Hawai'i's been a leader in mandating employer coverage of health care, but still has a stake in the health care reform debate as Congress looks to expand access and reduce skyrocketing costs.

That's the view of Dr. Jack Lewin, who once served as Hawai'i's health director and now is in the midst of the reform debate as chief executive officer of the American College of Cardiology in Washington, D.C.

"The state acting on its own really can't manage the process of universal coverage in isolation from national policy," said Lewin, who is here to address a meeting of the East Hawaii Independent Physicians Association.

Lewin, who headed the state Health Department from 1986 to 1994 and once ran for governor, is now called to comment on the health care debate as head of the 35,000-member professional society. In recent months he's been called to appear on MSNBC and Fox News as well as writing an opinion piece for Roll Call, a newspaper covering Capitol Hill.

Lewin had a role in overseeing Hawai'i's Prepaid Health Care Act that mandates employer-sponsored health care for full-time workers and a state insurance program at the time that helped provide affordable basic coverage for self-employed people, students and part-time workers.

Today, the state has one of the lowest levels of uninsured residents in the country, at about 8 percent in 2007. But Lewin said Hawai'i could gain from health care reform that expands coverage to all people while coming up with ways to lower costs.

"It's a moral imperative to have everybody with adequate coverage," Lewin said. "It's also an economic imperative."

Lewin said private health insurance premiums may rise 8 percent on average this year, while health care costs are most likely rising twice as fast as the gross national product.

The debate so far has been notable for its partisan fighting and worries about how reform will change what they've got now. There has been back and forth over a number of issues, including a public plan option, whether a single-payer solution will be included and worries that the government will be too intrusive in health care.

"I think they're listening (to reform ideas) but they're so caught up in the political battles," Lewin said. "What we want people to do is get beyond the partisan and look at how we are going to fix health care around the needs of the patients."

He said politicians need to focus on the core issues — ways to expand access, reduce the rate of cost increases and improve quality.

On that last point, Lewin said there should be more attention focused on paying for quality instead of paying for volume.

"We need to change the payment system to reward higher measured quality and better outcomes," he said. For example, 27 percent of Medicare patients with heart failure who are discharged from hospitals are re-admitted within a month.

A focus on a quality outcome could include having a team of providers — doctors, nurses and home care specialists — work in a way that cuts the return trips by making home visits to make sure patients understand medication instructions and other after-hospital care routines.

The cost of having a nurse advise and check on the patient with a home visit is probably around $200; the cost of a re-admission to the hospital of that same patient through an emergency room is around $35,000, Lewin said.

"The concerns I have are the bills coming out of Congress aren't really going to put teeth in to produce this kind of quality improvement and cost-effective care yet," Lewin said.

Still, there is time to make these changes in the next several months. Lewin sees Congress coming up with something before the end of the year. He said President Obama and the Democratic majority in Congress have too much invested politically not to get a bill passed that can be called historic.

"One way or another it's going to happen," said Lewin, who still considers Hawai'i home and tries to get back here on a regular basis.

"It may take three to four years to fix problems in whatever bill is passed. But something is going to come."