The health care reform plan instituted in Hawaii in 1974 with passage of a law which required all employers to provide health insurance for all employees working 20 hours a week or more. For the indigent and Medicaid, the insurance is subsidized by the government. Over 95% of Hawaiians are covered by health insurance vs. about 85% on the mainland. Hawaiians claim “near-universal” coverage. The Hawaii plan is advanced by some as a model for the entire U.S., citing Hawaii’s lower spending for health care (9% vs. 13% for the U.S. as a whole, despite a higher cost of living in Hawaii) and its statistical evidence, such as lower rates of hospitalization and lower death rates for certain conditions. Critics insist that we must lower our costs before we can provide as extensive coverage and achieve better health, while Hawaiian advocates claim that the greater coverage in Hawaii provides preventive care which is the cause of the lower costs. Critics also fault Hawaii for the uninsured population which still exists there, and the “makeshift” efforts to close the gap. Hawaii is held up as a model of the successful financing of health care by employer mandate (sometimes referred to as “pay or play”).