican and U.S. territory Medicare 

recipients.

5. In the alternative, NCD recommends Congress pass HR 4666 (2019). Passage of the bill 

would eliminate the enrollment penalty and provide a low-income subsidy program to 

cover partial or total costs for out-of-pocket medications for Puerto Rican and U.S. territory 

Medicare recipients.

6. NCD recommends Congress amend the Social Security Act to allocate Medicare benefits 

for residents of Puerto Rico and other U.S. territories equal to those benefits provided to 

residents living in the United States.

7. NCD recommends Congress amend the Deficit Protection Act of 2005, Public Law 

109-171 (2006) to extend the Money Follows the Person Demonstration Grant Funding to 

Medicaid recipients residing in U.S. territories.

90 National Council on Disability
Chapter 4: Income Assistance Benefits and Programs

Supplemental Security Income | Social Security Disability Insurance | Supplemental 

Nutrition Assistance Program | Nutrition Assistance Program

8. NCD recommends Congress pass HR 537, the Supplemental Security Income Equality 

Act (117th Congress), which would provide SSI benefits to residents of Puerto Rico and 

U.S. territories.

9. Alternatively, NCD recommends Congress amend Title XVI of the Social Security Act to 

extend SSI benefits to residents of Puerto Rico and U.S. territories.

10. NCD recommends Congress amend the Food Stamp Act to include Puerto Rico, the 

Northern Mariana Islands, and American Samoa in the SNAP program, as has been done 

for Guam and the USVI.

11. NCD recommends Congress amend the Food Stamp Act to provide expedited funding 

for food and nutrition benefits before, during, and after natural disasters for residents of 

Puerto Rico and U.S. territories, as is available in the states.

12. NCD recommends all federal and state agencies, as well as public and private 

universities, include data on Puerto Ricans with disabilities living on the island and other 

territories in data collection to improve accountability so as to ensure that appropriate 

resources are provided to ensure equity to programs that allow PWDs the opportunity to 

achieve economic independence (for example, data collection initiatives collected by the 

Census Bureau, National Health Interview Survey, and State of the States).

Chapter 5: Education

13. NCD recommends Congress amend IDEA’s funding formula to mitigate the high incidence 

of poverty and the islands increased cost to provide services to students with disabilities.

14. NCD recommends Department of Education amend 34 CFR 361.60, the cost sharing 

requirement for state vocational rehabilitation services grants, to allot for an exemption 

to the cost sharing requirement if a state or territory can prove they are fiscally incapable 

of providing the cost share portion.

Chapter 6: Employment

15. NCD recommends Department of Education amend 34 CFR 361.60, the cost sharing 

requirement for state vocational rehabilitation services grants, to allot for an exemption 

to the cost sharing requirement if a state or territory can prove they are fiscally incapable 

of providing the cost share portion.

(continued)

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 91
16. NCD recommends the Commonwealth of Puerto Rico implement tax incentives for 

employers who hire persons with significant disabilities, similar to established state 

programs.

Chapter 7: Housing

17. NCD recommends the U.S. Department of Housing and Urban Development (HUD) 

should require that all federally assisted housing units follow universal design principles 

and ensure that accessible housing units reflect the percentage of people with 

disabilities in need of federal housing assistance.

18. NCD recommends PRHD ensures that all construction projects destined for the island 

with CDBG-DR funds comply not only with the minimum design requirements of the 

ADA but also with universal design recommendations to ensure accessibility for PWDs.

Chapter 8: Transportation

19. NCD recommends Congress amend DOT legislative formula for formula grants so that 

funds are equitably distributed.

20. NCD recommends Congress amend Department of Transportation’s legislative formula 

to allot for an exemption to the cost sharing requirement if a state or territory can prove 

they are fiscally incapable of fulfilling the cost share requirement.

21. NCD recommends that the Puerto Rico Commonwealth prioritize and strategize efforts 

to match all federal matching funds, when fiscally possible, so that all federal funds are 

utilized to improve transportation on the island for PWDs.

22. NCD recommends that Puerto Rico create a unified systemic integration and capacity 

building among the transportation providers to PWDs on the island and the territories to 

improve access and coverage for PWDs.

23. NCD recommends that DOT reduces the life span for buses to ten years and for 

paratransit vehicles five years.

Recommendations by Chapter: continued

92 National Council on Disability
Chapter 9: Emergency Preparedness

24. NCD recommends that Congress require CMS to establish a process for Medicaid 

portability among states and territories during disasters to ensure uninterrupted 

health maintenance and medical care in the least restrictive environment for Medicaid 

recipients.

Chapter 10: Conclusion and Recommendations

25. NCD recommends the availability of these key safety net programs described within this 

report be made available to citizens of Puerto Rico and U.S. territories. The integration 

should occur simultaneously with each other so that vulnerable populations do not fall 

through the gaps.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 93
94 National Council on Disability
Appendix A: Town Hall Meeting

National Council on Disabilities

Town Hall Meeting in Puerto Rico

A Town Hall Meeting was held in Puerto Rico on May 23, 2019, to discuss the disparities in treatment, 

funding, and services available for PWD residing on the island in contrast to U.S. counterparts and to 

share information regarding the Achieving a Better Life Experience Act (ABLE) among the participants. 

This meeting was held by the National Council on Disability (NCD) in collaboration with the Puerto Rico 

Disability Community Relief Network, composed by the PR Independent Living Movement Center 

(MAVI), the PR University Center for Excellence in Developmental Disabilities (PR-UCEDD), the PR 

Assistive Technology Program (PRATP), the PR Protection and Advocacy System, and the State Council 

for Developmental Disabilities (CEDD). The following summarizes some of the issues discussed and 

comments received by PWDs during this meeting.

Topics Discussed

Political Status of the Island

Conversations included how the current political status of the island and its impact on PWDs in terms 

of access to federal programs, such as ineligibility for SSI, caps on Medicaid funds, and other federal 

programs and the effects of the Jones Act on the cost of DME for PWDs on the Island when compared 

with the United States. Some of the assertions expressed during the town hall were:

1. The political status on the island as one of the main reasons for disparity in federal funding.

2. Economic challenges and lack of funds for PWDs on the island is of great concern. Census 

data indicates an 81.2 percent unemployment rate for PWDs on the island. According to the 

participants, there is a great disparity in funding received from SSA. Puerto Rico residents are 

excluded from SSI, and a fixed block grant with much lower funds is provided to Puerto Ricans 

under the AABD.

3. The cost for purchasing DME is more expensive on the island due to the state inventory taxes and 

import cost (Jones Act regulations).

4. Lack of personal assistants for PWDs.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 95
Emergency Preparedness for PWD

Questions were raised regarding the accessibility of shelters, the availability of registries to identify 

the location of PWD, the effects of inventory tax laws on emergency preparedness, the coordination 

challenges between federal and Puerto Rican agencies responsible for emergency planning, and the 

implementation of those plans. Some of the concerns presented by the participants were:

1. A concern about the accessibility of the shelters in Puerto Rico, not prepared for PWDs, mobility 

issues or medical needs. People who had life sustaining medical equipment, for example, did not 

have access to connect them in the shelter.

2. Emergency preparedness plans in Puerto Rico are not inclusive.

3. The state inventory tax imposed on the island limits the resources on hand if a drastic change of 

demand comes in effect; a situation that is confronted when a disaster or emergency hits.

4. Ineffective communication of communicating important information during an emergency in 

accessible formats. Often news channels and government communication concerning emergency 

instructions or updates fail to include a sign language interpreter or literature distributed in 

alternate formats. This practice compromises the safety of people who have communication 

barriers.

Compliance of Accessibility Guides in the Americans with Disabilities Act (ADA)

The accessibility standards of facility reconstruction projects that use federal funds on the island were 

discussed (Section 504). The need for accessible public transportation is very limited on the island 

and extremely necessary. In San Juan there are two companies that offer accessible transportation 

services, Llama y Viaje and Transcita. However, these are only available during the week. Most other 

municipalities have fewer alternatives, many only offering transportation for medical appointments. 

There are no transportation alternatives for PWDs to assist in getting to a jobsite, participate in social 

activities or recreational outings. The mass transportation system in Puerto Rico is very limited as well 

and the limited accessible seating is usually occupied by other passengers.

Home Ownership Issues and FEMA Support on the Island

The question asked was whether the challenges in proving title ownership of their homes affected 

the qualification process with FEMA for aid. Comments from participants established that having 

ownership for their homes did not guarantee the funds were going to be approved. One of the 

situations many of the residents of Puerto Rico entailed after Hurricane Maria was the absence of 

official documentation of ownership for their property. People without documentation were not 

eligible to receive individual assistance funds from FEMA. FEMA later approved assistance requests 

with an affidavit, but many were not accepted. To this day thousands of people still have blue tarps in 

their homes.

96 National Council on Disability
This discussion among NCD board members and Puerto Rican citizens highlighted that even 

though Puerto Ricans have American citizenship, they do not have access to equal federal benefits 

compared to residents of the United States. Many funds and programs provided to PWDs in 

the United States are not available in Puerto Rico, resulting in limited services and limitation 

of resources essential for their health and wellbeing. It is important that the voices of PWDs 

be heard and that the disparities be addressed in order to improve their economic status and 

living conditions.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 97
98 National Council on Disability
Appendix B: Comparison of the percentage of adults 

with select types of functional disability between the 

United States’ unincorporated organized territories 

and the states

Note: There seems to be variability in terms of actual percentage, this difference can be attributed to 

many factors. No information could be found about this topic for the Northern Mariana Islands.

Types of disabilities United States Guam Puerto Rico USVI

Mobility: Serious difficulty walking or climbing 

stairs

12.9% 15.9% 21.8% 1

Cognition: Serious difficulty concentrating, 

remembering, or making decisions

11.4% 10.7% 15.4% 

Independent living: Difficulty doing errands 

alone, such as visiting a doctor’s office or 

shopping

7.0% 7.6% 12.8% 

Hearing: Deafness or serious difficulty hearing. 5.6% 6.6% 7.0%

Vision: Blind or serious difficulty seeing, even 

when wearing glasses

4.7% 7.8% 16.6% 

Self-care: Difficulty dressing or bathing. 3.8% 3.5% 7.0%

Source: Centers for Disease Control and Prevention. “Disability And Health Data System (DHDS) | CDC.”

CDC.gov. April 7, 2021. https://www.cdc.gov/ncbddd/disabilityandhealth/dhds/index.html?CDC_AA_refVal.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 99
100 National Council on Disability
Appendix C: Tables of Medicaid

Table A5.1-A.5.6 Tables A.1 through A.6 show comparative data of Medicaid programs available in 

New York, Pennsylvania, New Jersey, Florida, Massachusetts, and Puerto Rico. The table includes 

information regarding eligibility, mandatory, and optional benefits in addition to spending per enrollee 

and federal medical assistance percentage (FMAP). Puerto Rico has the highest income index 

necessary to be eligible for Medicaid when compared to New York, Pennsylvania, New Jersey, Florida, 

and Massachusetts. Puerto Rico only provides 10 of the 17 mandatory benefits and 13 optional 

benefits. Spending per enrollee is lower in Puerto Rico than in any of the compared states, with only 

$2,144 spent per enrollee. The FMAP in Puerto Rico is capped at 50 percent, but has a spending ceiling 

because of the 1108 federal cap. The 1108 cap is determined by the rate of the medical care component 

of the CPI-U.

Table A 3.1: Comparison of Medicaid Eligibility, Benefits, FMAP, and Spending 

per Enrollee

State or Territory: New York (2020)

Eligibility Requirements:

■ Adults in New York with incomes up to 138 percent of the poverty level are eligible for 

Medicaid

■ Pregnant women and children under the age of one are eligible with an income of up to 

218 percent of the poverty level

■ Children from age one to 18 are eligible for Medicaid with a household income up to 149 

percent of poverty, but the state also has separate CHIP coverage available for children with 

household incomes up to 400 percent of the poverty level

Mandatory and Optional Benefits

Mandatory benefits:

■ Hospital services for inpatients and outpatients

■ Health screenings for individuals and children under age 21

■ Nursing facility care and home healthcare

■ Physician checkups and other services including rural health clinic visits

■ Visits to federally qualified health centers

■ Laboratory tests and X-rays

■ Family planning

(continued)

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 101
State or Territory: New York (2020)

■ Nurse midwife care or maternity care and newborn care

■ Visits to pediatric and family nurse practitioners

■ Visits to licensed freestanding birth centers

■ Emergency and non-emergency medical transportation

■ Tobacco cessation programs for pregnant women

Optional benefits:

■ Hospital services for inpatients and for outpatients

■ Health screenings for individuals and children under 21

■ Nursing facility care and home healthcare

■ Physician checkups and other services including rural health clinic visits

■ Visits to federally qualified health centers

■ Laboratory tests and X-rays

■ Family planning

■ Nurse midwife care or other maternity care and newborn care,

■ Visits to pediatric and family nurse practitioners

■ Visits to licensed freestanding birth centers

■ Emergency and non-emergency medical transportation

■ Tobacco cessation programs for pregnant women

Spending per Enrollee and FMAP

■ New York spent $7,806 per enrollee in 2020

■ Because New York is a state, the amount awarded for financing (FMAP) Medicaid in New 

York is determined by the state’s per capita income relative to the nation’s per capita 

income. New York FMAP for 2020 was 50 percen

Sources:

“Medicaid Spending per Enrollee (Full or Partial Benefit).” Kaiser Family Foundation (KFF). January 20, 2021, 

https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=

%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family Foundation (KFF), 

January 20, 2021, https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTime

frame=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“New York and the ACA’s Medicaid expansion,” Health Insurance, January 20, 2021, https://www.healthinsurance

.org/new-york-medicaid/.

“Medicaid spending in New York,” Ballotpedia, January 24, 2021, https://ballotpedia.org/Medicaid_spending_in

_New_York.

102 National Council on Disability
Table A 3.2: Comparison of Medicaid Eligibility, Benefits, FMAP and Spending 

per Enrollee

State or Territory: Pennsylvania (2020)

Eligibility Requirements:

■ All legally present, non-disabled adults under age 65 living in Pennsylvania—parents or 

not—are eligible for Medicaid with household incomes up to 138 percent of the poverty 

level, as long as they meet Medicaid’s immigration requirements

■ Children are eligible for Medicaid or CHIP if their household income doesn’t exceed 

319 percent of poverty level

Mandatory and Optional Benefits

Mandatory benefits:

■ Hospital services for inpatients and outpatients

■ Health screenings for individuals and children under age 21

■ Nursing facility care and home healthcare

■ Physician checkups and other services including health clinic visits

■ Visits to federally qualified health centers

■ Laboratory tests and X-rays

■ Family planning

■ Nurse midwife care or other maternity care and newborn care

■ Visits to pediatric and family nurse practitioners

■ Visits to licensed freestanding birth centers

■ Emergency and non-emergency medical transportation

■ Tobacco cessation programs for pregnant women

Optional benefits:

■ Freestanding ambulatory surgery centers

■ Public and mental health clinics

■ Chiropractic care

■ Dental care

■ Dental surgery

■ Optometrists

■ Podiatrists

■ Dentures

■ Eyeglasses

■ Home medical equipment

■ Prosthetics

■ Adult health screenings

■ Case management

■ Home or community-based long-term care

(continued)

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 103
State or Territory: Pennsylvania (2020)

■ Program of All-Inclusive Care for the Elderly (PACE)

■ Inpatient psychiatric care for individuals under age 21

■ Inpatient care for mental diseases for individuals aged 65 and over

■ Intermediate care for intellectual disabilities

Spending per Enrollee and FMAP Pennsylvania spent $8,780 per enrollee in 2020. Because

Pennsylvania is a state, the amount awarded for financing (FMAP) Medicaid in Pennsylvania 

is determined by the state’s per capita income relative to the nation’s per capita income

Pennsylvania FMAP for 2020 was 52.25 percen

Sources:

“Medicaid Spending per Enrollee (Full or Partial Benefit),” Kaiser Family Foundation, January 20, 2021, https://

www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=%7B%

22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family Foundation, January 

20, 2021, https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTimeframe=1

&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Pennsylvania and the ACA’s Medicaid Expansion,” Health Insurance, January 20, 2021, https://www.healthinsurance

.org/pennsylvania-medicaid/.

“Medicaid spending in Pennsylvania,” Ballotpedia, January 24, 2021, https://ballotpedia.org/Medicaid_spending

_in_Pennsylvania.

Table A.3.3: Comparison of Medicaid Eligibility, Benefits, FMAP and Spending 

per Enrollee

State or Territory: New Jersey (2020)

Eligibility Requirements:

In addition to the aged, blind, and disabled, the following New Jersey residents are eligible for 

Medicaid:

■ Adults with incomes up to 138 percent of the poverty level

■ Children with household incomes up to 350 percent of the poverty level are eligible for 

CHIP in New Jersey

■ Pregnant women with incomes up to 200 percent of the poverty level

Mandatory and Optional Benefits

Mandatory benefits:

■ Hospital services for inpatients and outpatients

■ Health screenings for individuals and children under age 21

■ Nursing facility care and home healthcare

■ Physician checkups and other services including rural health clinic visits

■ Visits to federally qualified health centers

■ Laboratory tests and X-rays

■ Family planning

104 National Council on Disability
State or Territory: New Jersey (2020)

■ Nurse midwife care or other maternity care and newborn care

■ Visits to pediatric and family nurse practitioners

■ Visits to licensed freestanding birth centers

■ Emergency and non-emergency medical transportation

■ Tobacco cessation programs for pregnant women

Optional benefits:

■ Freestanding ambulatory surgery centers

■ Public and mental health clinics

■ Chiropractic care

■ Dental care

■ Dental surgery

■ Optometrists

■ Podiatrists

■ Psychologists

■ Dentures

■ Eyeglasses

■ Hearing aids

■ Home medical equipment

■ Prosthetics

■ Adult health screenings

■ Case management

■ Home or community-based long-term care

■ Personal care

■ Program of All-Inclusive Care for the Elderly (PACE)

■ Inpatient psychiatric care for individuals under age 21

■ Inpatient care for mental diseases for individuals aged 65 and over

■ Intermediate care for intellectual disabilities

■ Religious nonmedical care

Spending per Enrollee and FMAP

■ New Jersey spent $6,921 per enrollee in 2020

■ Because New Jersey is a state, the amount awarded for financing (FMAP) Medicaid in New 

Jersey is determined by the state’s per capita income relative to the nation’s per capita 

income. New Jersey FMAP for 2020 was 50 percen

Sources

“Medicaid Spending per Enrollee (Full or Partial Benefit),” Kaiser Family Foundation (KFF), January 20, 2021, 

https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=

%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

(continued)

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 105
State or Territory: New Jersey (2020)

“Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family Foundation (KFF), 

January 20, 2021, https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTime

frame=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“New Jersey and the ACA’s Medicaid Expansion,” Health Insurance, January 20, 2021, https://www.

healthinsurance.org/new-jersey-medicaid/.

“Medicaid spending in New Jersey,” Ballotpedia, January 24, 2021, https://ballotpedia.org/Medicaid_spending_

in_New_Jersey. 

Table A.3.4: Comparison of Medicaid Eligibility, Benefits, FMAP and Spending 

per Enrollee

State or Territory: Florida (2020)

Eligibility Requirements:

Able-bodied, non-elderly adults who don’t have dependents are not eligible for Medicaid in 

Florida, regardless of their income

Florida’s eligibility standards are:

■ Children up to one year old: 206 percent of the federal poverty level (FPL)

■ Children ages one through five up to 140 percent of FPL

■ Children ages six through 18 up to 133 percent of FPL

■ Pregnant women up to 191 percent of FPL

■ Adults with dependent children up to 27 percent of FPL

■ Be 65 years of age or older

* People who qualify for Supplemental Security Income (SSI) automatically qualify for 

Medicaid in Florida

Mandatory and Optional Benefits

Mandatory benefits:

■ Hospital services for inpatients and outpatients

■ Health screenings for individuals and children under age 21

■ Nursing facility care and home healthcare

■ Physician checkups and other services including rural health clinic visits

■ Visits to federally qualified health centers

■ Laboratory tests and X-rays

■ Family planning

■ Nurse midwife care or other maternity care and newborn care

■ Visits to pediatric and family nurse practitioners

■ Visits to licensed freestanding birth centers

■ Emergency and non-emergency medical transportation

■ Tobacco cessation programs for pregnant women

106 National Council on Disability
State or Territory: Florida (2020)

Optional benefits:

■ Freestanding ambulatory surgery centers

■ Public and mental health clinics

■ Chiropractic care

■ Dental care

■ Dental surgery

■ Optometrists

■ Podiatrists

■ Psychologists

■ Dentures

■ Eyeglasses

■ Hearing aids

■ Home medical equipment

■ Prosthetics

■ Adult health screenings

■ Case management

■ Home or community-based long-term care

■ Personal care

■ Program of All-Inclusive Care for the Elderly (PACE)

■ Inpatient psychiatric care for individuals under age 21

■ Inpatient care for mental diseases for individuals age 65 and over

■ Intermediate care for intellectual disabilities

■ Religious nonmedical care

Spending per Enrollee and FMAP

■ Florida spent $4,213 per enrollee in 2020

■ Because Florida is a state, the amount awarded for financing (FMAP) Medicaid in Florida 

is determined by the state’s per capita income relative to the nation’s per capita income

Florida FMAP for 2020 was 61.47 percen

Sources:

“Medicaid Spending per Enrollee (Full or Partial Benefit),” Kaiser Family Foundation (KFF), January 20, 2021, 

https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=

%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family Foundation (KFF), 

January 20, 2021, https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTime

frame=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Florida and the ACA’s Medicaid Expansion,” Health Insurance, January 20, 2021, https://www.healthinsurance.

org/florida-medicaid/.

“Medicaid spending in Florida,” Ballotpedia, January 24, 2021, https://ballotpedia.org/Medicaid_spending_in

_Florida.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 107
Table A.3.5: Comparison of Medicaid Eligibility, Benefits, FMAP and Spending 

per Enrollee

State or Territory: Massachusetts (2020)

Eligibility Requirements

Individuals qualify with incomes up to the following levels:

■ Children up to one year old: 200 percent of the federal poverty level

■ Children ages one to 18: 150 percent of FPL

■ Pregnant women are covered with a family income up to 200 percent of the FPL

■ Children with family income too high to qualify for Medicaid and pregnant women who 

aren’t eligible for Medicaid due to immigration status are eligible for the Children’s Health 

Insurance Program (CHIP); CHIP is available to kids with a family income up to 300 percent 

of FPL and to non-resident pregnant women with income up to 200 percent of FPL

■ Parents and other adults are covered with incomes up to 138 percent of FPL

Mandatory and Optional Benefits

Mandatory benefits:

■ Hospital services for inpatients and outpatients

■ Health screenings for individuals and children under age 21

■ Nursing facility care and home healthcare

■ Physician checkups and other services including health clinic visits

■ Visits to federally qualified health centers

■ Laboratory tests and X-rays

■ Family planning

■ Nurse midwife or other maternity care and newborn care

■ Visits to pediatric and family nurse practitioners

■ Visits to licensed freestanding birth centers

■ Emergency and non-emergency medical transportation

■ Tobacco cessation programs for pregnant women

Optional benefits:

■ Freestanding ambulatory surgery centers

■ Public and mental health clinics

■ Chiropractic care

■ Dental care

■ Dental surgery

■ Optometrists

■ Podiatrists

108 National Council on Disability
State or Territory: Massachusetts (2020)

■ Psychologists

■ Occupational therapy

■ Physical therapy

■ Speech, hearing, or language therapy

■ Dentures

■ Eyeglasses

■ Hearing aids

■ Home medical equipment

■ Prosthetics

■ Adult health screenings

■ Case management

■ Home or community-based long-term care

■ Personal care

■ Private duty nurse

■ Program of All-Inclusive Care for the Elderly (PACE)

■ Inpatient psychiatric care for individuals under age 21

■ Inpatient care for mental diseases for individuals aged 65 and over

■ Intermediate care for intellectual disabilities

Spending per Enrollee and FMAP

■ Massachusetts spent $7,898 per enrollee in 2020

■ Because Massachusetts is a state, the amount awarded for financing (FMAP) Medicaid in 

Massachusetts is determined by the state’s per capita income relative to the nation’s per 

capita income. Massachusetts FMAP for 2020 was 50 percen

Sources:

“Medicaid Spending per Enrollee (Full or Partial Benefit),” Kaiser Family Foundation (KFF), January 20, 2021, 

https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=

%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family Foundation (KFF), 

January 20, 2021, https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTime

frame=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Massachusetts and the ACA’s Medicaid Expansion,” Health Insurance, January 20, 2021, https://www.healthinsurance

.org/massachusetts-medicaid/.

“Medicaid spending in Massachusetts,” Ballotpedia, January 24, 2021, https://ballotpedia.org/Medicaid

_spending_in_Massachusetts.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 109
Table A.3.6: Comparison of Medicaid Eligibility, Benefits, FMAP and Spending 

per Enrollee

State or Territory: Puerto Rico (2020)

Eligibility Requirements:

■ Puerto Rico currently provides coverage to individuals with modified adjusted gross 

incomes up to 133 percent of the Puerto Rico Poverty Level (PRPL), $11,316 annually for a 

family of four

■ This represents 43 percent of the federal poverty level (FPL), which is $26,200 for a family 

of four in 2020

Mandatory and Optional Benefits

Mandatory benefits:

■ Early and periodic screening, diagnostic and treatment services for individuals under 21

■ Inpatient hospital services

■ Laboratory and X-rays

■ Medical or surgical services by a dentist

■ Outpatient hospital services

■ Physical services

■ Tobacco cessation for pregnant women

■ Family planning services

■ Federally qualified health services

■ Rural health clinic services

Optional benefits:

■ Clinic services

■ Dental services

■ Eyeglasses and prosthetics

■ Outpatient prescription drugs

■ Physical therapy and related services

■ Diagnostic, screening, preventive, and rehabilitation services

■ Inpatient psychiatric hospital services for individuals under age 21

■ Inpatient hospital and nursing facility services for individuals 65 or over in institution for 

mental diseases

■ Medicaid federal reimbursement rate known as FMAP is calculated based on the state’s 

per capita income relative to the nation’s per capita income, providing higher rates to 

poorer states. Puerto Rico and the other U.S. territories are assigned a permanent FM

of 50 percent and subsequently increased to 55 percent under the Patient Protection and 

Affordable Care Act (ACA)

110 National Council on Disability
State or Territory: Puerto Rico (2020)

■ However, the FMAP formula is applied until the 1108 federal cap is reached. The 1108 cap

is a mandatory ceiling for Medicaid funds. The funding cap increases at the rate of the

medical care component of the CPI-U

■ The Puerto Rican spending per enrollee projected for 2020 was 2,144. Lower than any other

state

Sources:

“Medicaid Spending per Enrollee (Full or Partial Benefit),” Kaiser Family Foundation (KFF), January 20, 2021, 

https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=

%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

“Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family Foundation (KFF), 

January 20, 2021, https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTime

frame=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

Solomon, Judith. “Puerto Rico’s Medicaid Program Needs an Ongoing Commitment of Federal Funds,”

Washington D.C: Center on Budget and Policy Priorities, January 20, 2021, https://www.cbpp.org/research

/health/puerto-ricos-medicaid-program-needs-an-ongoing-commitment-of-federal-funds.

“Medicaid in Puerto Rico: Financing and Spending Data Analysis and Projections,” Medicaid and CHIP Payment 

and Access Commission, January 20, 2021, https://www.macpac.gov/publication/medicaid-in-puerto-rico

-financing-and-spending-data-analysis-and-projections/.

Government Accountability Office (GAO), “MEDICAID AND CHIP Increased Funding in U.S. Territories Merits 

Improved Program Integrity Efforts,” Washington D.C: Government Accountability Office, January 20, 2021, 

https://www.gao.gov/assets/680/676438.pdf.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 111
112 National Council on Disability
Appendix D: Comparison of the number of school-age 

students served under IDEA, Part B, in 2019–2020, in 

U.S unincorporated organized territories. Note: tab

shows a comparison of the number of school-age 

students served under IDEA, Part B, in 2019–2020, in 

U.S. unincorporated organized territori

U.S. Unincorporated Organized Territories Number of Children Served from 5 to 21 Years 

of Age

Puerto Rico 95,112

American Samoa 520

Guam 1,706

Northern Mariana Islands 914

USVI 1,025

Sources:

U.S. Department of Education. “IDEA Part B Child Count and Educational Environments Collection.” April 26, 

2021. https://www2.ed.gov/programs/osepidea/618-data/state-level-data-files/index.html#bcc.

Find Affordable Rental Housing.” USAGov. January 25, 2021. https://www.usa.gov/finding-home#item-37252.

Gobierno de Puerto Rico Administracion de Vivienda Publica (AVP). “Solicitud de Vivienda Sección 8.” Gobierno 

de Puerto Rico Administración de Vivienda Pública. January 25, 2021, https://www.avp.pr.gov/servicios-solicitudvivienda.aspx.

“Eligibility.” New York City Housing Authority (NYC Housing Authority). January 25, 2021. https://www1.nyc.gov

/site/nycha/eligibility/eligibility.page.

“How to Apply for Pennsylvania Section 8.” Sectioneightapplication.com. January 25, 2021. https://www

.sectioneightapplication.com/apply/PA.

“Determining if Section 8 Housing in New Jersey is a Good Choice for You.” Eligibility. January 25, 2021. https://

eligibility.com/section-8/new-jersey-nj-section-8-benefits.

Eligibility.

“Florida’s Section 8 Housing Program.” Eligibility. January 25, 2021. https://eligibility.com/section-8/florida-fl

-section-8-benefits.

Commonwealth of Massachusetts. “A Guide to Obtaining Housing Assistance.” Mass.gov. January 25, 2021. 

https://www.mass.gov/guides/a-guide-to-obtaining-housing-assistance.

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 113
114 National Council on Disability
Endnotes

1 Jose Luis Vaello Madero V. United States of America, 3:17-CV-233-CAG, 97 (2019). https://drive.google.com/file

/d/1w2lvhzE-0fXyUjGJrAoGhQBbQ8vvnGgj/view.

2 History. “Puerto Rico.” History.com. September 2017. http://www.history.com/topics/us-states/

puerto-rico-history.

3 Jose G. Martinez Borras. “Sección 936 del código de rentas internas.” EnciclopediaPR. September 15, 2014. 

Sección 936 del Código de Rentas Internas - EnciclopediaPR.

4 Cheatham, Amelia. “Puerto Rico: A US territory in Crisis.” Council on Foreign Relations. November 25, 2020. 

https://www.cfr.org/backgrounder/puerto-rico-us-territory-crisis.

5 History. “Puerto Rico.” History.com. September 2017. http://www.history.com/topics/us-states/puerto-rico

-history.

6 U.S. Congress. “H. R. 5278 Sec. 5(20).” Congress.gov. Text - H.R.5278 - 114th Congress (2015–2016): 

PROMESA | Congress.gov | Library of Congress.

7 Austin, Andrew D. “The Puerto Rico Oversight, Management, and Economic Stability Act.” 2016. 

https://fas.org/sgp/crs/row/R44532.pdf.

8 “Puerto Rico.” History.com. September 2017. http://www.history.com/topics/us-states/puerto-rico-history.

9 Louis Noe Bustamante, Antonio Flores, and Sono Shah. “Facts on Hispanics of Puerto Rican Origin in the 

United States.” Pew Research Center Hispanic Trends. September 16, 2019. https://www.pewresearch.org

/hispanic/fact-sheet/u-s-hispanics-facts-on-puerto-rican-origin-latinos/.

10 Erickson, W., Lee, C., and S. Von Schrader. 2020. 2018 Disability Status Report: United States. Ithaca, 

NY: Cornell University Yang-Tan Institute on Employment and Disability (YTI). https://www.disabilitystatistics

.org/StatusReports/2018-PDF/2018-StatusReport_US.pdf.

11 Erickson, et.al. 2018 Disability Report PR. (Cornell University 2020, 5).

12 U.S. Department of Health & Human Services. “Disability & Health U.S. Profile Data for Puerto Rico (Adults 

18+ years of age).” Centers for Disease Control and Prevention. 2017. https://www.cdc.gov/ncbddd/disability

andhealth/impacts/puerto-rico.html.

13 Erickson, et.al. 2018 Disability Report PR. (Cornell University 2020, 6).

14 Houtenville, A., and S. Boege. 2019. “Annual Report on People with Disabilities in America: 2018.” Institute on 

Disability, Durham, NH: University of New Hampshire.

15 Erickson, et.al. 2018 Disability Report PR. (Cornell University 2020, 8).

16 Erickson, et.al. 2018 Disability Report PR. (Cornell University 2020, 33).

17 U.S. Bureau of Labor Statistics. “Persons with a Disability: Labor Force Characteristics — 2020.” February 24, 

2021. bls.gov/news.release/pdf/disable.pdf.

18 U.S. Bureau of Labor Statistics. “Databases, Tables & Calculators by Subject.” June 4, 2021. Data.bls.gov

/timeseries/LASST720000000000003.

19 U.S. Census Bureau. “QuickFacts Mississippi; Puerto Rico.” https://www.census.gov/quickfacts/fact/table

/MS,PR/LFE305219.

20 U.S. Census Bureau. “QuickFacts Mississippi; Puerto Rico.” https://www.census.gov/quickfacts/fact/table

/MS,PR/LFE305219.

21 Erickson, et.al. 2018 disability Report PR. (Cornell University 2020, 41).

Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 115
22 Red State Data Center de Puerto Rico (SDC-PR). “Población de 65 años o más iguala a la población menor de 

18 año.” June 21, 2018. https://censo.estadisticas.pr/Comunicado-de-prensa/2018-06-21t122055.

23 U.S. Government Accountability Office. “Puerto Rico Information on How Statehood Would Potentially Affect 

Selected Federal Programs and Revenue Sources.” GAO-14-31 (Washington, DC, 2014). https://www.gao.gov

/assets/670/661334.pdf.

24 U.S. Government Accountability Office. “Puerto Rico Information on How Statehood Would Potentially Affect 

Selected Federal Programs and Revenue Sources.” GAO-14-31 (Washington, DC, 2014). https://www.gao.gov

/assets/670/661334.pdf.

25 U.S. Government Accountability Office. “Puerto Rico: Characteristics of the Island’s Maritime Trade and 

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Disparate Treatment of Puerto Rico Residents with Disabilities in Federal Programs 131
132 National Council on Disability
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