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Mulligan studies Puerto Rico’s health care system in new book

​​​​Dr. Jessica Mulligan, assistant professor of health policy and management, has taken an in-depth look into the privatization of Puerto Rico’s health care system in her new book, Unmanageab​le Care: An Ethnography of Health Care Privatization in Puerto Rico (NYU Press, 2014). 

In Unmanageable Care, Mulligan, an anthropologist, goes to work at an HMO in Puerto Rico and records what it’s really like to manage care. The book chronicles how the privatization of the health care system in Puerto Rico transformed the experience of accessing and providing care on the island.

Below, Mulligan explains why she took on this project and talks about what happened when Puerto Rico’s system privatized.

Tell me how the idea for the book came about? Why tackle this subject? What interested you about it?

I never intended to write this book at all. I am an anthropologist and anthropologists conduct extensive field work, usually for one year or more.  I was planning to do my research in Puerto Rico because I was fascinated by the fact that this island, which is a U.S. territory, has some of the highest female sterilization and cesarean section rates in the world. So, I had finished my graduate exams and was ready to start field work, but after submitting grant applications, I came up empty-handed.

So, instead of sitting around in Cambridge for another year trying to get funds to carry out fieldwork, I decided to move to Puerto Rico and get a job. I wanted to work part-time and get started doing research. Through a friend, I found out about a job at a Medicare managed care firm — they needed someone who was bilingual and could write policies and procedures. I applied and got the job. So, I began working at this firm and wondering what was going on there. Why are there so many managed care firms selling Medicare insurance plans in Puerto Rico? How are all of these privatized, for-profit companies impacting the provision and quality of medical care? 

I also saw things that anthropologists were increasingly interested in: auditing as a social practice, privatization of government, a belief that people are all accountants — interested in making choices about everything in their lives by weighing costs and benefits. For the last few decades we have seen disillusionment with the ability of the government to provide services efficiently. We commonly hear that “the market” is the best way to distribute health care. Anthropologists have been deeply skeptical of these claims. I set out to study how this market reform would play out on the ground.

Can you give me some examples of chapters in the book or some principal topics?

In Part 1, Elements of a System, the book examines the parts that make up the health system in Puerto Rico. Chapter 1 retraces a hundred year history of reforms to the health system on the island beginning with the U.S. occupation in 1898. The shifting organizing principles of health planners and regulators are highlighted in this chapter and include sanitation and controlling communicable diseases during the first half of the twentieth century, public health goals and ensuring universal access to care at mid-century, and efficiency and the free market beginning in the 1990s. Chapter 2 depicts the everyday nature of regulation through audit, performance management, and corrective action plans. It also shows the unstable side of private enterprise by retelling the stories of Acme employees who were fired, quit, or downsized. Chapter 3 tells the life histories of particular citizen/consumers who struggled to obtain care in the privatized health system. This chapter also argues that the subject making aspirations of neoliberal health policies never quite managed to remake patients into calculating, health seeking consumers. 

​Part 2 of the book, The Business of Care: Market Values and Management Strategies, consists of shorter chapters focused on specific technologies for managing care. In a sense, Part 2 shows the system in motion — it relates how the actors in Part 1 (health planners and regulators, HMO administrators, citizen/consumers, and health care providers) came into contact with one another through the contradictory project of managing care. Chapter 4 Quality, Chapter 5 Complaints, and Chapter 6 Market Values: Partnering and Choice explore specific technologies and practices that are essential to managed care: quality measurement, complaints processing, the role of choice, and partnering efforts between the federal government and managed care organizations. In each chapter, management sets out on an ambitious project of remaking the organization of care and the behavior of individuals who work in and are served by the health care system. Yet, in each chapter, management never quite achieves its aims. In the conclusion, I argue that failure and the unmanageable are central components of market reform. The conclusion revisits the moral implications of market reform, the legacy of U.S. colonialism in Puerto Rico, and the future of health reform on the island and the U.S. mainland.

The description says that you went to work at an HMO. What did you do there?

I worked in the compliance department initially part-time as an editor of policies and procedures. I was promoted to supervisor and then to manager. The compliance department oversaw all communication with the HMO’s regulator: the Centers for Medicare and Medicaid Services (CMS). This included handling audits, requests for information, the processing of complaints and ensuring that the firm was following federal regulations. Since the firm operated under a federal contract with CMS — being in compliance was pretty key to its success.

Explain some of the changes [substantial] that occurred when healthcare was privatized.

In the public health system, government went from being the direct provider of care at a network of clinics and hospitals throughout the island to a contract administrator who paid a private insurance company to manage eligible beneficiaries. Residents could no longer just go to a local health clinic and receive care from a government doctor — they had to apply for benefits and enroll with an insurance company who then assigned them a primary care physician. Since eligibility was tied to income and assets and had to be re-certified every year, some people lost access to health care.

In your estimation, why is privatization not working out in Puerto Rico?

Proponents of privatization promised more rational and efficient care management, expanded access to pharmaceuticals and specialists, and a new emphasis on self-care practices that would ultimately make the population healthier. Few of these promises were realized. Instead, privatization was accompanied by a number of failures. Rather than producing a health system that was rational and easy to navigate, privatized managed care created new barriers to accessing care through eligibility requirements, enrollment processes, and administrative procedures for securing authorization. Other failures include escalating costs and care rationing by physicians and health plans, especially in La Reforma. Whether it was securing a mental health appointment or being able to purchase prescription drugs, care coordination never quite worked for the most vulnerable people that I interviewed. Little evidence exists that efforts to alter patients’ behavior through care management has produced improved health outcomes. 

This book argues that privatized managed care failed to deliver on many of its promises. But why? Where did managed care go wrong? There are four interconnected answers to that question: (1) privatized for-profit managed care is far better at making and managing money than managing health (or people); (2) neoliberal health programs are based on asocial and ahistorical understandings of human subjects and behavior; (3) these programs are undermined by their own hubris; and (4) in Puerto Rico, colonial relations of rule have contributed to the failures of managed care and the creation of a health system that is largely unmanageable. You’ll have to read the book to find out more!

What audience is this book written for? 

Unmanageable Care adds a fresh perspective to debates about health care reform because it challenges the popular common sense assumption that market-based interventions are more efficient and less costly.  The book also goes further than examining policy justifications for market-based health programs and considers the complicated ethnographic questions of how these policies were actually implemented and understood in Puerto Rico.  It underscores the gaps between the goals expressed in health policy and how reform programs actually unfolded in practice. The book will attract scholarly readership from a variety of disciplines, including anthropology, sociology, public health, Latin American studies, and policy studies.