Hawaii’s Lessons in Universal Coverage Useful In Framing The Health Care Reform Discussion

Emily Friedman, in her recent piece “Almost Paradise” featured in Hospitals & Health Networks, gave a great history of Hawaii’s efforts to establish and maintain universal health coverage for its residents (it ranks second among the states in terms of population coverage). And, while the history was fascinating in terms of its magnification of the issues being discussed today in Washington, Ms. Friedman’s “ten lessons learned” were even more compelling for thinking about our current reform efforts:

1. Every state is unique. Whatever the health care reform prescription coming out of D.C., if it is a ‘national’ as opposed to state-based approach, variation at the state level is key to long-term success.
2. The right people have to be in the right places at the right time. To get big initiatives passed, alignment behind core tenets is necessary in several sectors of government. Given the current state of certain parts of the U.S. Congress (the ‘just say no’ contingent), this is problematic—it’s hard to figure out what they would support.
3. The political, economic, and cultural environments have to be right. Passing an expansion of health care coverage is difficult now given the economics. The proponents need to do a better job of making the case for expansion of health care coverage in the current context.
4. Having a predominantly nonprofit health care sector helps. In Hawaii, at the time that health care reform was passed, the health care sector was predominantly non-profit. In the current debate, there has been no end of the controversy about the role of for-profit sectors of the U.S. health care system.
5. If costs are not controlled, nothing will work in the long term. If costs keep on escalating, there is no coverage program in the world that can continue to function—public or private, employer-based or individual.
6. Mandates help but are difficult to enforce. Whether mandates to purchase insurance or mandates to provide coverage or mandates for taxation, mandates are easy to pass and hard to enforce. Complete compliance can never be assumed.
7. Truly universal coverage is impossible to achieve. "Universal coverage" is a great goal but a practical myth. Some small percentage(5% is a common figure cited by scholars ) of people participate, even if the coverage is free.
8. Providers can (or will) absorb only so much loss. There is much discussion about the end of fee-for-service and moving risk to provider organizations. This is a great potential model but cannot be the only cost containment measure.
9. Don't underestimate your opponents. Those who oppose an idea are generally more fervent than those who support it, especially when the benefits will largely go to people other than themselves.
10. All situations change over time. Flexibility needs to be built into any health care reform initiative. Accommodation of change (financial, political, technological, etc.) are necessary for health policy initiatives to last.