IN THE STATES: Sun, Sand and Employer Mandates in Hawaii

Hawaii is a popular destination for anyone seeking sun, sand, surf, or even volcanoes. It's also a top spot for affordable health care coverage.

As The New York Times reported this weekend, Hawaii has the lowest Medicare costs per beneficiary and is tied with North Dakota for the nation's lowest health care premiums. People in Hawaii also tend to live longer than those elsewhere in the United States. As we've mentioned before, Hawaii ranks as one of the top states when looking at health indicators that represent health care access, quality, costs, prevention and treatment, equity and health outcomes.

There are many different theories as to what causes relative health and longevity in Hawaii's population. April Donahue, executive director of the Hawaii Medical Association, told American Medical News Hawaii's population typically has a healthy diet. The Times interviewed a number of doctors and hospitals, and found answers ranging from an active population to a significant military presence to dominance by just a few non-profit insurers in the market.

But the most obvious answer to Hawaii's healthy population may be Hawaii's health care coverage laws. Even with the recession, Hawaii has one of the highest levels of health coverage in the nation, second only to Massachusetts. Of adults under the age of 65, only 10.7 percent are uninsured in Hawaii -- about half of the national rate of 20.4 percent for that age bracket.

Starting in 1974, Hawaii mandated employers provide health care coverage to employees who work more than 20 hours a week. This policy is regarded as an important key to the overall health of the population and the low costs of care, reports the Times. For example, Kaiser Permanente Hawaii covers approximately one-fifth of the state, and of those, it screens 85 percent of 42 to 69 year old women for breast cancer. That's one of the highest screening rates in the U.S.. Hawaiians are the most likely to be diagnosed with breast cancer, but at the same time, the most likely to survive it, according to the Times.

Emergency room utilization is low -- approximately 34 percent lower than the national average. Widespread health care coverage makes it easier to reserve emergency rooms for emergencies, not things like routine prescription refills. Hawaiian hospitals and insurers argue having 90 percent of the population covered frees up resources to fuel innovation --  Hawaii's top three medical providers are in the midst of adopting electronic medical records.

Hawaii's distance from the rest of the mainland U.S. also has a hand in aiding reform efforts, argues the Times. Health providers have less hope of attracting customers from other states (so they didn't feel the need for huge facilities and lots of expensive equipment), and it's more difficult for employers to threaten a move across state lines when they don't like the state health care laws (the Pacific Ocean is a big place). Hawaiians are less likely to get MRIs and less likely to be admitted to the hospital -- but they're still healthier and live longer than people in other parts of the country.

Some policymakers feel Hawaii's system could be a model for health care reform in the rest of the United States. The Times says, "The Hawaii experience suggests that overhauling health insurance before changing the way care is provided could work, eventually." Current Hawaiian law requires health plans have, at minimum, low co-pays, no deductibles, and limited out-of-pocket costs -- a package that is more generous than some of the national health reform legislation currently under consideration, Some Hawaiian employers are concerned national reform will allow competitors to undermine them with cheaper, but lower quality health plans.

Others feel the coverage laws in Hawaii put too much strain on employers. With the economy still struggling, many employers in Hawaii are hiring part-time workers to avoid paying for health benefits, like pizza shop owner Barbara Zacchini -- she has 17 employees who all work under 20 hours per week, reports the Times . Additionally, though Hawaii's distance from the rest of the U.S. may have stemmed excessive cost growth, small hospitals on the state's outer islands are losing money. 

Hawaii's system may not be perfect, but it  looks pretty good from here. The state has taken big steps forward in health care cost, coverage, and improving the overall health of the population, And those are the main goals of  health reform.