Unmanageable Care

Jessica Mulligan is Associate Professor of Health Policy and Management at Providence College. Her current research explores insurance, financial security, and health reform from the perspective of the newly insured and those who continue to lack coverage. She is the author of Unmanageable Care: An Ethnography of Health Care Privatization in Puerto Rico (NYU Press, 2014), as well as multiple journal articles.

• Contents Acknowledgments ix Introduction: Learning to Manage 1 Part I: Elements of a System 1. A History of Reform: Colonialism, Public Health, and Privatized Care 312. Regulating a Runaway Train: Everyone Is Replaceable 61 3. New Consumer Citizens: Life Histories 89 Part II: The Business of Care: Market Values and Management Strategies 4. Quality: Managing by Numbers 125 5. Complaints: The Wrong Glucometer ... Again! 151 6. Market Values: Partnering and Choice 179 Conclusion: Ungovernability as Market Rule 209 Appendix 1: A Methodological Appendix 231 Appendix 2: Interview Descriptions 241 Notes 253 Works Cited 277 Index 295 About the Author 299

"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)