GEOGRAPHY

Hawaii is situated almost in the center of the Pacific Ocean and is one of the most isolated yet populous places on Earth. The west coast of North America is 2,400 miles from Honolulu, roughly a 5-hour flight by air. Five time zones separate Hawaii from the eastern U.S. This means 9 am in Washington, D.C. is 6 am in Los Angeles and 3 am in Hawaii. Nationally, Hawaii is the 11th smallest state by population size and 4th smallest by land area.

 

The State is composed of 7 populated islands in 4 major counties: Hawaii, Maui, Oahu, and Kauai. The county is the lowest civil subdivision in the state. As a result, counties in Hawaii provide some services, such as fire and police protection, that in other states are performed by cities or towns. Counties also elect a mayor and council. Likewise, the state government is responsible for functions usually performed by counties or cities in other states. Hawaii is the only state, for example, with a single unified public school system. Similarly, Hawaii has no local health departments, but district health offices for each of the three neighbor island counties.

 

Approximately 70% of the state population resides in the City and County of Honolulu on the island of Oahu, concentrated in the Honolulu metropolitan area. The neighbor island counties are Hawaii, Kauai (includes Niihau which is privately owned with restricted access) and Maui (includes Molokai, Lanai, and Kahoolawe-which is unpopulated).

 

Only 10% of the state's total land area is classified as urban. The City and County of Honolulu is the most urbanized with a third of its land area and 96% of its population in urban communities. Most tertiary health care facilities, specialty and subspecialty services, healthcare providers are located on Oahu. Consequently, neighbor island and rural Oahu residents often travel to Honolulu for these services. Interisland passenger travel is entirely by air. Air flights are frequent, but comparatively expensive. Airfare costs can be quite volatile based on varying fuel costs. This creates a financial barrier for neighbor island residents since round-trip airfare costs range from $130 to over $200.

 

Geographic access is further limited because public transportation is inadequate in many areas of the state except for the Honolulu metropolitan area. Over the past five years, the islands of Maui, Kauai, and Hawaii have established limited public bus service, but their use by residents is largely sporadic. Residents in rural communities, especially on the neighbor islands, rely on automobiles to travel to major population centers on their island where health care services are available including primary care, hospital, specialty, and subspecialty services. Because of the mountainous nature of the islands, road networks are sparse and, in some places, limited to a single highway near the coast. Access to emergency care on neighbor islands often requires the use of helicopters or fixed-wing aircraft.

 

DEMOGRAPHICS

The estimated 2018 state population is 1,420,491 residents, the 30th most populous state in the U.S. Oahu (980,080 residents) is home of 69.0% of the state’s population, while 14.1% live on the Big Island (200,983 residents), 11.8% (167,207 residents) in Maui County, and 5.1% (72,133 residents) in Kauai County. From 2010 to 2018, the U.S. Census Bureau estimated an overall growth in the state of 4.4%:  7.5% in the county of Kauai, 8.0% in the county of Maui, 8.6% in the county of Hawaii, and 2.8% in the city and county of Honolulu.

 

ETHNIC DIVERSITY

Hawaii is one of the most ethnically diverse states in the U.S. with no single race majority. According to the 2017 American Community Survey (ACS), 23.3% of the population reported two or more races, and the following single race proportions (White=25.0%, Asian=38.2%, Native Hawaiian or Other Pacific Islander (NHOPI)=10.2%. The largest Asian single race sub-groups were Filipino (15.6%), and Japanese (11.8%) and the largest NHOPI single race sub-group was Native Hawaiian (6.1%). The individual Asian and NHOPI sub groups are listed in the table below and show the heterogeneity of these aggregated Race groupings.

 

Table: Asian and Native Hawaiian or Other Pacific Islander Race Groupings Detail, 2010 Census.

 

 

Those that report two or more race groups are not included in the single race groups commonly reported.  Due to the large proportion with more than one race, recommendations are to report race as “alone” or “alone or in combination” with another group. For example, Native Hawaiian accounted for 21.2% of the state population when reported as “alone or in combination,” compared to just 6.1% when Native Hawaiian is reported singly. There is also variation among race sub groups an overall estimate of 31.6% of those in the Asian Alone or in combination reporting another race but variation in the 3 largest sub groups range from 39.4% in Filipino to 59.7% in Chinese. The other Asian sub groups are likely newer immigrants to Hawaii compared to these three and have smaller numbers reporting more than one race group.

 

Given the state’s unique characteristics, particularly the diversity in ethnicity, language and cultural practices, many best practices may not translate well to Hawaii.

 

Immigration

Hawaii is considered a gateway to the U.S. for immigrants from Asia and the Pacific. According to the 2017 ACS, 18.6% of Hawaii's population is foreign-born, the 6th highest percentage in the U.S. Nearly 39,000 immigrants were legally admitted to the state between 2003 and 2013, mainly from the Philippines, Japan, Korea and Vietnam. Smaller groups of Hispanic immigrants have settled in parts of Maui and Hawaii Islands, attracted by jobs in tourism and agriculture. Estimates of illegal immigrants in Hawaii range from six to nine thousand.

 

Languages Spoken

Because of Hawaii’s ethnic diversity, limited English proficiency poses challenges for educational achievement, employment, and accessing services, and may impact the quality of care for immigrant communities. Based on 2013-2017 ACS, an estimated 25.8% Hawaii resident ages 5 years and over spoke a language other than English at home, compared to 21.3% nationally. An estimated 12.4% of Hawaii residents reported limited English proficiency (4th highest state ranking), compared to 8.5% nationally. Based on the 2009-2013 ACS 5-year estimates, the most common languages spoken at home other than English include Other Pacific Island languages (81,555), Tagalog (58,345), Japanese (45,633), and Spanish (25,490), followed by Chinese (17,360), Korean (17,276) and Vietnamese (9,418).[1]

 

In School Year 2015-2016 (latest available data), 8.3% (13,619) of the state's public school students were enrolled in English Language Learner Program.[2] The top five languages spoken by Hawaii public school students are Ilokano, Chuukese, Marshallese, Tagalog, and Spanish.

 

Compact of Free Association (COFA)

In Hawaii, there is a growing concern over the impact of COFA migrants that includes Federated States of Micronesia, Republic of Marshall Islands, and Republic of Palau. Under the compact, COFA migrants are designated as legally residing noncitizen nationals who can freely live and work in the U.S. This status was negotiated in exchange for allowing the U.S. military to control strategic land and water areas in the region. Prior to 1996, COFA migrants qualified for federal benefits such as Medicaid, Social Security, disability, and housing programs. The passage of the 1996 Welfare Reform Act removed their eligibility to these entitlement programs with the state assuming most of the costs for services.

 

There are reports of high rates of morbidity due to chronic disease (diabetes, obesity, smoking), reports of communicable diseases (tuberculosis, Hansen’s disease/leprosy), and other medical concerns (which may be related to U.S. nuclear tests conducted in the Pacific nations) with additional challenges due to substantial language and cultural barriers within the COFA population. In 2017, the social, health, educational, and welfare system costs attributed to the estimated 14,700 COFA migrants in Hawaii was $147.3 million dollars. Estimates indicate roughly 1,000 migrants are homeless. Migrants account for about 2-3% (400-600) births annually in Hawaii, with low rates of prenatal care utilization, high rates of low birth weight, and recent concerns about high rates of NICU admissions.[3]

 

In 2018, the Title V agency served an estimated 6,485 COFA migrants at a cost of

$2.8M. Programs reporting COFA clients served included WIC, State-funded Primary Care program (for uninsured/underinsured), Hawaii’s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, Family Planning, Perinatal Support Services, and Early Intervention Services.

 

Military

Other sub-populations within the state include U.S. Armed Forces personnel and their dependents which, in 2017, comprise an estimated 7.4% of the state’s population (105,272 people).[4] There are several major military health facilities to serve this population located on Oahu. The Tripler Army Medical Center is the only federal tertiary care hospital in the Pacific Basin. It supports 264,000 local active duty and retired military personnel, their families, and veteran beneficiaries. Medical services are also available on military bases through several clinics for active duty members and their dependents.

 

Homelessness

Hawaii’s 2018 Point-in-Time homeless study estimates the total number of homeless individuals statewide at 6,530. The proportion of unsheltered individuals (53.2%) was higher than sheltered individuals (46.8%). The trend of homeless has declined from 7,220 in 2017. About 36.7% (2,399) of the homeless were part of families, including 16.2% (1,060) children under age 18 years living sheltered, and 295 children living unsheltered.[5]

 

Maternal and Child Population

The 2017 estimates show that there were 265,924 women of reproductive age (15-44 years old) a 1.4% increase from 2010, representing 18.6% of the entire state population.

 

During the last 24 years, the number of births in Hawaii varied from about 17,000 to 20,500 annually. There was a steady increase in the number of births since the late 1990's with about 18,000 births every year in the state over the past 5 years.

 

The 2017 population estimates show that there were 176,901 children 9 years of age or younger in Hawaii, which represents a 3.6% increase from 2010. This group represents 12.4% of the state population. There were 159,029 children 10-19 years of age in Hawaii, which represents a 5.1% decrease from 2010. This group represents 11.1% of the state population.

 

Based on the 2017 National Survey of Children with Special Health Care Needs (CSHCN), there are an estimated 40,367 CSHCN, representing 14.5% of all children ages 0-17 years old.

 

Older Population

Hawaii's population, like the U.S., is aging. Based on 2017 population estimates, persons age 65 years and over comprised 17.8% of the population, compared to 14.3% in 2010. Nationwide, this population comprised 15.6% in 2017 compared to 13.0% in 2010.

 

ECONOMY

Hawaii’s economy is largely driven by tourism, real estate, construction sectors, and military spending. Like the rest of the U.S., the Hawaii economy has improved since the 2009 recession.

 

Economic Growth

The Hawaii State Department of Business, Economic Development and Tourism (DBEDT) first quarter 2019 outlook shows slower but stable growth for Hawaii’s economy, with the final growth rate for 2018 at 1% and forecasted growth for 2019 at 1.2%. This outlook is based on the most recent developments in the performance of Hawaii’s tourism industry, low unemployment rate, labor market conditions, and the growth of non-agriculture payroll jobs and healthcare industries.[6] The state real gross domestic product (GDP) grew 2.0% in 2018, and is expected to grow by 2.3% in 2019 and in 2020. The per capita real GDP in Hawaii was $55,668 in 2017 (in 2012 dollars), $250 or 0.5% higher than the U.S. average.[7] Hawaii ranked 18th among the 50 states.

 

Unemployment

Hawaii unemployment rates reflect the state’s economic recovery. The state’s unemployment rate peaked at 7.4% after the 2009 recession with a record 47,000 individuals unemployed. According to the Bureau of Labor Statistics, the annual average unemployment rate in Hawaii was 2.4% in 2018, 1.5% points lower than the U.S. average of 3.9%.[8] Hawaii ranked the lowest among the 50 states.

 

State Budget

According to the Hawaii Department of Taxation, the State Council on Revenues lowered its forecast for growth in the State General Fund tax revenue in FY 2019 from 4.2% to 3.0%.[9] The Council also maintained its annual growth forecast for FY 2020 to FY 2025 at 4.0%. The Council noted that the decision to lower the estimate was based on the expectation of lower economic growth and lower than expected tax revenue growth. The Council also discussed the temporary effects of the tax law changes of Tax Cuts and Jobs Act passed in December 2017, which may have caused a one-time increase in state tax payments in the prior fiscal year.

 

Tourism

2018 was another record-breaking year for tourism with 10.0 million travelers coming to the islands and visitor expenditures of $17.8 billion. Although vulnerable to changing markets and trends, in 2019, forecasters expect visitor arrivals and visitor expenditures will continue to increase.

 

Poverty

Based on 2017 estimates, Hawaii’s poverty rate was 9.5% (all ages in poverty), lower than the U.S. rate of 13.4%. This represents an estimated 132,549 individuals living in poverty in the state; over 34,441 or 11.5% of those under 18 years of age live in households below the Federal Poverty Level (FPL). Like unemployment rates, poverty rates are variable across counties: Honolulu 8.4%; Maui 9.7%; Kauai 9.5%; and Hawaii 15.0%.

 

The official FPL obscures the struggles faced by many families in Hawaii because of the high cost of living in the state and the generally low wage structure given the dependence of service industry jobs in tourism. The Census Supplemental Poverty Measure, which considers factors such as the cost of living and entitlements, reports that the 3-year average 2015-2017 poverty rate for Hawaii was higher than the official poverty rate of 12.3%.[10]

 

Wages

According to the Bureau of Labor Statistics, average annual wages for employees in Hawaii was $49,671 in 2017, $5,719 or 10.3% lower than the U.S. average of $55,390. Hawaii ranked 24th among the 50 states. Among private sector employees only, the situation is worse. Average annual wages for employees in the private sector was $47,037 in 2017, $8,301 or 15.0% lower than the U.S. average, ranking Hawaii 30th.

 

HIGH COST OF LIVING

Hawaii has the highest cost of living in the nation - nearly 65 percent higher than the national average. In a recent report by Forbes.com, “The Best and Worst States to Make a Living In 2017,” ranked Hawaii as the worst state to make a living. The cost of living is 67% higher than what the average American pays. It also has the second-highest state income tax.

 

Housing Costs

The primary driver for the high cost of living is Hawaii’s housing costs which are the highest in the U.S. Hawaii’s high housing costs create a burden for families, resulting in less income available for other expenses needed for households to maintain optimum health. Lack of affordable housing also forces families to live in conditions that can negatively impact MCH health outcomes. Overcrowded, substandard housing, and homelessness can increase stress and family violence.

 

Based on data from the Honolulu Board of Realtors, in April 2019, the median housing cost for a single-family dwelling on Oahu was $766,750 and for a condominium was $418,950. The median monthly owner mortgage cost in 2017 was $2,337, $824 or 54.5% higher than the U.S. average. Among these homeowners, 29.5% spent 35% or more of their household income, which was higher than the U.S. average of 20.7% (2017 ACS 1-year estimates). Hawaii ranked the highest in the nation for this indicator. Not surprisingly, the homeownership rate in Hawaii in 2017 was one of the lowest in the U.S. (47th among the 50 states) at 58.5%, which was lower than the U.S. average of 63.9%.

 

Rental Costs

Even for working families, the high cost of fair market rent is out of reach. Based on 2017 ACS 1-year estimates, estimated 41.5% of Hawaii residents rent in 2015 (compared to 36.1% nationally). The median monthly gross rent for the renter-occupied units (excluding units not paying rent) in Hawaii in 2017 was $1,573, $561 or 55.4% higher than the U.S. average of $1,012. Hawaii had the highest cost among the 50 states.

 

Multi-generational Households

Another consequence of high housing costs is the high number of multigenerational households. Based on 2017 ACS 1-year estimates, the percentage of multigenerational family households among all family households in Hawaii was 11.1%, which was higher than the U.S. average of 5.9%. Hawaii had the highest rate among the 50 states.

 

Cost of Health Insurance

Health insurance premiums continue to increase annually and can comprise a significant amount of an individual or family’s budget. According to the Hawaii State Insurance Commissioner,[11] the average health insurance group plan premium rate increase significantly declined from 2011 to 2014 to a 4% average annual increase compared to 9.3% average annual increase between 2007 and 2010. The impact of the Affordable Care Act (ACA) on individuals and family budgets/expenses has yet to be determined.

 

Health Services Infrastructure

According to the Hawaii State Health Planning and Development Agency, a 2017 report lists about 105 health facilities in the state.[12] These facilities include, but are not limited to, 28 hospitals,[13] 2 psychiatric only hospitals, 38 federally qualified health centers and rural health clinics.[14] Of the 28 hospitals, 12 are birthing hospitals, and 7 have psychiatric beds. A map of the location of the state’s birthing hospital is in the report “Supporting Documents” section. There are three pediatric hospitals with NICUs on Oahu while other hospitals have less acute pediatric services.   

 

There are 480 family and general practitioners, 130 obstetricians and gynecologists, and 140 pediatricians in the State of Hawaii.[15] Based on the 2017 population estimate (1,427,538), there are 9.1 obstetricians and gynecologists, and 9.8 pediatricians per 100,000 population, which are similar or slightly higher compared to the estimates in the U.S. population while the rate for family and general practitioners in Hawaii (33.6 per 100,000 population) is below the national rate (38.8).

 

HEALTH INSURANCE & HEALTHCARE REFORM

Hawaii has a long history of supporting initiatives to make health insurance broadly available to residents. Hawaii was among the first six states that implemented a Medicaid program in 1966. In 1974, Hawaii implemented its Prepaid Health Care Act (PHCA), which mandated that most employers make health insurance available to employees who work at least 20 hours a week.

In conjunction with the Affordable Care Act (ACA), Hawaii implemented a state-run health insurance marketplace and adopted Medicaid expansion. The marketplace transitioned to a fully federally-run exchange in 2017. Nothing changed for state Medicaid coverage with the switch to Healthcare.gov; the expanded Medicaid eligibility guidelines are still in effect in Hawaii. Through its efforts, Hawaii consistently has low uninsured rates and high overall health scores, although disparities remain.

Hawaii is one of the few states where enrollment in Health Plans through the exchange has increased every year. In 2018, 20,193 people enrolled, a 2% increase over the previous year (19,799). The major gains in coverage have occurred through Medicaid expansion. Under the Medicaid expansion provision of the ACA, coverage increased to 138% of FPL. The number of people on the program rose significantly from 292,000 in 2013 to about 345,709 in 2018.[16] This mirrors the national average of roughly 25% Medicaid coverage of the state population. In Hawaii, Medicaid covers more than 40% of the state’s children. Under ACA more than 20,000 people have enrolled in private insurance and about 53,000 people have enrolled in Medicaid.

With the possible repeal of the ACA, state lawmakers in 2018 integrated some of the more significant pieces of the legislation into the Prepaid Healthcare Act.  Act 111 ensures the following ACA benefits remained available under Hawaii law:

• Ensuring dependent coverage for adult children until the age of twenty-six years;
• Prohibiting health insurance entities from imposing a preexisting condition exclusion; and
• Prohibiting health insurance entities from using an individual's gender to determine premiums or contributions.

 

The ACA provided state-level and provider organization-level demonstation models around innovation.  Nearly 100 practices which represent several hundred primary care physicians are participating in the Comprehensive Primary Care Plus innovation program.  While this is primarily a Medicare program, the impact that practice transformation occurs for all patients, regardless of the payor.  The focus of the program is on screening, prevention, and care coordination.

 

Hawaii Medical Service Association (HMSA), the stateʻs largest insurer, continues its effort in Payment Transformation.  A majority of the stateʻs primary care providers, as of July 1, 2018, are receiving capitated rates. This new payment model continues to receive mixed reviews from the provider community with pediatricians expressing the most concern given the intensive schedule of visits needed for infant care.

 

MEDICAID

The State Medicaid program is administered by the Department of Human Services (DHS) Med-QUEST Division (MQD). QUEST is an acronym that stands for: Quality Care, ensuring Universal Access, encouraging Efficient utilization, Stabilizing costs, and Transforming the way health care is provided. QUEST has 2 basic objectives: to expand medical coverage to include populations previously ineligible for Medicaid and to contain costs by shifting fee-for-service to a managed care delivery system. Savings realized from such a shift would be used to expand coverage. Under this waiver all Medicaid eligibles, excluding those with disabilities and over 65, received their services through managed care.

 

Hawaii’s Medicaid eligibility levels for children are much higher than the national average and about average for pregnant women and parents.

• Children ages 0-18 qualify with family income levels up to 300% of the federal poverty level (FPL)
• Pregnant women qualify with family income up to 191% of FPL
• Parents and other adults qualify with family income up to 1335 of FPL.

 

As of September 2018, The Hawaii Medicaid Progam provided coverage to 348,607 individuals with 112,490 of them being children through traditional, SCHIP, and current and former foster care eligibility rules.[17]  Additionally, the program continues to support medically needy children who are determined to need nursing home level of care.

 

Hawaii's SCHIP program, a Medicaid expansion, covers all children under 19 years of age with family incomes up to 300% of the FPL for Hawaii. There is no waiting period for SCHIP eligibility. All immigrant children who are Legal Permanent Residents or citizens of a COFA nation are enrolled in a Medicaid program under SCHIP.

 

The state continues to provide the most vulnerable COFA migrants, including the aged, blind, disabled, children and pregnant women, with full state-funded Medicaid coverage. COFA adult migrants must enroll through Healthcare.gov. However, the state-funded Medicaid Premium Assistance Program may help, by paying the premiums for eligible COFA migrants and legally permanent residents who have incomes less than 100 percent of the FPL

 

Medicaid beneficiaries have a choice to select medical plans from five participating health plans: AlohaCare, HMSA, Kaiser Foundation Health Plan, 'Ohana Health Plan, and United Healthcare Community Plan. All the health plans will provide services to beneficiaries statewide, except for Kaiser Foundation Health Plan, which has chosen to operate only on the islands of Oahu and Maui.

 

CMS approved the Hawaii State Plan Amendment which eliminated restrictions to telehealth services.  Since January 1, 2017, providers are able to provide and bill for telehealth services through Medicaid.  This puts Medicaid in alignment with commercial insurance.

 

GOVERNMENT

Hawaii’s Executive Branch of government is organized into 16 Cabinet-level agencies. The major health programs are administered at the state level by the Department of Health (DOH) and by the DHS. DHS administers the Medicaid program; while DOH serves as the public health agency for the state. In addition to Medicaid, DHS houses the major social service/entitlement programs (Child Welfare, Temporary Assistance for Needy Families, Supplemental Nutrition Assistance Program, and Vocational Rehabilitation).

 

Similar to the Department of Education, DOH is the only public health agency for the state. There are no local health departments in Hawaii. The state’s three neighbor island counties (Hawaii, Maui and Kauai) are represented by District Health Offices that oversee DOH staffed services at the county level. Contracted services on the neighbor islands are handled directly by the central Title V programs on Oahu.

 

The Governor appoints all state department directors and deputy directors; thus, the Director of Health reports directly to the Governor. The DOH is divided into 3 major administrations: Health Resources Administration (HRA), Behavioral Health (BHA), and Environmental Health (EHA). There are 6 major divisions within HRA including the Family Health Services Division (FHSD), which is responsible for the administration of all Title V funding. The three branches within FHSD are the Maternal and Child Health, Women Infants and Children (WIC) Services, and Children with Special Health Needs Branches.

 

Democratic Governor David Ige was re-elected to a second term in 2018. Dr. Bruce Anderson, PhD, serves as Director of Health. The former FHSD Chief, Danette Wong Tomiyasu is the DOH Deputy Director for HRA. Matthew Shim, PhD., is the FHSD Chief/Title V Director.

 

STATE DEPARTMENT OF HEALTH: CURRENT PRIORITIES & INITIATIVES

The current DOH Strategic Plan is currently under review by the new administration. It is anticipated the plan will remain largely the same with a greater focus on mental health issues. The three strategic plan priorities are:

A. Invest in Healthy Babies and Families;

B. Take Health Where People Live, Work, Learn, and Play; and

C. Create a Culture of Health throughout Hawaii.

 

Many of the strategies and activities in Title V Maternal and Child Health (MCH) 5-Year Plan fall into the Strategic Priority A.

[1] http://census.hawaii.gov/acs/american-community-survey-2013/

[2] Hawaii State Department of Education, English Language Learners, P. 48 of the Consolidated State Performance Report for school year 2015-16 https://www2.ed.gov/admins/lead/account/consolidated/sy145-156part1/hi.pdf

[3] COFA reports are found on https://www.doi.gov/oia/reports/Compact-Impact-Reports . The latest available update is 2017.

[4] Number of armed forces residents and military dependents at http://dbedt.hawaii.gov/economic/databook/2017-individual/_01/

[5] https://www.partnersincareoahu.org/2018-hawaii-statewide-point-time-count

[6] Report on Hawaii’s economy http://dbedt.hawaii.gov/economic/qser/

[7] http://dbedt.hawaii.gov/economic/ranks/

[8] 2016 unemployment rate is found at https://www.bls.gov/lau/lastrk16.htm

[9] General fund forecast on March 15,2019, http://tax.hawaii.gov/useful/a9_1cor/

[10] Supplemental Poverty Measure is found on https://www.census.gov/library/publications/2018/demo/p60-265.html

[11] Based on the news release from the Department of Commerce and Consumer Affairs http://cca.hawaii.gov/ins/news-release-insurance-commissioner-reduces-hmsas-rate-increase-request/

[12] Based on the facility address provided on http://health.hawaii.gov/shpda/agency-resources-and-publications/health-care-utilization-reports-and-survey-instructions/2017-data/

[13] Based on information provided on http://health.hawaii.gov/ohca/medicare-facilities/hospitals/

[14] Based on information provided on https://health.hawaii.gov/docd/files/2013/07/VFC_Centers.pdf

[15] Based on 2017 state data provided in Form 11.

[16] Based on Department of Human Services, State of Hawaii, 2018 Annual Report found on http://humanservices.hawaii.gov/reports/annual-reports/

[17] Based on the 2018 enrollment report from https://medquest.hawaii.gov/en/resources/reports.html