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.