Hawaii: A Sane State

[Tender Branson]

In Hawaii’s Health System, Lessons for Lawmakers

HONOLULU — Imee Gallardo, 24, has been scooping ice cream at a Häagen-Dazs shop at Waikiki Beach for five years, and during that time the shop has done something its counterparts on the mainland rarely do: it has paid for her health care.

Ms. Gallardo cannot imagine any other system.

“I wouldn’t get coverage on the mainland?” Ms. Gallardo asked. “Even if I worked? Why?”

Since 1974, Hawaii has required all employers to provide relatively generous health care benefits to any employee who works 20 hours a week or more. If health care legislation passes in Congress, the rest of the country may barely catch up.

Lawmakers working on a national health care fix have much to learn from the past 35 years in Hawaii, President Obama’s native state.

Among the most important lessons is that even small steps to change the system can have lasting effects on health. Another is that, once benefits are entrenched, taking them away becomes almost impossible. There have not been any serious efforts in Hawaii to repeal the law, although cheating by employers may be on the rise.

But perhaps the most intriguing lesson from Hawaii has to do with costs. This is a state where regular milk sells for $8 a gallon, gasoline costs $3.60 a gallon and the median price of a home in 2008 was $624,000 — the second-highest in the nation. Despite this, Hawaii’s health insurance premiums are nearly tied with North Dakota for the lowest in the country, and Medicare costs per beneficiary are the nation’s lowest.

Hawaii residents live longer than people in the rest of the country, recent surveys have shown, and the state’s health care system may be one reason. In one example, Hawaii has the nation’s highest incidence of breast cancer but the lowest death rate from the disease.

Why is Hawaiian care so efficient? No one really knows.

In dozens of interviews, doctors and hospital and insurance executives in Hawaii offered many theories, including an active population that is culturally disinclined to hospitals, a significant military presence and a health care market dominated by a few not-for-profit organizations.

But there was another answer: With nearly 90 percent of the populace given relatively generous benefits, patients stay healthy and health providers have the money and motivation to innovate.

If true, it’s a crucial lesson. Health care overhaul efforts at the state and national levels have so far been largely confined to providing bare-bones insurance coverage to those in need. But changing the way care is provided has been given short shrift, and medical experts warn that costs could soar if overhaul legislation passes. After expanding coverage in 2006, Massachusetts is only now tackling the cost problem as expenses continue their inexorable rise.

But the Hawaii experience suggests that overhauling health insurance before changing the way care is provided could work, eventually. With more people given access to care, hospital and insurance executives in Hawaii say they have been able to innovate efficiencies. For instance, the state’s top three medical providers are adopting electronic medical records — years ahead of most mainland counterparts.

The Hawaii Medical Service Association, the state’s largest insurer and a Blue Cross Blue Shield member, recently offered the nation’s only statewide system whereby anyone for a nominal fee can talk by phone or e-mail, day or night, to doctors of their choosing.

Kaiser Permanente Hawaii, which covers about 20 percent of the state’s population, screens 85 percent of its female members ages 42 to 69 for breast cancer, among the highest screening rates in the country.

One result of Hawaii’s employer mandate and the relatively high number of people with health insurance is that hospital emergency rooms in the state are islands of relative calm. In 2007, the state had 264 outpatient visits to emergency rooms per 1,000 people — 34 percent lower than the national average of 401.

Dr. Ray Sebastian splits his time between the emergency room at Kapi’olani Medical Center at Pali Momi and a hospital in Los Angeles. Nearly all of his poorest patients in Hawaii have routine access to family doctors who can provide follow-up care, while fewer than half of those in Los Angeles do, he estimated. So, he said, the emergency room in Hawaii is not clogged with patients suffering minor problems like medication adjustments and cold symptoms, and patient waiting times are a small fraction of those in Los Angeles:

“It’s like greased lightning here,” he said.

Other states tried employer-mandated care only to repeal the efforts after employers threatened to move across state lines. Hawaii’s isolation forestalled such threats, and its paternalistic plantation history made employer-provided care an easy fit.

In interviews, leaders and employers in Hawaii referred with surprising earnestness to an “aloha spirit” and a sense of familial obligation known as ohana to justify providing care to nearly everyone.

(story continues)

http://www.nytimes.com/2009/10/17/health/policy/17hawaii.html

[Simfan34]

If I were a Hawaiian politician, I'd take advantage of my state's tourism based, non easily relocatable economy to implement sweeping progressive programmes. Single payer, vacations time, mandatory paternal leave, unconditional basic income,  free public college, you name it. Already high prices mean the marginal impact would be reduced, whereas in say, Vermont, businesses can easily pick up their bags and go elsewhere.

Be very noisily feminist and pro-multiculturalism, a la the slightly naive segments of the European left or Justin Trudeau, and slightly alarmingly supportive of student activists and their demands, which would also extend to BLM. This is only feasible because there aren't many blacks in Hawaii in the first place. Jack up gas taxes over time to 50% of European levels.

My politics disincline me from thinking this would necessarily end well, but it would make me a progressive hero. Thrown in measures to attract the tech and other new industry, expand Honolulu airport to serve as a Pacific hub, expand the port. Attract affluent Chinese immigrants perhaps? Probably have a "mixed record" on public sector organized labor.

[KingSweden]

If I were a Hawaiian politician, I'd take advantage of my state's tourism based, non easily relocatable economy to implement sweeping progressive programmes. Single payer, vacations time, mandatory paternal leave, unconditional basic income,  free public college, you name it. Already high prices mean the marginal impact would be reduced, whereas in say, Vermont, businesses can easily pick up their bags and go elsewhere.

Be very noisily feminist and pro-multiculturalism, a la the slightly naive segments of the European left or Justin Trudeau, and slightly alarmingly supportive of student activists and their demands, which would also extend to BLM. This is only feasible because there aren't many blacks in Hawaii in the first place. Jack up gas taxes over time to 50% of European levels.

My politics disincline me from thinking this would necessarily end well, but it would make me a progressive hero. Thrown in measures to attract the tech and other new industry, expand Honolulu airport to serve as a Pacific hub, expand the port. Attract affluent Chinese immigrants perhaps? Probably have a "mixed record" on public sector organized labor.

Hawaii is more conservative than you think. The Asian machine is not exactly a liberal bulwark

[Devout Centrist]

A seven year gravedig. Holy sh*t.

[Rules for me, but not for thee]

Actually maybe a good compromise is have states (especially blue/Atlas-red states) go with a state single-payer system each controlled in-state.  Red states could do it too or see if they can really free the market and bust the stranglehold of insurance companies and big pharma.

[Figueira]

A seven year gravedig. Holy sh*t.

I remember when 7 years was a long time. 2009 feels so recent now.

[Devout Centrist]

Actually maybe a good compromise is have states (especially blue/Atlas-red states) go with a state single-payer system each controlled in-state.  Red states could do it too or see if they can really free the market and bust the stranglehold of insurance companies and big pharma.

That's not a good idea, as it would effectively hobble both systems.

[🦀🎂🦀🎂]

If I were a Hawaiian politician, I'd take advantage of my state's tourism based, non easily relocatable economy to implement sweeping progressive programmes. Single payer, vacations time, mandatory paternal leave, unconditional basic income,  free public college, you name it. Already high prices mean the marginal impact would be reduced, whereas in say, Vermont, businesses can easily pick up their bags and go elsewhere.

Be very noisily feminist and pro-multiculturalism, a la the slightly naive segments of the European left or Justin Trudeau, and slightly alarmingly supportive of student activists and their demands, which would also extend to BLM. This is only feasible because there aren't many blacks in Hawaii in the first place. Jack up gas taxes over time to 50% of European levels.

My politics disincline me from thinking this would necessarily end well, but it would make me a progressive hero. Thrown in measures to attract the tech and other new industry, expand Honolulu airport to serve as a Pacific hub, expand the port. Attract affluent Chinese immigrants perhaps? Probably have a "mixed record" on public sector organized labor.

Perhaps this is the aim of Tulsa Gabbard. Although one would be fearful of becoming the left equivalent of Jindal and Brownback.

I do wonder if Hawaii is a bit too peripheral for making national splashes, and its unique nature means its issues are very state specific.

[Simfan34]

A seven year gravedig. Holy sh*t.

Calm down. I was looking for a Hawaii politics thread, couldn't find one. Why make a new one if there's a perfectly good one here?

[Simfan34]

Interesting. Question Crab cake.

Upzone Honolulu and have an affordable housing mandate. Of course it's not that simple, but I'm supposed to be a progressive here (Hey. If Yglesias can get behind it, so can I). Emphasize the "missing middle" and denser single family housing (I'm not completely different here), in line with transit oriented development. Build an elevated rapid transit system in Honolulu as well. A tropical Vancouver, with affordable housing. Have a pied à terre tax, sell to Chinese. Also get them to visit Hawaii more rather than Hainan, just as the Japanese stopped visiting outlying islands.

Be very pro Transgender while I'm at it, restrict homeschooling, have sex and LGBT education. Also best be elected in 2014, endorse Bernie in the primary, and Hillary in the general. Enthusiastically endorse the latter while positioning myself as the successor of the former for 2020 or more likely 2024, challenging Hillary's awful Republican successor.

Hang around Justin Trudeau for some reason, and associate myself with the Swedish Feminist Initiative and their policies. Crib opposition to intervention in Syria from Tulsi Gabbard, but condemn all sides, especially the Gulf and their "moderate" rebels (also the same as real me!) but the Kurds, whom I praise effusively and might just visit on the front lines. For that matter steal the HDP's 50% female, 10% LGBT mandate for the Hawaii Democratic Party's legislative caucus. Possibly stick the word "Social" in their name.

And be ideologically opposed to wearing ties. Not against dressing well, but just wearing ties.

And lobby to accept a (slightly too) large number of Syrian refugees. 10-15,000?

[KingSweden]

Interestingly enough Honolulu is a pretty tall city and they are building a boondoggle of a transit line. Lord knows they need it

[Matty]

Hawaii would be an incredibly healthy state regardless of how it's health system operates. Asians usually have the lowest rates of disease and the state is second only to CO in how active its people are.