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Donald B. Louria, MD
University of Medicine and Dentistry of New Jersey Newark

JAMA. 1993;270(17):2052.

	Since this article does not have an abstract, we have provided the first 150 words of the full text PDF and any section headings.

To the Editor.

—Hawaii adopted an employer mandate in 1974 as the Prepaid Health Care Act, and according to a May 19 article in JAMA,¹ this is responsible for reduced health care costs and better health indexes, including far fewer productive years lost. Drs Lewin and Sybinsky indicate that in Hawaii the emphasis is on ready access and outpatient care. They suggest the Hawaiian program be adopted nationally.

All this may be true, but is the hypothesis adequately documented? The following should be noted:

1. A lower breast cancer death rate is frequently cited, but according to a Centers for Disease Control and Prevention (CDC)2 publication, in 1979, breast cancer deaths in Hawaii were 40% lower than the rest of the United States. The Hawaii employer mandate was started in 1974 and implemented primarily in the 1980s and therefore could not account for the lower rate. Furthermore, if early intervention
   

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