Unmanageable Care

An Ethnography of Health Care Privatization in Puerto Rico

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.