Health system reform legislation (HSRL) is the most domestic issue facing the United States Congress, and a comprehensive bill may become law in early-mid 2010. If so, states will likely be required to take significant, costly actions within the next several years. Stay tuned for updates discussing the role of the states. Meanwhile let us focus upon four states (Hawaii, Maine, Massachusetts, and Vermont) that enacted comprehensive health system reform plans on their own.

Hawaii

Established January 1, 1975, the “Prepaid Health Care Act” was developed and ushered through the legislature in 1975 to parallel to the proposal President Richard Nixon was proposing to Congress. Employers contested the new law, and it went through nearly a decade of legal challenges before the US Supreme Court nullified it on the basis of violating the federal law ERISA. ACC CEO Jack Lewin, an activist physician in the state who was appointed to the Cabinet of then Governor Waihee in 1985 as the State Director of Health, helped assure that the US Congress provided an ERISA exemption to the state to allow the law to be fully implemented---ALL employed workers (and most of their families) were guaranteed private health coverage. The law requires nearly all employers to provide health insurance to employees who work 20 hours or more a week for four consecutive weeks. Employees must maintain the minimum of at least 20 hours a week to remain eligible. To date, Hawaii is the only state that has implemented an employer mandate.  Hawaii has one of the highest rates of individuals covered under employer-sponsored insurance. After the Prepaid Health Care Act became law the uninsured rate in Hawaii dropped from 30 to 5 percent. However, since then it has risen to 10 percent. The “Prepaid Healthcare Act” is viewed by many as a model for reform due to its success in providing cost-effective quality coverage. 

The Act requires a fixed formula that requires employers to contribute 50 percent of the premium cost for single coverage, and the employee must contribute to the balance. The employee's share can not exceed 1.5 percent of his or her wages. Additionally, coverage benefits must be equal to those provided by the plan with the largest number of subscribers in Hawaii.  Some employers including approved seasonal employment, insurance agents and real estate salespersons paid solely by commission and small business owners with no employees are exempted from the Act's requirements. As a result of the law, Hawaii's access to primary care, prevention services, and the state's morbidity and mortality rates are among the lowest in the nation.  

Maine

In 2003 Maine became the first state to pass universal access legislation with the Dirigo Health Reform Act. The goal of this legislation is to provide every citizen of Maine access to health care by 2009. It includes three aspects: a new health plan to achieve universal access to health coverage; new and improved systems to control health care costs; and, initiatives to ensure the highest quality of care statewide. Under this health plan Maine businesses with 50 or fewer employees, the self-employed, and individuals an affordable, high-quality option for health coverage. Enrollees receive discounts on monthly payments and reductions in deductibles and out-of-pocket expenses based on their income and family size.

Massachusetts

The Massachusetts legislature enacted the “Access to Affordable, Quality, Accountable Health Care” on April 12, 2006 and sent it to then Governor Mitt Romney for his signature. Chapter 58 of the bill reflects a 16 month debate and series of compromises between Democrats and Republicans aimed at ensuring universal access. The final bill passed with four "nay" votes out of 200 Senate and House members. The law pulled together a number of strategies targeting various uninsured populations, including an individual mandate requiring that almost all residents have health insurance by July of 2007. It also created the Commonwealth Health Insurance Connector, which assists small businesses and individuals in navigating the insurance world. In May 2009, the Massachusetts Taxpayers Foundation produced a report that evaluated the fiscal impact of the legislation. The report concluded that Healthcare Reform has had a marginal impact on state spending.

Vermont

Vermont enacted the Health Care Affordability Act (H861) in 2006 to address soaring health care costs.  An integral piece of this reform is a new health insurance program called Catamount Health. This comprehensive legislation provides affordable coverage for the uninsured by focusing on better management of chronic care and making health care affordable and accessible.

Since 70 percent of health care costs in Vermont can be attributed to care for chronic condition, the Vermont reform keys in on chronic care management. The act makes chronic care management more accessible by establishing a system including

early and coordinated screening for conditions such as diabetes and asthma, better management of chronic care and an emphasis on patient self-management and waiving co-pays for patients who seek appropriate care. Additionally, the act changes the provider reimbursement system to encourage excellence in chronic disease management. 

Through Catamount Health, everyone who is uninsured for 12 months or more will have access to, as well as help paying for a comprehensive health insurance package, following policymakers’ guiding principle that everybody is covered and everybody

pays. The plan is offered by the private sector and subsidized with public funds through a sliding scale for anyone under 300 percent of poverty.  The program will be financed with sliding-scale co-pays, tobacco taxes, Medicaid dollars, and an employer assessment. State fiscal obligations are controlled through enrollment caps.

For more on state health system reform, visit the National Governors Association and National Association of State Legislatures.