Unmanageable Care

An Ethnography of Health Care Privatization in Puerto Rico

320 pages

1 map, 1 figure, 2 halftones, 3 tables

August, 2014

ISBN: 9780814770313



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Jessica Mulligan is Assistant Professor of Health Policy and Management at Providence College. 

All books by Jessica M. Mulligan

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.


  • “A telling ethnography of the privatization of health care in Puerto Rico. Written from within the system of managed care, Mulligan’s impressive understanding of historical, cultural, economic, entrepreneurial, and moral aspects of reform paints a troubling picture of what is wrong with market approaches to care. Clear, timely, and insightful, Unmanageable Care contributes importantly to the medical anthropology of health care. It also goes beyond that to illustrate the limits and failures of market approaches to manage caregiving that are regularly overlooked by health policy experts with unfortunate results. An important book!”

    —Arthur Kleinman, M.D., Esther and Sidney Rabb Professor of Anthropology, Harvard University

  • "A persuasive account and `insider’s’ view of how Managed Care really works. Managed Care, Jessica Mulligan argues, is really `ungovernable’ care. The assumption that `rational consumers’ can exercise `choice’ ignores the way ordinary people understand and deal with their health care issues. `Consumers’ see themselves as retired workers, mothers, or those who have chronic diseases like diabetes. `Choice’ is bewildering or limited. `Satisfaction’ boils down to surveys that code statements like `I can’t complain’ and omit narratives about struggles to get better care.  Mulligan argues we need to diagnose these ills that characterize neoliberal models of healthcare reform before we can work to change them."

    —Louise Lamphere, Distinguished Professor of Anthropology Emerita, University of New Mexico

  • “Mulligan does an excellent job of, as she puts it, ‘tak[ing] seriously’ the potential of market-based solutions to reducing healthcare costs….While methodologically appealing to anthropologists, this book also has broader implications for those seeking healthcare solutions for disadvantaged populations in resource-constrained settings.” 

    American Anthropologist