Hawaii's near-universal health insurance--lessons learned.

To date, Hawaii is the only state to have implemented near-universal health insurance. The cornerstone of this program is the country's only requirement that employers provide health insurance for all employees who work at least 20 hours per week. Combined with low unemployment, voluntary modified community rating by health insurers, and expanded Medicaid and Medicare, this employer mandate has been part of a patchwork mechanism that insures upwards to 95 percent of the state's population. Indeed, by adding a state-sponsored gap group-insurance program, Hawaii may now insure in excess of 95 percent of its population. The program has generated good health outcomes, good consumer satisfaction, and relatively modest overall health care expenditures. But for all that near-universal insurance provides, there is still a great need for community-based preventive and primary care programs with outreach and family support services. In addition, traditionally underserved populations continue to be at increased risk. Both funding reform and continued infrastructure development must occur to achieve universal access to care.