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Unmanageable Care

Unmanageable Care: An Ethnography of Health Care Privatization in Puerto Rico

Jessica M. Mulligan
Copyright Date: 2014
Published by: NYU Press
Pages: 320
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  • Book Info
    Unmanageable Care
    Book Description:

    InUnmanageable Care, anthropologist Jessica M. Mulligan goes to work at an HMO and records what it's really like to manage care. Set at a health insurance company dubbed Acme, this book chronicles how the privatization of the health care system in Puerto Rico transformed the experience of accessing and providing care on the island. Through interviews and participant observation, the book explores the everyday contexts in which market reforms were enacted. It follows privatization into the compliance department of a managed care organization, through the visits of federal auditors to a health plan, and into the homes of health plan members who recount their experiences navigating the new managed care system.In the 1990s and early 2000s, policymakers in Puerto Rico sold off most of the island's public health facilities and enrolled the poor, elderly and disabled into for-profit managed care plans. These reforms were supposed to promote efficiency, cost-effectiveness, and high quality care. Despite the optimistic promises of market-based reforms, the system became more expensive, not more efficient; patients rarely behaved as the expected health-maximizing information processing consumers; and care became more chaotic and difficult to access. Citizens continued to look to the state to provide health services for the poor, disabled, and elderly. This book argues that pro-market reforms failed to deliver on many of their promises.The health care system in Puerto Ricowasdramatically transformed, just not according to plan.

    eISBN: 978-0-8147-6499-2
    Subjects: Anthropology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
    (pp. ix-xii)
  4. Introduction: Learning to Manage
    (pp. 1-28)

    The tick-tack of high heels echoed on the polished tile floor. The health plan’s employees had straightened up their desks, turned off their computers, and clocked out. They joked and gossiped as they hurried toward the lobby. It was 4:30 and the elevators descended through the modern glass office building packed with customer service representatives, authorization nurses, and claims processors who filed out to the parking lot. Cars already clogged the side streets; they lunged forward and stopped in the irregular rhythm of San Juan’s rush-hour traffic. Many employees would drive for more than an hour before reaching homes in...


    • 1 A History of Reform: Colonialism, Public Health, and Privatized Care
      (pp. 31-60)

      When neoliberal programs come to life, when they are transferred from the pages of policy tracts to historically constituted and dynamic social institutions, the programs are fundamentally altered. Policies are not implemented in a void—they are grafted onto a corpus of already existing cultural practices and legal traditions that in themselves ascribe to no internal logical consistency. In order to understand what privatization does, this chapter explores what came before. When privatization was sutured to the public health system in Puerto Rico, it was one more in a long history of reforms aimed at refashioning health and health care...

    • 2 Regulating a Runaway Train: Everyone Is Replaceable
      (pp. 61-88)

      Two executives—one Puerto Rican, the other a gringo from the Midwest—stood before a group of 50 middle managers. The restaurant banquet room on the first floor of Acme’s modern office building used to easily hold the company’s management, but now the long tables were crammed with chairs. Some attendees had difficulty finding a spot on which to rest their plates. In the past, meetings provided easygoing opportunities to gossip and catch up with friends. Today, however, there were far fewer kisses on the cheek and calls ofDios te bendiga(God bless you).

      The purpose of the meeting...

    • 3 New Consumer Citizens: Life Histories
      (pp. 89-122)

      In addition to the time I spent working at Acme—avoiding getting fired, preparing for audits, and creating policies for putting papers in a file—I also wrote to Acme members and asked if I could interview them. I was received into homes all over the island where Acme members answered intimate questions about illness, disability, how they were brought up, and their economic struggles. This chapter recounts some of what I learned from listening to their stories.

      In life history interviews, I asked Acme members how they made sense of the changing health system and how they understood their...


    • 4 Quality: Managing by Numbers
      (pp. 125-150)

      Dr. Benedetti would not listen to stories. Soon after starting work at the Medicare health plan in Puerto Rico, I learned that the U.S.-born medical director would not entertain anecdotes or rumors. His office door was always open and he would meet with anyone in the company, but they had to bring numbers. As a new manager in the Compliance Department, I wanted Dr. Benedetti to take action to resolve a sudden increase in members’ complaints about delivery delays for medical equipment. He was not impressed when I recounted the story of the woman in Guaníca whose oxygen was delayed,...

    • 5 Complaints: The Wrong Glucometer . . . Again!
      (pp. 151-178)

      Recall the story from the introduction about the two brothers from Río Grande, Don Ignacio and Don Enrique. The brothers repeatedly requested a glucometer from Acme with an extra-large print display so they could manage their diabetes, but the company kept sending them the standard model. Each time the brothers called Acme to complain, a member of the Customer Service Department opened a grievance in the electronic complaints system and a new glucose monitor was sent to their home. When I met with them, several blood glucose monitors that they could not read were gathering dust on a shelf in...

    • 6 Market Values: Partnering and Choice
      (pp. 179-208)

      A great deal of symbolic and cultural work has gone into transforming “the market” into the solution for the social problems that ail us. As I argued in chapter 1, markets in health care are a relatively recent phenomenon in Puerto Rico. Proponents of privatized managed care had to contend with a previous consensus that health care was a human right best provided by the government. But market reforms came to make sense to Puerto Rican policy makers and their constituents because they resonated with, upheld, and created values that were compelling and commonsensical.¹

      Market values naturalize and valorize a...

  7. Conclusion: Ungovernability as Market Rule
    (pp. 209-230)

    The privatization of the Medicare and Medicaid programs in Puerto Rico radically transformed the health system on the island. Currently, almost half of the island’s population receives government-sponsored health benefits through private managed care health plans. In less than 10 years, managed care went from nonexistent on the island to the dominant form of receiving health care.

    Proponents of privatization promised more rational and efficient care management, expanded access to pharmaceuticals and specialists, and a new emphasis on self-care practices that would ultimately make the population healthier. Few of these promises were realized. Instead, privatization was accompanied by a number...

    (pp. 231-240)
    (pp. 241-252)
  10. NOTES
    (pp. 253-276)
    (pp. 277-294)
  12. INDEX
    (pp. 295-298)
    (pp. 299-299)