Book reviews 673

history of the movement. This account offers reassurance that there is no ‘right’ way
to pursue advanced nursing practice, and that perseverance as well as federal support
can make a significant difference in acceptance of nurse practitioners.
At times the book is repetitive, with some confusing chronology that can obstruct
the main points. However, given that there are so few texts that address the history
of nurse practitioners, and that the author incorporates interviews and notes from
original practitioners and pioneers, this book is well worth reading.

Reviewed by Lesley Magnussen, Yale University School of Nursing, New Haven, CT, USA.

US health care reform: a comparative book review

Emanuel EJ 2008: Healthcare guaranteed: a simple, secure solution for America. New York:
Public Affairs. 219 pp. USD14.95 (PB). ISBN 978 1 58648 662 4.
Halvorson G 2007: Healthcare reform now! A prescription for change. San Francisco, CA:
Wiley. 361 pp. USD27.95 (HB). ISBN 978 0 7879 9752 6.
Relman AS 2007: A second opinion: rescuing America’s healthcare – a plan for universal
coverage serving patients over profit. New York: Century Foundation. 205 pp. USD24.00 (HB).
ISBN 978 1 58648 481 1.

In this comparative book review, two physicians and a health care executive offer three
plans for health care reform in the USA. The plans range from the radical to reiterations
of well-worn policy discussions that have circulated among health care policy experts
for over 20 years. Universal coverage is the main goal for all three proposals, along
with the digitization of medical records to streamline many of the systemic problems
that emerge from the fragmented administration in the current US system. They also
share the characteristic of failing to mention the roles nurses, advanced practice nurses,
or other allied health care professionals will play in their plans, to the point that none
of these roles have a reference in the index. Emanuel is the one exception because
roles outside of physicians and administrators receive regular mention throughout his
proposal. With universal coverage and electronic medical records agreed upon, the
three diverge in approaches and ideas.
I begin with Relman’s work, a solution centered on retaining and maintaining physi-
cian power in the US health care system. His main argument is that practicing physicians
must become involved in health care reform or they will lose any remaining power
they possess within the system. He believes these physicians have been politically mar-
ginalized in the health policy-making arena and offers only anecdotal evidence to sup-
port his statements. The main theoretical backing of his writing lies yet again in the
only sociologist that physicians seem to read when making arguments about medical
professionalism: Eliot Freidson.1,2 Relying heavily on Friedson’s medical dominance
arguments for his health care reform solution, he offers little new information or ideas.
His ideas rest on shifting power structures back to the hands of physicians and ignore
the current economic and professional practice realities that will require the use of
many other kinds of health care providers in order to deliver care to all Americans at
all levels. Physician-centered provision of care cannot be the sole solution.
Halvorson’s plan offers solutions that work within the current system, with several
major infrastructure changes related to finance and, of course, integrating electronic
medical records. He provides several options for how to implement each infrastructure

Nursing Ethics 2009 16 (5)

674 Book reviews

shift and the pros and cons of both. The uniqueness of Halvorson’s approach is his advo-
cacy of integrating systems thinking into the health care delivery system. He posits that,
by moving away from the individual patient care approach (which currently shapes the
fragmented delivery process and provides inadequate management for more complex,
chronic disease problems), system architects should restructure the system so that,
basically, all the parts talk to each other and know what’s going on. By default, then,
the system better serves the individual’s health care needs, no matter how complex.
The plan’s weakness lies in that the politics behind his approach reinforce existing
power structures and, therefore, do not create the environment necessary to implement
systemic change.
Emanuel’s plan for health care reform offers something that few others provide:
institutional change and reorganization. The strategy he outlines makes the most sense
from an operations standpoint. It reflects someone who has recently worked in the
system and studied its flaws exhaustively. The Guaranteed Healthcare Access Plan
offers what may be the most functional and realistic plan for health care reform in the
USA. One of its strengths is that system oversight decentralizes to regional boards
responsible for regulation and outcomes tracking. It offers the possibility for regional
outcomes comparisons and financial structuring around regional population health
needs. The main problem with this plan is that he wrote it before the current economic
reality. For example, partial financing of the plan comes from a 10% value added tax on
goods and services. These taxes, commonly implemented in developing countries to
make up for their inability to collect individual income taxes, often adversely affect the
poor and middle classes. He also theorizes that companies will raise wages because
they no longer have to pay for employee insurance. Given the recent behavior of cor-
porations and the current economic reality, I see little evidence that would suggest
they would give average employees a raise when they have just saved millions by no
longer providing health care insurance.
Of the three solutions, Emanuel’s plan is the most creative and may be the most
politically feasible. As a practitioner and researcher, it made the most sense to me at
individual, implementation and intellectual levels. Where all three plans could find
themselves caught off guard is their failure to address the multitude of human resources
issues that will emerge from any health care reform in the USA. Apart from the current
registered nurse shortage, lessons from Massachusetts health care reform have already
shown that universal coverage will create a primary care provider shortage whose
solution cannot be simply expanding medical school enrollment levels. The human
resources requirements to implement universal coverage in the USA will generate
radical shifts in the organization of health care work that will change the balance of
political power among the professionals who deliver health care services. No plan for
health system reform is complete without a section that outlines what kinds of human
resources will be needed to implement the reform.

Reviewed by Allison Squires, University of Pennsylvania, Center for Health Outcomes and
Policy Research, PA, USA

References
1
Freidson E. Professional dominance. New York, NY: Atherton Press, 1970.
2
Freidson E. Professional powers. Chicago, IL: University of Chicago Press, 1986.

Nursing Ethics 2009 16 (5)