Managed lives

In the 1990s, the newly elected statehood party reinvented the healthcare system using a managed care model in Puerto Rico. In a period of two years, the government sold off public hospitals, closed local health centers and enrolled eligible beneficiaries with private insurance companies. The reformers sought to modernize the practices of providers, produce healthier and more health savvy Puerto Ricans, and rationalize health care delivery through corporate management techniques. To study neoliberal health reforms ethnographically, this research combines several sites of inquiry. The investigation was conducted over a period of three years and includes life history interviews with patients, physicians, and government officials as well as participant observation at a managed care organization. These distinct research sites enable a complex portrayal of how privatization reshaped health and healthcare in Puerto Rico. This research tracks the manifestations of the state in privatized health care and, in turn, the presence of business in government agencies and discourse. The dismantling of the Keynesian welfare state in favor of a neoliberal model is likewise the source of political struggle, unexpected consequences and contradictions. From these struggles, new forms of care emerge and new experiences of treatment. A focus on preventive care such as disease management attempted to change how illness was conceptualized and experienced. Much of the new medical discourse in Puerto Rico was concerned with giving patients the tools and training to become the managers of their own chronic conditions like diabetes and high blood pressure. However, the neoliberal patient did not always behave in ways that the system anticipated. The health reform contained certain assumptions about subjects and human behavior that were confounded by the actual administration of such programs. This research shows how Medicare and Medicaid recipients have gone from being the welfare state's beneficiaries to the neoliberal corporation's consumers. This project seeks to ethnographically trace out these transformations in Puerto Rico in order to better understand how managed care and privatization reshape the entanglements of the state, business and citizens.