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Unmanageable Care

An Ethnography of Health Care Privatization in Puerto Rico
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In Unmanageable 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 Rico was dramatically transformed, just not according to plan.
Contents Acknowledgments ix Introduction: Learning to Manage 1 Part I: Elements of a System 1. A History of Reform: Colonialism, Public Health, and Privatized Care 312. Regulating a Runaway Train: Everyone Is Replaceable 61 3. New Consumer Citizens: Life Histories 89 Part II: The Business of Care: Market Values and Management Strategies 4. Quality: Managing by Numbers 125 5. Complaints: The Wrong Glucometer ... Again! 151 6. Market Values: Partnering and Choice 179 Conclusion: Ungovernability as Market Rule 209 Appendix 1: A Methodological Appendix 231 Appendix 2: Interview Descriptions 241 Notes 253 Works Cited 277 Index 295 About the Author 299
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