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.
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 persuasive account and `insiders 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 cant 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
"A telling ethnography of the privatization of health care in Puerto Rico. Written from within the system of managed care, Mulligans 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
"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