The Skeleton Key: Will the Federal Health Care Reform Legislation Unlock the Solutions to Diverse Dilemmas Arising from the State Health Care Reform Laboratories?

Article excerpt

     A. The Hawaii Prepaid Health Care Act
     B. Hawaii's Coverage Outcomes
     C. The Impact of the National Health Reform Law
        on Hawaii
     A. The Dirigo Health Reform Act
     B. Maine's Coverage Outcomes
     C. The Impact of the National Health Reform Law
        on Maine
     A. The Health Care Affordability Act
     B. Vermont's Coverage Outcomes
     C. The Impact of the National Health Reform
        Law on Vermont


Almost two years ago, the late Senator Edward Kennedy declared:

   For me, this is a season of hope, new hope for a justice and fair
   prosperity for the many and not just for the few, new hope. And
   this is the cause of my life, new hope that we will break the old
   gridlock and guarantee that every American--north, south, east,
   west, young, old--will have decent, quality health care as a
   fundamental right and not a privilege. (1)

Today, Senator Kennedy's "new hope" for universal health care coverage is a reality. In March 2010, Congress finally enacted nationwide health care reform and an overhaul of the United States health insurance system, which aims to deliver near-universal coverage for all Americans. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (2) ("PPACA") and, on March 30, 2010, he signed the Health Care and Education Reconciliation Act of 2010 (3) ("HCERA") (collectively the "Reform Law"), together representing the biggest overhaul of the United States health care system in the last 50 or 60 years. (4) The Congressional Budget Office has predicted that the final legislation "will provide coverage to more than 95% of all Americans." (5)

The significance of the federal health care reform legislation cannot be understated; the 111th Congress has succeeded where so many before have failed. (6) Still, Congress has arrived "late to the health care reform ball," as a number of states, starting with Hawaii in the 1970s, and more recently, Maine, Vermont and Massachusetts, have been progressing towards universal health care coverage for many years. These states have often been described as laboratories of innovation for health care reform efforts. (7) In fact, Massachusetts' recent health care reform legislation is seen as a model for the Reform Law. (8)

Given that the Reform Law is not operating on a blank slate, this article examines its impact on the health care reform efforts of three states: Hawaii, Maine, and Vermont. More specifically, this article examines each state's health care reform plan, the outcomes of each plan in terms of achieving universal coverage or near-universal coverage, and the likely impact of the federal health care reform legislation on these plans, with a particular focus on how the federal legislation and state laws will or will not work together to achieve near-universal coverage. The article aims to determine whether the Reform Law unlocks the solutions to some of the dilemmas resulting from state health care reform efforts, or whether the Reform Law fails to do so or even exacerbates existing problems.

This article focuses on the health care reform efforts of Hawaii, Maine and Vermont for three reasons. First, each of the three states has taken different approaches toward achieving universal coverage. Second, all three rank highly in terms of their low rate of uninsured residents, but have yet to achieve near-universal or universal coverage. (9) Third, Maine and Vermont were chosen because the Kaiser Family Foundation has identified those two states as two of three states, Massachusetts being the third, which have enacted universal health care coverage legislation. (10)


A. The Hawaii Prepaid Health Care Act

Hawaii may be viewed as the "grandfather" of state health care reform in the United States, given that it first implemented health care reform over 30 years ago. …


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