The national uproar over health care reform, centering in Washington, D.C., has not echoed with anything approaching full volume in distant Hawaii. This state’s history with the issue goes back decades, and people have come to expect fairly broad access to health care as simply part of the landscape.

And this week, as oral arguments over the Obama administration’s Affordable Care Act begin before the U.S. Supreme Court, many states are putting their plans on ice until the justices rule, presumably by this summer.

Hawaii, by contrast, is pressing ahead with some of its provisions. Rising costs — and a general consensus that a more affordable health marketplace is a good thing — have made health care "transformation" the current watchword here, regardless of the high court.

Dr. Jack Lewin is one of a few people who understand how the Hawaii perspective developed, even though he was not there at the very start. The original law was enacted in 1974, but as the state’s health director from 1985 to 1994, Lewin, now chief executive officer of the American College of Cardiologists, saw a lot of the revisions play out.

Among the ironies he enjoys noting: Hawaii lawmakers took their inspiration from Republican health policy wonks of the time.

"In President Nixon’s tenure, in the mid 1970s, not anticipating his imminent resignation, Nixon was about to implement nationally what Hawaii has, to counter Sen. Ted Kennedy’s desire for ‘Medicare for all,’ a single-payer approach," Lewin said. "Believe it or not, the Hawaii Prepaid Health Care Act, the idea came out of a Republican administration, intended to be the anti-single-payer model, private health coverage but an employer mandate.

"And what people fail to fully understand was that it was also an individual mandate," he added. "One way or another, you’re paying for your health coverage, either out of lost wages or indirectly you’re paying for it because your employer is paying for it."

The reason that so much of the health policy development took place on Lewin’s watch is that the Hawaii law was challenged before it could be completely implemented. The Employee Retirement Income Security Act (ERISA), which regulates employer health benefits, had been passed at about the same time; the Hawaii law was nullified by the federal act until the state’s congressional delegation won an exemption.

The final roll-out of the law began in the 1980s, years ahead of the debates over the Clinton or Obama models, Lewin said. Nobody here ever anticipated any of the future battlegrounds, most notably the controversy over contraception being provided by religiously affiliated employers.

"The Prepaid Health Care Act is elegantly simple," he said. "It is only a 10-page law. There is not a lot of detail in it. It basically said, ‘Everyone who has a job has to have health insurance, as a shared cost between the employee and the employer.’

"In the simplicity, it didn’t get into details of how religious organizations might be treated differently from organizations," Lewin said. "It was just treating all employees the same."

Even when the state did confront that issue later, he said, it was nothing like the recent national debate over accommodating religious exemptions for issues such as contraception. Religiously affiliated employers who claimed the Hawaii exemption had to see to it that their employees could get access to the services on their own, he said — and it was made broadly available, at low or no cost.

"And that could be through one of the free clinics, like Kalihi-Palama or one of those places, or through Planned Parenthood or some other approach.

"Hawaii has always been respectful of multicultural considerations," Lewin added. "It just didn’t rise to the occasion of being a big loud public argument, for whatever reason. The religious institutions knew they weren’t going to be forced to do something against their will, and the Legislature knew that there were other options for women."

Assuming the federal Affordable Care Act is upheld, the expansion of government-funded Medicaid coverage will deal less of a shock to Hawaii than elsewhere because this state already has a fairly liberal distribution of benefits, including more than the poorest populations.

But health insurers and providers are dealing with the same rising cost curve here as in other states. Partly on their own, and partly spurred by the national conversation over reform, they have started to embrace aspects of the law aimed at reducing waste and delivering care more effectively.

Among the initiatives providers are moving to adopt, said longtime health care advocate Beth Giesting, are the development of electronic medical records that will enable medical professionals to share information on a patient, reducing the likelihood of unnecessary or duplicate tests.

Giesting, formerly chief executive officer of the Hawaii Primary Care Association, last July was appointed by Gov. Neil Abercrombie as the state’s "health care transformation coordinator." It’s a new post created by executive order, according to the announcement at the time, "transforming the organization and delivery of health care services, including payment reform, health information technology and primary care workforce."

Implementing federal health care reform is part of the agenda, Giesting said, but she added that the state remains committed to the legislation’s initiatives at the state level, regardless of what happens to the federal directive.

One of those initiatives: Hawaii Health Connector, the state’s version of the health insurance exchanges intended to create a selection of plans for purchase by individuals and for small businesses otherwise not served in the marketplace.

"It really is almost irrelevant if the courts overturn it," Giesting said. "For one thing, I think Hawaii will go ahead with the exchange, harking back to the fact that having insurance is a value here.

"There almost is no question at all that everyone should have access to insurance."

There are certainly rough seas ahead, however, especially nationally. Some of the critics from conservative think tanks argue that even if the law is entirely upheld by the court, the Affordable Care Act could prove disastrous to providers and consumers alike.

Devon Herrick, a health economist with the National Center for Policy Analysis, said the penalties meant to enforce the mandate are cheaper than buying the insurance.

This means people will continue to "game the system," Herrick said, refusing to buy coverage and passing on costs to the rest of the insured population.

Even the relatively congenial health care environment of Hawaii has started heating up over the next steps. The budding Hawaii Health Connector exchange is a development that has run into some unexpected drama. Last week’s legislative action included some heated testimony from consumer advocacy groups worried that the exchange is being set up as a private nonprofit, which is unaccountable to open-government rules, and that a slate of appointees were industry representatives with financial conflicts of interest.

Among them was Barbara Kim Stanton, executive director of AARP Hawaii, who believes the exchange needs greater transparency and oversight than any nonprofit would allow. That’s all the more reason why, she said, the decisionmakers on the board should not be those with a financial interest in the plans offered on the exchange.

"In July it will become a nonprofit," she said. "You have the foxes in the henhouse, and the lights will go out at that point."

Much of health care reform, locally or nationally, is inevitably going to be turbulent, but observers say that some of it is being whipped up by the political environment, especially in Washington circles. Lewin, for example, pointed out that the reality of contraception availability in Catholic institutions is not what’s being presented in the public forum.

"Many of the Catholic hospitals in the United States are currently merging with other hospitals that are not Catholic," he said. "If you look at those mergers, what’s going on in the mergers is contraception is being offered in the merged entities. That’s how it’s playing out in many jurisdictions."

The Obama law does not yet control rising health care costs or settle on a way to provide better quality primary care, he said, but it makes a start at making America’s "cobbled-together" health care system work more rationally. And the voting public will not want to give up the benefits it already has in place, he said.

"If the Affordable Care Act gets tossed out by the Supremes," Lewin said, "we are going to have to recreate it shortly thereafter because it will be a nightmare.

"Hopefully we won’t go backwards, we’ll go forwards. It’s imperative as a nation."