With the appointment of Hillary Rodham Clinton to direct the
national health care reform process and his vow to present a plan
to Congress in 100 days, President Clinton has acknowledged the
urgency of resolving the health care crisis.
The debates rage on over legislation to contain the explosive
costs of health care, and ensure universal access to care.
Underlying this lack of consensus in Washington, D.C., is a
growing momentum of intellectual resources and energy on the
state level to resolve the inefficient and inaccessible health
As states take on resolution of the health care crisis within
their own borders, two questions arise: Can reform on the state
level be successful? What can we expect in the future of health
care? By examining several examples of state reform plans and
analyzing Oklahoma's own proposal, one can assess the viability
of state health care reform plans and obtain some directive for
Three states exemplify some of the diverse mechanisms for
change in health care systems being pursued.
Hawaii _ Considered a leader in health care reform, Hawaii has
achieved wide insurance coverage through two pieces of
legislation. Since 1974, employers in Hawaii have been required
to provide insurance for all full-time workers through the Health
Employers pay at least one half of the premiums, and the
employee must not pay more than 1.5 percent of his or her wages.
For smaller businesses, a premium supplementation fund was
established. This coverage plan also requires insurers to accept
In 1988, the State Health Insurance Program was enacted to
increase coverage opportunities by providing for those residents
not included in the previous legislation. It subsidizes the costs
of premiums to individuals on a sliding scale and offers low cost
insurance to people with incomes below 300 percent of the poverty
These two major pieces of health care reform, in addition to
Medicaid, have achieved almost 93 percent coverage of Hawaiian
residents. A significant aspect of Hawaii's system is the fact
that only two insurers exist: a local Blue Cross-Blue Shield
affiliate and Kaiser Permanente, a health maintenance
Both insurers favor primary and preventive care, which results
in less time for patients in hospitals. This is the main reason
for Hawaii's low health costs. The two competitors act as cost
regulators as they compete for clients.
A final noteworthy aspect of Hawaii's plan is a health
planning agency established to control medical technology in
order to avoid duplication and waste. Problems exist in Hawaii's
plan, especially with regard to cost shifting. Because hospitals
are having a difficult time keeping up with costs, privately
insured patients are often charged more to cover the insufficient
reimbursements received through Medicaid patients. Employers
shift increased cost to their employees in the form of higher
Minnesota _ Another site for studying health care reform can be
found in Minnesota, where half of the population belongs to
health maintenance organizations. In this type of situation, the
opportunity exists for health care providers to be major
participants in leading the state through the reform measures
mandated in April 1992 by the establishment of MinnesotaCare.
This law establishes a commission to advise, enforce and
recommend cost containment measures. The commission is made up of
providers, payers, employers and consumers and has set a goal of
reaching an annual 10 percent decrease in the increment in health
care spending. The law also enacts state-subsidized insurance for
low income Minnesotans.
Payment is set by a sliding scale according to income.
Coverage began for uninsured families with children that earn up
to 185 percent of the federal poverty level on Oct. …