Comprehensive Reforms:  State Examples

Hawaii | Maine | Massachusetts | Vermont

Hawaii - Prepaid Health Care Act

Established January 1, 1975, The Prepaid Health Care Act requires nearly all employers to provide health insurance to their 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.  This is, in large part, due to the legal restrictions of the federal Employee Retirement Income Security Act (ERISA).  ERISA was passed the same year as the Prepaid Health Care Act and Hawaii  was allowed an exemption from ERISA.  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 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 government services, approved seasonal employment, insurance agents and real estate salespersons paid solely by commission and sole proprietors with no employees are exempted from the Act's requirements. 
Link to text of enacted legislation:
Chapter 393: 1-51
Additional Resources:
The Hawaii Uninsured Project

Maine - The Dirigo Health Reform Act 

In June 2003 Maine became one of the first states to pass comprehensive health care legislation.  The Dirigo Health Reform Act aims to provide every citizen with access to quality health care by 2009. The goals of Dirigo Health are:

• To ensure high quality health care statewide.
• Lower costs through new and improved systems.
• Increase access to health care through DirigoChoice health coverage.

The Act includes a number of cost-containment initiatives, including system-wide health planning, public price disclosure, simplification of administrative functions, reductions in paperwork, and voluntary limits on the growth of health insurance premiums and health care costs.

The Act creates the Dirigo Health Agency, which administers the Dirigo Health plan and establishes the Maine Quality Forum. The Forum promotes quality of care initiatives. A new insurance plan, called DirigoChoice, serves as an affordable health insurance option for small businesses, the self-employed, and eligible individuals without access to employer-sponsored insurance. People earning less than 300 percent of the federal poverty level will be eligible for a sliding scale subsidy for DirigoChoice.

Funding for the Dirigo Health Plan will combine a variety of financing options, including employer contributions, individual contributions, general fund, Medicaid, and the recovery of bad debt and charity care. 
News
High Court Gives Governor A Victory On Dirigo
The Associated Press
Senate votes to expand Maine's role in Dirigo
MaineToday.com, ME - May 25, 2007
NOTE: NCSL provides links to other Web sites from time to time for information purposes only. Providing these links does not necessarily indicate NCSL's support or endorsement of the site.
Link to the Dirigo Health Webpage:
Dirigo Health
Governor Baldacci Unveils Plan to Expand Health Coverage
Blue Ribbon Commission - A Blue Ribbon Commission on Dirigo Health was created pursuant to Executive Order 14  (dated May 24, 2006) to make recommendations with respect to long-term funding of Dirigo Health and cost containment methods in order to continue the efforts of Dirigo Health
Link to the text of enacted legislation:
Me. Rev. Stat. Ann. tit. 24-A, § 6901-15 - Establishes the Dirigo Health Reform Act. Arranges for the provision of comprehensive, affordable health care coverage to eligible small employers, including the self-employed, their employees and dependents, and individuals on a voluntary basis.
Additional Resources:
Dirigo Health Reform Act: Addressing Health Care Costs, Quality, and Access in Maine

Massachusetts Passes Universal Health Care Package:
"An Act Providing Access to Affordable, Quality, Accountable Health Care"

The Massachusetts legislature enacted its comprehensive health care reform package  on April 12, 2006 and sent it to Governor Mitt Romney for his signature.  The law, the "Act Providing Access to Affordable, Quality, Accountable Health Care," Chapter 58 of the Acts of 2006 [full text], reflects a 16 month debate and series of compromises between Democrats and Republicans aimed at ensuring that all citizens have access to health care; the final bill passed with four "nay" votes out of 200 Senate and House members.  Senate President Robert Travaligni told State Legislatures Magazine, "We started on a marathon course few have finished.  There have been no easy solutions to the health care crisis, but I believe we have produced a blueprint of creative programs that serve as a template for other states."  The law pulls 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 creates 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 impact of the state's health reform on costs. The report concluded that Healthcare Reform has had a marginal impact on state spending. Click here to view the full report.
* Commonwealth Connector
* Commonwealth Care: Frequently Asked Questions
* "Health Insurance Coverage in Mass.: Estimates from the 2008 Health Insurance Survey" (Mass. Division of Health Care Finance and Policy Report,12/2008)
* Health Reform Progress Report, 2007-2008 (Massachusetts, 102 pages)
     "Two years after passage of Massachusetts’ landmark Health Care Reform law, nearly 440,000 individuals are newly insured. Nearly half of the newly covered are enrolled in private plans with no government subsidies. To date, there is little evidence of crowd-out, or the shifting of enrollment from the private to the public sector. ."
* Governor Deval Patrick's six weeks on intense negotiations with health insurance plans CEOs results in lower prices more in-line with 2006 predictions.

* Connector Commonwealth Care Enrollment Contribution Tables
* Authority Expands Access

Hear from the Programs' Creators:
Presentations from the Annual Meeting session, Massachusetts Health Reform
Speaker of the House Salvatore F. DiMasi
Senator Richard T. Moore
Heritage Foundation's Center for Health Policy Studies Research Fellow Edmund F. Haislmaier

More information on MA:

• Massachusetts released affordability definitions in 2007; click here for more information: link 
• Legislature's act summary, PowerPoint presentation
• Governor Romney's partial veto message, press release 
• Note: The Legislature overturned all but one (Section 112) of Gov. Romney's vetos
• NCSL's State Health Notes Article 
• Kaiser Comission on Medicaid and the Uninsured's Brief: Link

Vermont - Catamount Health

In order to address soaring health care costs, Vermont passed the Health Care Affordability Act (H861) in 2006.  An integral piece of this reform is a new health insurance program called Catamount Health.  This program, a comprehensive model of healthcare, provides affordable coverage for the uninsured by focusing on two major components: 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 pay for a comprehensive health insurance package, following a guiding principle that everybody is covered and everybody pays.  The plan will be 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.

Link to the text of enacted legislation:
Act No. 191 (H. 861) An act relating to health care affordability for Vermonters.
Act No. 190 (H. 895) An act relating to Catamount Health.

Link to the Vermont Legislature Catamount Health Webpage:
Catamount Health

Link to the Catamount Health Webpage:
Catamount Health 

Lessons Learned-Report from October 2009: 
The Vermont Experience

Compiled April 2007; additions November 2009