Introduction
The rising cost of healthcare, the increasing number of uninsured through the years, and the decreasing number of employers offering private health plans has motivated state governments to reform their health system. One of the reforms that has been implemented in several states is universal health insurance, programs designed to provide health insurance coverage to all. Maine, Hawaii, Illinois, Vermont, Indiana, Washington, and Massachusetts have all implemented universal health insurance reform to one degree or another. Massachusetts, in 2006, implemented the most sweeping program, which includes a provision that mandates individuals to obtain health insurance. While states are considering various reforms to their health systems, from minor changes to major reforms, it is worthwhile to examine established universal health insurance programs.

The Uninsured
The U.S. Census Bureau reports that in 2007 about 45,657,000 people were without health insurance. According to the U.S. Census Bureau, the number and percentage of Americans without health insurance decreased in 2007 when compared to 2006. “The percentage without health insurance was 15.3 percent in 2007, down from 15.8 percent in 2006, and the number of uninsured was 45.7 million, down from 47.0 million” (US Census Bureau 2007). However, the increased number of Americans with health insurance does not seem to be from an increase in the number of people insured through private health plans. The percentage of people insured through private health plans actually decreased, 67.5 percent in 2007 compared to 67.9 in 2006. The percentage of people insured through the government increased from 27 percent in 2006 to 27.8 percent in 2007 (U.S. Census Bureau 2007). Table 1 outlines the number of uninsured in each state.

Table 1: Number of uninsured individuals per state, 2007

State	Number Uninsured	Percent of Population without Insurance
Alabama	549,000	12
Alaska	123,000	18.2
Arizona	1,164,000	18.3
Arkansas	451,000	16.1
California	6,613,000	18.2
Colorado	801,000	16.4
Connecticut	326,000	9.4
Delaware	96,000	11.2
District of Columbia	55,000	9.5
Florida	3,648,000	20.2
Georgia	1,662,000	17.5
Hawaii	96,000	7.5
Idaho	209,000	13.9
Illinois	1,700,000	13.4
Indiana	717,000	11.4
Iowa	275,000	9.3
Kansas	345,000	12.7
Kentucky	570,000	13.6
Louisiana	776,000	18.5
Maine	115,000	8.8
Maryland	762,000	13.7
Massachusetts	340,000	5.4
Michigan	1,151,000	11.6
Minnesota	433,000	8.3
Mississippi	545,000	18.8
Missouri	729,000	12.6
Montana	146,000	15.6
Nebraska	232,000	13.2
Nevada	441,000	17.2
New Hampshire	137,000	10.5
New Jersey	1,348,000	15.8
New Mexico	437,000	22.5
New York	2,519,000	13.2
North Carolina	1,510,000	16.4
North Dakota	61,000	10.0
Ohio	1,322,000	11.7
Oklahoma	631,000	17.8
Oregon	632,000	16.8
Pennsylvania	1,176,000	9.5
Rhode Island	113,000	10.8
South Carolina	721,000	16.4
South Dakota	80,000	10.1
Tennessee	883,000	14.4
Texas	5,962,000	25.2
Utah	340,000	12.8
Vermont	69,000	11.2
Virginia	1,135,000	14.8
Washington	737,000	11.3
West Virginia	254,000	14.1
Wisconsin	451,000	8.2
Wyoming	70,000	13.6
Total	45,657,000	15.3

Source: U.S. Census Bureau, Health Insurance Coverage Status and Type of Coverage by State All People. At http://www.census.gov/hhes/www/hlthins/historic/index.html. Accessed September 9, 2008.

Universal Health Insurance
A few states have programs that seek to provide health insurance to all; however, Massachusetts is the first state to develop a program that mandates individuals to obtain coverage. Below is an overview of universal health insurance programs in Maine, Hawaii, Illinois, Vermont, Massachusetts, Indiana, and Washington.
 
Maine became one of the first states to pass a universal health care bill in 2003 (NCSL 2006). The Dirigo Health Reform Act (Public Law 469) “is a system-wide health reform law designed to afford access to coverage to every man, woman and child in Maine within five years, to bring down the cost growth of health care in Maine and to launch initiatives to continually improve the quality of care provided to Maine citizens” (http://www.dirigohealth.maine.gov/ ). The plan includes three components: 1) a new health plan (DirigoChoice) to achieve universal access to health coverage; 2) new and improved systems to control health care costs; 3) initiatives to ensure the highest quality of care statewide. Dirigo Choice provides discounted health insurance coverage to Maine businesses and municipalities with 50 or fewer employees, the self-employed and uninsured individuals (http://www.dirigohealth.maine.gov/). DirigoChoice operates on a sliding scale. Enrollees obtain a comprehensive policy from Maine's largest insurer, Anthem Blue Cross/Blue Shield, but pay what they can afford according to an income index. The difference is covered by the state (http://www.pbs.org/now/science/dirigodebate.html). Participation in the program is voluntary (http://www.dirigohealth.maine.gov/ ). Approximately 10,000 individuals have enrolled in DirigoChoice (Tomsa 2006).
 
Hawaii enacted the Prepaid Health Care Act in 1974. The act requires employers to provide health care insurance coverage to employees who 1) work at least twenty hours a week for four consecutive weeks; and 2) earn at least 86.67 times the current state minimum wage ($6.25/hour x 86.67 = $542/month). Employees’ contribution is capped at 1.5% of their salary. Hawaii reported that 28,879 full time employees were uninsured in 2002. The Census Bureau reported that only 9.9% of Hawaii’s population was uninsured, the second lowest rate in the nation in 2003-2004 (http://www.hawaii.gov/labor/DO/phc_9-9-05/phc_9-9-05_files/frame.htm). Employers can choose one of three ways to provide coverage to employees: 1) purchase an approved plan; 2) purchase an insured plan of employers’ choice; 3) provide a health care plan that is funded by the employer (http://www.hawaii.gov/labor/dcd/aboutphc.shtml).
 
In 2005 Illinois passed the All Kids Health Insurance Program. Under the All Kids Program, children under the age of 18, if not already covered by parents or another state-sponsored program, could qualify for the insurance program (National Conference of State Legislatures 2006).
Vermont recently passed the Health Care Affordability Act in 2006 (NCSL no date; see also http://www.leg.state.vt.us/HealthCare/catamount.htm) to improve the quality of care, slow the growing costs of health care, and provide insurance to those who are lack coverage. It includes two key sections. The first is a “major change in Vermont’s health care system, from a focus on treating acute illness to managing chronic diseases.  This change will improve the quality of care in the state, while reducing the rate of growth in health care costs” (http://www.leg.state.vt.us/HealthCare/H861_Two_Pager.htm). The second section is the creation of a new health care insurance program, Catamount Health. Catamount Health will help to insure more individuals by creating a new insurance market for individuals without insurance. “Insurers will be invited, not required, to offer products in this market.  Two insurers, Blue Cross/Blue Shield and MVP have already indicated that they would like to participate. There will be one standard plan.  It will look a lot like the typical insurance plan that is offered in Vermont today, with one major difference.  In order to make it as easy as possible for people to get the care they need, there will be no cost to the patient for preventive care such as mammograms or for recommended services for chronic illness, such as eye exams for people with diabetes” (http://www.leg.state.vt.us/HealthCare/H861_Two_Pager.htm). “The second major part of Catamount Health is a mechanism to provide coverage for people who are uninsured, but eligible for insurance through their employers, if the insurance meets coverage standards.  In this case, the state will help with the employee share of the premiums, and with cost sharing (deductibles, coinsurance) for care related to chronic conditions” (http://www.leg.state.vt.us/HealthCare/H861_Two_Pager.htm).
In April 2006, the Massachusetts Legislature passed a “sweeping health care reform package” aimed at insuring the nearly 550,000 uninsured individuals in that state (AP 2006). The increase in the uninsured population is due to slow economic recovery, erosion of employer-sponsored coverage, and reduced uptake by employees as costs have risen (Massachusetts Legislature 2006). The high rate of the uninsured prompted the U.S. Department of Health and Human Services to threaten to eliminate $385 million in Medicaid funding unless the state reduced the number of uninsured people (Belluck 2006).
 
House Bill 4479 (An Act Providing Access to Affordable, Quality, Accountable Health Care) passed the House 154-2 and passed the Senate unanimously 37-0. Governor Romney signed the legislation on April 12, 2006. However, the Governor also vetoed several sections of the bill (Romney 2006) The plan is expected to cover 515,000 uninsured people within three years, leaving less than 1 percent of the population without the protection of insurance (Belluck 2006). It is expected to cost $1.2 billion over three years, but only $125 million of the costs will be new state money; the remainder will come from federal funds and existing state money (Belluck 2006). The Massachusetts Legislature completed a report in early April 2006 outlining the provisions of the legislation (http://www.mass.gov/legis/summary.pdf).The key provisions are:
 

1. Commonwealth Health Insurance Connector
   a. The Connector certifies and offers products of high value and good quality that individuals can purchase using pre-tax dollars.
   b. Any Massachusetts business with fifty or fewer employees can designate the Connector as its insurance plan. Workers will be able to select from several plans offered by the Connector. Workers will also be able to switch plans during an annual open enrollment period and they will be able to keep coverage if they change employers.
   c. Individuals will also be able to buy coverage directly through the Connector.
    
   
2. Insurance Market Reform
   a. Merges the non-group and small group markets in July 2007. Also enables HMOS to offer coverage plans that are linked to Health Savings Accounts.
    
   
3. Subsidized Health Insurance
   a. Creates a subsidized health insurance program called the Commonwealth Care Health Insurance program. Individuals who earn less than 300% of the Federal Poverty Level and are ineligible for MassHealth will qualify for coverage. Premiums are on a sliding scale, and there are no deductibles.
    
   
4. Medicaid Waiver
   a. The bill meets the terms set by the Centers for Medicare and Medicaid for renewal of Massachusetts’ 1115(a) MassHealth demonstration waiver.
    
   
5. Medicaid Expansion, Restoration, and Enhancements
   a. Expands Medicaid coverage by providing $3 million for comprehensive community based outreach programs to reach people who are eligible for Medicaid but not yet enrolled; expands eligibility to children.
   b. Restores all MassHealth benefits that were cut in 2002, including dental and vision services, creates a 2-year pilot program for smoking cessation treatment.
    
   
6. Individual Responsibility for Health Care
   

In 2007, Indiana enacted the Healthy Indiana Plan (HIP) to insure the working poor and uninsured (NCSL 2007; see also http://www.in.gov/legislative/bills/2007/HE/HE1678.1.html). One main component of HIP was to help insure those without insurance so that those who were insured were not paying the bills for the uninsured through increased insurance premiums (Robb and Verma 2008). HIP is available for persons nineteen to sixty-four years of age that have been devoid of healthcare coverage for a period of about 180 days and have an income that is less than 200 percent of the Federal Poverty Level. Indiana subsidizes HIP; however, HIP is provided through private health companies. HIP members pay monthly premiums from two percent to five percent of their incomes. In order to avoid the pitfalls of permanent budgetary obligations to HIP, the bill included an anti-entitlement provision. A forty-four cent increase in the cigarette tax partially funds HIP (Robb and Verma 2008).
 
The State of Washington also chose to implement health system reform in 2007. Senate Bill 5930 established a government sponsored health insurance program (http://www.leg.wa.gov/pub/billinfo/2007-08/Pdf/Bills/Senate%20Bills/5930-S2.E.pdf). The program is available to individuals based on their income. The bill also calls for "insurance market reforms, and the establishment of an "entity that pools insurance together to offer more affordable, insurance options to individuals" (NCSL 2007).
 
Conclusion
With nearly 45 million people living without health insurance, states are seeking solutions. Already established plans to provide health insurance coverage, such as those in Maine, Hawaii, Illinois, Vermont, Indiana, Washington, and Massachusetts, may be a model for other states who seek a solution to the rising number of the uninsured.

Reference List:
 
Associated Press. 2006. Mass. Lawmakers Approve Mandatory Health Care Plan. April 5. Accessed at www.foxnews.com.
 
Associated Press. 2006b. Massachusetts Requires Health Insurance for All. April 13. Accessed at http://deseretnews.com/dn/view/0,1249,635199327,00.html.
 
Belluck, Pam. 2006. Massachusetts Sets Health Plan for Nearly All. The New York Times. April 5. Accessed at www.nytimes.com.
 
DeNavas-Walt, Carmen, Bernadette D. Proctor, and Cheryl Hill Lee. 2005. Income, Poverty, and Health Insurance Coverage in the United States: 2004. U.S. Census Bureau, Current Population Reports, P 60-229. Washington, D.C.: U.S. Government Printing Office.
 
Helman, Scott, and Liz Kowalczyk. 2006. Joy, worries on healthcare as Romney signs bill, doubts arise about revenues. The Boston Globe. April 13. Accessed at http://www.boston.com/news/local/massachusetts/articles/2006/04/13/joy_worries_on_healthcare/.
 
Maine. Public Law 469. http://mainegov-images.informe.org/governor/baldacci/healthpolicy/DH-Passed-Signed.pdf.
 
Massachusetts Legislature. 2006. Health Care Access and Affordability Conference Committee Report. April 3. Accessed at http://www.mass.gov/legis/summary.pdf.
 
National Conference of State Legislatures. No date. Vermont: Catamount Health. Accessed at http://www.ncsl.org/programs/health/vermont.htm
 
National Conference of State Legislatures. 2006. Universal Health Care Coverage: 2006 Bills Legislature Fill in the Gaps. Accessed at http://www.ncsl.org/programs/health/universalhealth2006leg.htm.
 
National Conference of State Legislatures. 2007. Side-by-side comparison of 2007 Comprehensive Health Care Reforms: Market Reforms, Subsidized Health Insurance, and Employer Assessments. Accessed at http://www.ncsl.org/programs/health/MarketReforms.htm
 
Robb, Mitchell and Seema Verma. 2008. “Indiana: Health Care Reform Amidst Colliding Values.” May 1. Accessed at http://healthaffairs.org/blog/2008/05/01/indiana-health-care-reform-amidst-colliding-values.
 
Romney, Mitt. 2006. Letter to the Honorable Senate and House of Representatives. April 12.
 
Tomsa, Gloria, Director of Operations, Dirigo Health Agency. 2006. Email communication with author. April 13.
 
U.S. Census Bureau. 2007. Health Insurance Coverage: 2007. Accessed at http://www.census.gov/hhes/www/hlthins/hlthin07/hlth07asc.html