The Casa Ismael clinic is short on funds in part because of cuts in food stamps that hit about 1.3 million residents of Puerto Rico this month — a new crisis for an island still struggling from the effects of Hurricane Maria in September 2017.

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“We just don’t have the money right now,” Izquierdo, 56, said in an interview in the clinic’s sparse first-floor office, where a chunk of ceiling tiles remains missing since the hurricane. Izquierdo pulled out a chart with each patient’s name, annotated with the cost of his adult diapers for the month. “It’s very hard. It is so unfair. That cut is going to kill us.”

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The federal government provided additional food-stamp aid to Puerto Rico after the hurricane, but Congress missed the deadline for reauthorization in March as it focused on other issues before leaving for a week-long recess. Federal lawmakers have also been stalled by the Trump administration, which has derided the extra aid as unnecessary.

Now, about 43 percent of Puerto Rico’s residents are grappling with a sudden cut to a benefit they rely on for groceries and other essentials.

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And while Congress may address this issue soon, the lapse underscores the broader vulnerability of Puerto Rico’s economy, as well as key parts of its safety net, to the whims of an increasingly hostile federal government with which it has feuded over key priorities.

Puerto Rico will again need the federal government’s help to stave off drastic cuts to Medicaid, the health-care program for the poor and disabled, as well as for the disbursement of billions in hurricane relief aid that has not yet been turned over to the island.

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The island would not need Congress to step in to fund its food-stamp and Medicaid programs if it were a state. For states, the federal government has committed to funding those programs’ needs, whatever the cost and without needing to take a vote. But Puerto Rico instead funds its programs through a block grant from the federal government, which needs to be regularly renewed, and also gives food-stamp benefits about 40 percent smaller than those of states.

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After initially vowing to reject the food-stamp funding, President Trump has agreed to the emergency request to help Senate Republicans pass a broader disaster-relief package, which may be taken up for a vote this week.

But at an Oval Office meeting on Feb. 22, Trump asked top advisers for ways to limit federal support from going to Puerto Rico, believing it is taking money that should be going to the mainland, according to senior administration officials who spoke on the condition of anonymity to share details of the president’s private remarks.

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The meeting — an afternoon session focused on Department of Housing and Urban Development grants — ended abruptly, and Trump has continued to ask aides how much money the island will get. Then, Trump said he wanted the money only to fortify the electric grid there.

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Trump has also privately signaled he will not approve any additional help for Puerto Rico beyond the food-stamp money, setting up a congressional showdown with Democrats who have pushed for more expansive help for the island.

A senior administration official with direct knowledge of the meeting described Trump’s stance: “He doesn’t want another single dollar going to the island.”

Trump's anger at Puerto Rico

Puerto Rico’s government first started cutting benefits for food-stamp beneficiaries by an average of 25 percent during the first week of March. By March 12, more than 670,000 people had received reduced monthly food-stamp payments. The cuts were in effect for the entire program by Friday.

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Congressional lawmakers knew of the deadlines for months. In January, House Democrats approved $600 million in additional food-stamp funding to finance the program until the fall, but the bill immediately stalled in the Senate, with the Trump administration releasing a letter calling the additional food-stamp aid “excessive and unnecessary.”

Multiple Senate Republicans, led by Sen. David Perdue (R-Ga.), have incorporated the $600 million for Puerto Rico in legislation aimed at helping farmers in states such as Georgia who have been hurt by other storms, in a bid for broader support for their bill.

Senate Majority Leader Mitch McConnell (R-Ky.) was rumored to be considering a vote in the middle of March on that package, which if passed could have spared about half the program beneficiaries on the island from cuts. Instead, Congress spent the week consumed in a debate over a vote to disapprove of Trump’s emergency declaration for a border wall. It adjourned for an additional week without resolving the emergency relief package.

Congressional negotiators also remained divided on the exact contours of the funding bill, with Perdue’s bill costing $13.5 billion and Senate Democrats seeking more than $14 billion, including some additional measures to help Puerto Rico that Senate Republicans do not expect Trump would support. Negotiations were continuing as of late Friday, but lawmakers are expected to vote to begin debate on the emergency aid package this week, according to congressional aides.

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The impasse comes amid a hardening opposition by the president against extending additional aid to Puerto Rico. Trump sees the island as fundamentally broken and has told advisers that no amount of money will ever fix its systemic problems.

He describes in meetings that large swaths of the island never had power to begin with and that it is “ridiculous” how much money is going to Puerto Rico in food-stamp aid, according to the senior official. He has occasionally groused about how ungrateful political officials in Puerto Rico were for the administration’s help, the official said.

Trump also read a Wall Street Journal report from October and became convinced that bondholders and others were profiting off federal government aid — and grew furious. (The report describes prices on Puerto Rico’s bonds increasing after its governing fiscal board projected that disaster funding would boost the island’s overall economic health.) Since then, aides have described a president who regularly brings up the island to make sure it is not getting too much money. Current and former officials say Trump often complains in meetings that Puerto Rico does not even know how to spend the money the island has been allocated.

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Additionally, Trump administration officials who defended the island — Tom Bossert, the former homeland security adviser, and Pam Patenaude, the former deputy HUD secretary — are no longer in the administration. Mick Mulvaney, Trump’s acting chief of staff, has also been critical of how the island has spent its money.

'We will buy less and eat less'

The emergency food-stamp aid approved by Congress after Maria gave the Puerto Rican economy an immediate cash infusion, while also shielding the hurricane’s victims from the rising cost of basic food staples and safe water.

The Agranel supermarket group, for instance, has hired at least two employees — and often as many as seven — in each of its 37 stores since the hurricane, often in neighborhoods with very high rates of poverty and unemployment.

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“It helps not only these poor communities but injects the economy with money to start running. It helps the trucker who moves the food, the janitor who cleans the store, the guy who fixes the refrigerator where the food is stored,” said Felix G. Aponte Lopez, a food supplier for Agranel. “It’s had a very positive domino effect.”

But now that the additional food-stamp money has run out, Puerto Ricans see a familiar story in the unreliability of federal aid over which they have no control.

“The problems of Puerto Rico have a root-cause problem attached to it: We don’t have political power and are not treated as equal citizens,” said Ricardo Rosselló, Puerto Rico’s governor, noting the island does not elect voting members of Congress (though it does elect a non-sitting member) or have a general-election vote in U.S. presidential races. “Maria has crystallized and enhanced this sense of powerlessness.”

For Amadita Jimenez Gutierrez, 63, the food-stamp infusion meant a near doubling of her income, to about $200 a month. Although she has not been paying rent and fears eviction, the higher food-stamp benefit allowed her to cook more-healthful meals.

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But this month, Gutierrez’s food-stamp benefit fell to about $115, while a small cash supplement under the program was also cut from about $40 to around $20. As she walks through an aisle full of cooking supplies, Gutierrez said, she will skip purchases of rice and beans this month, as well as detergent and cleaning supplies.

“We will buy less and eat less,” she said.

Some Puerto Rico residents on food stamps will see a cash supplement that comes as part of the food-stamp cut to levels lower than before the hurricane, in part because the island’s government expanded the program’s eligibility after Congress appropriated the emergency aid without providing permanent funding. The cuts also come as Puerto Ricans continue to struggle with the fallout from the hurricane: Hundreds of thousands of people have moved to states, while others continue to spend their money on repairs and other damage caused by Maria.

Effects on the vulnerable

Luz Rivera Morales works full time as a nurse at Auxilio Mutuo, one of the best hospitals in Puerto Rico. She has two daughters, 8 and 5, the younger of whom requires expensive asthma medication.

This month’s food-stamp cut reduced Rivera Morales’s benefit from $420 a month to $218. She plans on having to stop or restrict purchases for yogurt, meat and vegetables for her and her children.

“Everything goes up. Nothing goes down,” Rivera Morales, 33, said in an interview from a San Juan office of the Families Department, which administers the food-stamp program. “Yes, I’m very worried.”

Across the room from Rivera Morales sat Rafael Veles, 82, who had already been waiting for two hours to learn how severe his benefit cut will be. His wife of 56 years has Alzheimer’s disease, and Veles — her caretaker — fears the cut will put the adult diapers he buys, at $16 for each package, outside their budget.

“It’s too little for our expenses,” Veles said. “I have to change her diapers often, and the money is not enough to pay for the Pampers. Sometimes, I have to change her five times a day. It’s not enough.”

Cecilia Estrada, 88, saw her benefit cut to around $100 a month from around $200. Estrada said she will buy the cheapest things possible. She is particularly worried about the cost of milk, at close to $5 a jug.

“I am buying only a few things, trying to make sure I don’t spend more than I have,” Estrada said while shuffling slowly through a Loiza supermarket in San Juan.

Of the Puerto Ricans on the food-stamp program in February 2018, about 55 percent are children, elderly or disabled, according to the preliminary findings of a forthcoming research paper by Hector Cordero-Guzman, a professor at Baruch College, part of the City University of New York.

Of the remaining 45 percent, about 42 percent were looking for work; 15 percent were working; and 17 percent were in school or had a family-related reason for not being able to work, according to Cordero-Guzman’s research.

In 2018, more than 200,000 Puerto Rico residents with disabilities relied on food stamps every month, according to Cordero-Guzman’s research. Among them were the 11 men of the Casa Ismael HIV clinic in Toa Baja.

Izquierdo’s parents founded Casa Ismael after their son — Izquierdo’s brother — died of HIV in Puerto Rico. Izquierdo, a professional accountant, decided to help her mother after the death of her father in 2016.

Izquierdo tries to break up the monotony of life in the home with special meals on Fridays, including the occasional lasagna or a homemade pizza. She will sometimes use the food-stamp money to buy a birthday cake. On special occasions, she tries holding picnics outside, at least for the men who can take their wheelchairs down a rickety red ramp to the small backyard, which is still littered with debris from the hurricane.

But the food-stamp cut reduced her budget by more than $1,000 every month. Earlier this month, Izquierdo went to Walgreens and charged three packs of Pampers to her credit card because they had run out completely.

Izquierdo said she will continue to cook lasagna and throw birthday parties regardless of the food-stamp cuts. She has no idea how she will pay for them.

“We’re just going to have to find a way,” she said.