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Unmanageable CareAn Ethnography of Health Care Privatization in Puerto Rico$

Jessica M. Mulligan

Print publication date: 2014

Print ISBN-13: 9780814724910

Published to NYU Press Scholarship Online: March 2016

DOI: 10.18574/nyu/9780814724910.001.0001

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(p.295) Index

(p.295) Index

Source:
Unmanageable Care
Publisher:
NYU Press
Acevedo-Vilá, Aníbal, 49, 204, 261n21, 271n13
Affordable Care Act (ACA), 8, 191, 230, 255nn10–11, 262n5
Allen, Charles H., 35
American Medical Association (AMA), 121, 167, 217, 259n9
anthropology of policy, 18–20, 28
Arana-Soto, Salvador, 32–33, 258nn4–5, 273n5
Arbona, Guillermo, and Annette B. Ramírez de Arellano, 4, 9, 35, 36–40, 275n12
Ashford, Bailey K., 33–35
auditing, 4, 18–19, 27;
audit culture (or society), 18, 218, 263n11;
and governing from afar (or arms length control), 18, 72, 75–76, 83, 127, 129, 161, 164, 185, 217–218;
and La Reforma, 56, 58, 218
Beck, Ulrich, 201–202
Berman, Marshall, 63
Bush, George W., 4, 17–18, 24, 65–66, 90–91, 102, 120, 181, 191, 215, 262n4, 273n8
Calderón, Sila, 271n13
capitation, 11, 170, 256n15;
of primary care physicians, 49–50, 58, 217
Centro Médico (Puerto Rico Medical Center), 38, 40, 98, 99, 101, 217
choice, 5;
and colonial constraints, 202–205;
of health plan, 115, 126, 134, 141, 161, 191–202, 269n6, 270n4;
limitations on, 90, 108, 114, 121, 155, 173, 179–180, 192–193, 195–202, 213, 218, 271n10;
as a market value, 17, 21, 24, 28, 90–92, 130, 132, 149, 189–191, 205–207, 215, 222, 224–226, 226;
of medical care to receive, 52, 96, 102, 129, 225
citizenship:
biologic citizenship, 154, 268n2;
and colonialism, 182, 262n3;
consumer citizens, 19–20, 27, 89–122, 156, 173, 177, 224;
and disability, 119–120, 267n25;
hollowing out of citizenship, 153–155, 164, 177;
and participation, 181–182, 186, 193;
and privatization, 4, 6, 27, 118–122, 152–153, 215;
and a right to healthcare, 16, 161, 174–175;
U.S./Puerto Rican citizenship, 36, 155, 259n13;
and voting, 206
Clarke, John, 18, 72, 80, 91, 128–130, 138, 264n3, 267n2
Clinton, Bill, 18;
health reform policies 9–10, 47, 191
CMS (Centers for Medicare and Medicaid Services), 65–68, 133, 153, 165–169, 177, 193;
and partnering, 180–189;
and quality, 133–134, 140, 147–149;
and regulation at Acme, 67–71, 73–82, 87–88, 140, 162, 163–164, 170, 172, 195, 203–205, 223, 229, 256n15, 264n13, 264n2, 268nn3, 4;
and regulatory capture, 188, 195
colonialism:
in anthropology, 238;
and hybridity, 261n1;
as a limit on policy maker’s autonomy, 9, 20, 28, 63, 182, 202–205, 210, 227–229, 259n11, 262n3;
in Puerto Rico, 24–25, 43–44, 59, 155–156, 64;
Spanish colonial legacy, 32–33, 38, 44;
U.S. early period, 31–38, 258n3, 258n5
Comisión Para Evaluar el Sistema de Salud 2005, 50, 56, 171, 183, 217–220, 235, 261n21
complaints:
defined, 268n4;
hesitancy to complain, 142–143, 145, 147–148;
about marketing violations, 194–195, 203, 271n8;
processing at Acme, 15, 68, 70, 85, 125, 137–138, 151–152, 161–165, 226;
and privatization, 154–156, 175–177;
about providers and/or networks, 114, 156–159;
about La Reforma, 53, 170–171, 172–174;
(p.296) complaints:
regulation of, 152–154, 159–161, 271n11;
Constitution of Puerto Rico, 39, 228, 259nn11–12, 274nn10–11
contact zone, 24–26, 28, 261n1
Department of Health, 36, 39, 203, 261n22
Dietrich, Alexa, 10, 63, 260n15
disease or care management, 7, 8, 13, 21, 23, 172, 209, 211–212, 216, 221, 225, 227, 273n6, 274n9
Donald, Alasdair, 64, 126, 132, 135
durable medical equipment (DME), 15, 27, 149–150, 152, 167, 176, 221, 223, 226, 238
entrepreneurial governance, 16, 18–20, 83, 181
Estroff, Sue, 113, 266n16
familism, 263n10
Farmer, Paul, 21, 28, 225, 238
fieldnotes, 12, 22–23, 77, 80
Fish!, 2–3, 5, 62, 253n1
Fortuño, Luis, 257n1
Foucault, Michel, 28, 71, 141, 254n4
governmentality, 4, 28, 209, 254n4
Harvey, David, 4, 18, 179, 206–207, 213, 222, 253n2, 262n2
Health Maintenance Organizations (HMOs), 1–2, 6–8, 12, 23, 86–87, 96, 100, 101, 103, 114, 116, 120, 127–128, 132, 138, 156–158, 159–161, 167, 176, 189, 190, 192, 203, 204, 229, 235, 254nn6–7, 255nn8–10
HIPAA (Health Insurance Portability and Accountability Act), 70, 235
Ho, Karen, 64, 83, 275n1
Holland, Dorothy, et al., 18–19, 181, 189
hookworm, 31, 33–35
Horton, Sarah, 19, 20, 28, 65, 116, 126, 131, 132, 255n11
Huertas Goldman, Sarah, 45, 272n2
Independence Party (PIP), 25, 46
Institute of Tropical Medicine, 33, 36
Izquierdo Mora, Luis, 36, 55, 57–58, 274n11
Johnson, Lyndon, 16–17
Jones Act, 36
Kleinman, Arthur, 96, 227, 265n3, 267n25
laboratory metaphor, 9–10, 41, 260n15
Lamphere, Louise, 19–20, 28, 65, 116, 126, 131, 271n1
La Reforma, 9–10, 32, 45–59, 169–171, 204, 225–226, 229, 256n12, 257n1, 271n13;
beneficiary experiences of, 50–54, 93, 96, 99, 100–102, 103, 143–146, 172–174, 176, 198–200, 236, 241–252;
costs of, 48–49, 218, 262n5;
and care rationing, 49–50, 54, 142–143, 145–146, 209, 216–217, 223;
eligibility procedures (recertification), 47, 108, 115–117, 171, 173, 218, 243, 248;
events leading up to, 44–45, 110, 213–214, 272n2;
implementation of, 46–52;
impact on medical education, 56–58, 217;
insurance card, 51–55, 58, 99, 116, 199, 216;
provider network issues, 114, 198–200;
privatization of facilities, 56, 217, 219–220. See also Medicaid; Mi Salud
managed care, 6–8;
backlash, 8, 128, 256n13, 269n8;
managed competition, 191, 200, 270n6
Marx, Karl, 63
Medicaid, 7, 9;
coordination of coverage 197–200, 204–205, 267n23, 270n5, 271n12;
eligibility procedures, 116, 173, 213, 255n11;
funding cap in Puerto Rico, 43, 49, 59, 229, 261n19;
impact on Puerto Rico’s health system, 9, 41–44, 48–49, 59, 180, 275n12;
managed care in, 8, 19, 128, 170, 209, 255nn10–11, 269n3, 271n4;
in New Mexico 19, 130–132, 166, 171, 173, 255n11, 271n1. See also La Reforma; Mi Salud
Medical Card Systems (MCS), 48
Medicare (original or fee-for service), 10–11, 19, 43, 67, 87, 190, 193, 218, 220, 223, 256n15, 269n9, 272n4, 274n9;
creation of, 16–17;
impact on Puerto Rican health system, 41–44, 275n12;
premiums in, 19, 204, 217, 263n7
(p.297) Medicare Advantage, 10–11, 62, 65, 76, 79, 87, 153, 165–166, 184, 188, 202–204, 220, 223, 229, 256n14, 270n6, 271n10, 271n12;
market share (penetration);
and preemption, 203, 229, 271n11;
Medicare Modernization Act (MMA), 4, 17, 65-67, 90, 108, 120, 141, 182, 188, 190–193, 202–205, 214, 223, 256nn14–15, 262nn3–4, 267n23, 268n3, 273n5, 273n8. See also Medicare Advantage
Medicare Part D, 65, 77, 193, 236, 267n23, 268n4
Mental Health and Substance Abuse Administration (ASSMCA), 45, 171
mental health care:
access problems, 20, 50, 95–96, 131, 169–175, 209, 212–213, 217, 219, 255n11, 261n21;
and advocacy, 109–118, 186–187;
and disability, 102–108, 109–118, 242, 245;
fifteen minute med checks, 64, 103, 144, 172–174;
hospitals, 102–108, 109–118, 266n8;
in the regional system, 9, 45;
MBHOs, 48, 114, 169;
quality complaints, 102–108, 109–118, 143, 169–175;
and spiritism, 265n5. See also nervios, ataques de
migration:
rural to urban, 38, 98, 265 n.10;
to the U.S. mainland, 155, 259n13
Mi Salud (new name for La Reforma), 220, 230, 257n1. See also La Reforma
Mountin, Joseph, 36–37, 258n4
Muñoz Marín, Luis, 37, 259n10
Nader, Laura, 12–13, 233, 256n16
NCQA (National Committee for Quality Assurance), 130, 133–135, 140, 147–150, 267nn3–4, 272n4. See also quality
neoliberalism, 4, 10, 18, 23, 27–28, 41, 46–47, 55, 72, 129, 132, 149–150, 154, 206, 228, 238, 267n2;
and consumerism, 28, 53, 89, 91, 102, 108, 118–121, 264n3;
and creative destruction, 62–63, 262n2;
definition of, 253n2;
and flexibility, 2, 61, 64, 83–88, 117, 121;
ideas about personhood and subjectivity (or homo economicus), 28, 69–71, 89–90, 121–122, 141, 149, 201, 210, 224–225, 253n2, 264n12;
and implementation, 6, 31, 47, 58;
and optimism, 213–215, 222
nervios, ataques de, 267n5;
symptoms, 111, 146, 158, 247, 250
New Deal, 36, 155, 258n2, 259n10, 260n15
New Progressive Party (statehood party), 9, 10, 22, 25, 46–47, 118, 175, 214, 257n1, 260n15, 271n13
Nine Curt, José, 37, 40–42, 260n16
oral health, 50, 261n10
Operation Bootstrap, 39, 260n14
Pérez, Gina, 94
Popular Democratic Party (PPD), 25, 39, 40, 46, 259n10, 259n13, 260n15, 260n17, 271n13
Puerto Rican Medical Association, 40, 259n9
quality:
of care, 22, 159, 186, 234, 270n5;
concerns in privatized programs, 50, 55–56, 111, 130–132, 172, 175, 193, 218–220, 223, 255n11, 264n13, 272n4;
defined, 133–136;
gaming quality measurement, 139–141, 262n6;
as a market value, 19, 24, 52, 90, 127–130, 135–138, 141–142, 149–150;
measurement of, 4–6, 12, 27, 82, 125–130, 136–141, 216, 267nn1–4, 272n4;
from the perspective of beneficiaries, 52, 53, 93, 108, 122, 141–149;
as a rationale for privatization 17, 46–47, 170, 190, 214–215, 229. See also CMS: and quality; NCQA; QIO
QIO (Quality Improvement Organization), 159, 161–162, 268n5
regional health system, Puerto Rico, 4, 9, 32, 37, 38–47, 48, 52, 54–55, 57–58, 96, 116, 218, 261n21, 275n12
remedios caseros (home remedies), 97, 102, 251, 265n5
risk adjusted premiums, 223, 256n15, 273n7
Rose, Nikolas, 5, 18, 28, 128, 154, 209, 254n4, 263n11, 268n2
Rosselló, Pedro, 9, 47, 51, 118, 214, 271n13
Rylko-Bauer, Barbara, 21, 28, 238
Santiago-Valles, Kelvin, 35–36, 38, 258n1, 259n8
schizophrenia, 103, 105, 107, 108, 113, 147, 250, 266n16, 266n18
Scully, Thomas A., 66, 180–181, 188
Silvestrini, Blanca, 35
studying through, 12–13, 149, 235, 257n16
(p.298) studying up, 12–13, 233, 235, 256n16
Superior Board of Health, 34, 35
Tomes, Nancy, 90, 108, 120, 224, 264n3
uninsured, 9, 48, 52, 207, 216–217, 230
University of Puerto Rico, 118, 187;
School of Public Health, 41, 261n21;
School of Medicine, 33, 40, 57, 272n2
utilization review/management, 4, 6–7, 8, 26, 56, 128, 154, 166–169, 204, 211–212, 221, 269n8;
appeals of, 160–161, 165, 169;
negative impact of, 131, 166, 170–171, 212, 217;
underutilization, 171, 211–212