Hawaii’s cost of living is 30 percent higher than it is on the mainland – except, that is, when it comes to health insurance. Hawaii tied with North Dakota for the lowest employer-sponsored health insurance premiums in the U.S in 2008. This in a state with an employer mandate since 1974.

How is Hawaii different from Massachussetts? Let us count the ways. According to the Commonwealth Fund, Hawaiians are healthier, have good access to primary care and have a dominant player in high-performance integrated health delivery in Kaiser Permanente. Notably, Kaiser Hawaii “experienced a 26 percent decrease in the rate of physician visits following implementation of electronic health records.”

So which came first, the coverage chicken or the lower-cost/improved system egg, and how can we be sure that one thing caused the other? Any reform discussion has to acknowledge complex interactions, but that doesn’t mean it would be smart to ignore what’s happened in Hawaii since 1974.