But there was another answer: With nearly 90 percent of the populace given relatively generous benefits, patients stay healthy and health providers have the money and motivation to innovate.

Image Richard Caldarazzo, a manager at Lulus Waikiki Surf Club, said restaurants on the mainland had never provided health care. Credit... Cory Lum for The New York Times

If true, it’s a crucial lesson. Health care overhaul efforts at the state and national levels have so far been largely confined to providing bare-bones insurance coverage to those in need. But changing the way care is provided has been given short shrift, and medical experts warn that costs could soar if overhaul legislation passes. After expanding coverage in 2006, Massachusetts is only now tackling the cost problem as expenses continue their inexorable rise.

But the Hawaii experience suggests that overhauling health insurance before changing the way care is provided could work, eventually. With more people given access to care, hospital and insurance executives in Hawaii say they have been able to innovate efficiencies. For instance, the state’s top three medical providers are adopting electronic medical records  years ahead of most mainland counterparts.

The Hawaii Medical Service Association, the state’s largest insurer and a Blue Cross Blue Shield member, recently offered the nation’s only statewide system whereby anyone for a nominal fee can talk by phone or e-mail, day or night, to doctors of their choosing.

Kaiser Permanente Hawaii, which covers about 20 percent of the state’s population, screens 85 percent of its female members ages 42 to 69 for breast cancer, among the highest screening rates in the country.

One result of Hawaii’s employer mandate and the relatively high number of people with health insurance is that hospital emergency rooms in the state are islands of relative calm. In 2007, the state had 264 outpatient visits to emergency rooms per 1,000 people  34 percent lower than the national average of 401.

Dr. Ray Sebastian splits his time between the emergency room at Kapi’olani Medical Center at Pali Momi and a hospital in Los Angeles. Nearly all of his poorest patients in Hawaii have routine access to family doctors who can provide follow-up care, while fewer than half of those in Los Angeles do, he estimated. So, he said, the emergency room in Hawaii is not clogged with patients suffering minor problems like medication adjustments and cold symptoms, and patient waiting times are a small fraction of those in Los Angeles:

“It’s like greased lightning here,” he said.

Other states tried employer-mandated care only to repeal the efforts after employers threatened to move across state lines. Hawaii’s isolation forestalled such threats, and its paternalistic plantation history made employer-provided care an easy fit.