International perspectives: USA/Hawaii.

Most of the factors that underlie Hawaii's current healthcare system were in place by 1950. Many of its healthcare features were shaped during the period from the eighth century AD until the revolution in 1893. Early chiefs made care available for the entire population through specially trained kahunas, or priests, who specialized in healing. There was a uniform, seamless healthcare system. The historical legacy, which came through from the early days, fostered the existence and acceptance of group and salaried practice by physicians, acceptance by employers of the responsibility to provide healthcare to workers, capitated payments to providers, focus on outpatient services, and historically short hospital lengths of stay. The success of Hawaii's system is rooted in its past. Whether other states could or should adopt Hawaii's system is conjectural. In Hawaii healthcare reform is not a new paradigm but rather an evolutionary phenomenon.