Jessica M. Mulligan

Unmanageable Care

Jessica M. Mulligan

In Unmanageable Care, anthropologist Jessica M. Mulligan goes to work at anHMO and records what it’s really like to manage care. Set at a health insurancecompany dubbed Acme, this book chronicles how the privatization of the healthcare system in Puerto Rico transformed the experience of accessing andproviding 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 careorganization, through the visits of federal auditors to a health plan, and intothe homes of health plan members who recount their experiences navigating thenew managed care system. Inthe 1990s and early 2000s, policymakers in Puerto Rico sold off most of theisland’s public health facilities and enrolled the poor, elderly and disabledinto for-profit managed care plans. These reforms were supposed to promoteefficiency, cost-effectiveness, and high quality care. Despite the optimisticpromises of market-based reforms, the system became more expensive, not moreefficient; patients rarely behaved as the expected health-maximizing informationprocessing consumers; and care became more chaotic and difficult to access.Citizens continued to look to the state to provide health services for thepoor, disabled, and elderly. This book argues that pro-market reforms failed todeliver on many of their promises.Thehealth care system in Puerto Rico was dramatically transformed, just notaccording to plan.