Health care in Hawai'i: An agenda for research and reform

I. INTRODUCTION

In 1999, the United States Census Bureau reported that 16.3% of Americans did not have health insurance in 1998, up from 16.1% in 1997 and 13% in 1990.1 The increased lack of health insurance is particularly troubling because the unemployment rate is down and the economy is vibrant. The Census Bureau also reported that Hawaii led the Nation in providing health insurance, with only 8.8% of the population uninsured.2 This fact alone makes Hawai'i a model for the U.S. Hawai'i's success goes beyond providing health insurance coverage. "Coverage is not care."3 The state is also a model in terms of providing care through community health centers.4 Broad insurance coverage, and access to care through community-- based primary care centers, help to make the people of Hawai'i healthy.5 Further, Hawai'i's health care costs are lower than costs in the rest of the nation.6

Part II of this Article explores the reasons why Hawai'i leads the nation in all these respects. Part III discusses the application of Hawai'i's approach in other states. Two key factors limit the application of Hawai'i's approach to other states: (1) Hawai'i enjoys a unique exemption from the Employee Retirement Income Security Act that sharply limits the ability of the states to try new approaches, and (2) in Hawai'i, important voices of organized labor have supported state mandates, while in other states they have not. Part IV focuses on providing health insurance coverage and care for children, an area in which Hawai'i lags behind national averages and does even worse than many less affluent states.