GEOGRAPHY

Situated in the Pacific Ocean's center, Hawaii 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 United States. Hawaii is the 11th smallest state in the nation by population size and 4th smallest by land area.

 

The state is composed of seven populated islands in four major counties: Hawaii, Maui, Oahu, and Kauai. The county is the lowest civil subdivision in the state. Counties provide some services, such as fire and police protection, that are performed by cities or towns in other states. The state government is responsible for functions usually performed by counties or cities in other states. For example, Hawaii is the only state with a single unified public school system. Similarly, Hawaii has no local health departments but has district health offices for 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 urban 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. Oahu is the most urbanized, with a third of its land area and 96% of its population in urban communities. Most tertiary healthcare facilities, specialty and subspecialty services, and healthcare providers are on Oahu. Consequently, neighbor island and rural Oahu residents often travel to Honolulu for these services. Interisland passenger travel to and from Oahu is entirely by air. Air flights are frequent but comparatively expensive. Airfare costs can be volatile based on varying fuel costs. This creates a financial barrier for neighbor island residents since roundtrip 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 healthcare services are available. 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 using helicopters or fixed-wing aircrafts.

 

DEMOGRAPHICS

The estimated 2021 state population is 1,441,553 residents, the 30th most populous state in the U.S. Oahu is home to 69.4% (1,000,890 residents) of the state’s population, while 14.1% (202,906 residents) live on Hawaii Island, 11.4% (164,268 residents) in Maui County, and 5.1% (73,454 residents) in Kauai County. Compared to 2019 (1,415,872),[1] There was a 25,681 (1.8%) population increase in the state.

 

ETHNIC DIVERSITY

Hawaii is the most ethnically diverse state in the nation.[2] According to the 2021 American Community Survey (ACS) data, 26.3% of the population reported two or more races and the following single race proportions: White=22.2%; Asian=37.2%; and Native Hawaiian or Other Pacific Islander (NHOPI)=10.1%. The largest Asian single-race subgroups were Filipino (14.8%) and Japanese (11.6%), and the largest NHOPI single-race subgroup was the indigenous Native Hawaiians (6.3%). The individual Asian and NHOPI subgroups from the U.S. Census are listed in the table below, showing the heterogeneity of these aggregated race groupings.

 

Asian Native Hawaiian and Other Pacific Islander 013 - Asian Indian 014 - Bangladeshi 015 - Cambodian 016 - Chinese 017 - Chinese (except Taiwanese) 018 - Taiwanese 019 - Filipino 020 - Hmong 021 - Indonesian 022 - Japanese 023 - Korean 024 - Laotian 025 - Malaysian 026 - Pakistani 027 - Sri Lankan 028 - Thai 029 - Vietnamese 030 - Other specified Asian 072 - Bhutanese 073 - Burmese 075 - Mongolian 076 - Nepalese 077 - Okinawan 078 - Singaporean 051 - Polynesian 052 - Native Hawaiian 053 - Samoan 054 - Tongan 055 - Micronesian 056 - Guamanian or Chamorro 057 - Melanesian 058 - Fijian 088 - Tahitian 089 - Tokelauan 091 - Carolinian 092 - Chuukese 093 - I-Kiribati 094 - Kosraean 095 - Mariana Islander 096 - Marshallese 097 - Palauan 098 - Pohnpeian 099 - Saipanese 162 - Yapese 164 - Papua New Guinean

 

Reporting is further complicated by the growing category of those with two or more race groups. They are not included in the single-race groups commonly reported. Hawaii State Department of Health (DOH) guidance instructs race data to be reported as “Alone” or “Alone or in Combination” with another group. For example, Native Hawaiians accounted for 26.4% of the state population when reported as “Alone or in Combination,” compared to just 6.3% when reported singly. There is also variation among race subgroups with an overall estimate of 34.2% of those in the “Asian Alone or in Combination” reporting another race. Variation in the three largest Asian subgroups ranges from 36.3% Filipino to 60.6% Chinese. The other Asian subgroups are likely newer immigrants compared to these three and have smaller numbers reporting more than one race.

 

Race	Resident Population in the State (N)	Percent of State Population (%)	Proportion Reporting at least one other Race (5)
White Alone	319,677	22.2%	0
White Alone or in Combination	617,903	42.9%	48.2%
Native Hawaiian or Other Pacific Islander (NHOPI) Alone	145,556	10.1%	0
NHOPI Alone or in Combination	380,825	26.4%	61.8%
Native Hawaiian Alone	90,370	6.3%	0
Native Hawaiian Alone or in Combination	309,807	21.5%	69.3%
Asian Alone	536,161	37.2%	0
Asian Alone or in Combination	814,349	56.5%	34.2%
Filipino Alone	213,337	14.8%	0
Filipino Alone or in Combination	370,594	25.7%	36.3%
Japanese Alone	166,881	11.6%	0
Japanese Alone or in Combination	314,102	21.8%	37.2%
Chinese Alone	86,861	6.0%	0
Chinese Alone or in Combination	220,460	15.3%	60.6%
Source: U.S. Census Bureau. 2021. ACS Calculations by Hawaii DOH, FHSD.

 

Immigration

Hawaii is a gateway to the U.S. for immigrants from Asia and the Pacific and has a sizeable immigrant community. Based on the 2021 ACS, there were 270,345 immigrants in Hawaii, or nearly one in five (18.8%) residents. This is the 6th highest of all states. Hawaii immigrants were 56.2% women and 5.6% children (under 18 years old). The largest ethnic group of immigrants comprised of Asians (75.1%), followed by NHOPI (9.1%) and White (7.6%).

 

Most immigrants in Hawaii (81.7%) speak a language other than English, and 47.4% speak English less than “very well.” About 19.5% had a bachelor’s degree; 9.3% had a graduate or professional degree. Approximately 62.2% of immigrants 16 years and over were employed in the labor force in 2021.

 

Undocumented Immigrant Estimates

According to the Pew Research Center, in 2016, an estimated 45,000 undocumented immigrants were in Hawaii (3.3.% of the population).[3] The majority were from the Philippines. Hawaii was the only state where undocumented women (55%) outnumbered men. The following table summarizes characteristics of Hawaii’s undocumented immigrant population compared to the U.S.

 

Unauthorized Immigrant (UI) Characteristics	Hawaii	US
Unauthorized population	45,000 (3.3% of population)	10.7 million (3.3% of population)
Proportion of all immigrants undocumented	17.0%	24.0%
Proportion of adults in the U.S. for 5 years or less	34%	18%
K-12 students with unauthorized immigrant parent(s)	7.0%	7.6%
Proportion of labor force that is unauthorized	4.5%	4.8%
Industries & occupations with most unauthorized immigrant workers	Leisure/hospitality, service; Agriculture/farming	Construction, Service, Farming

 

DACA (Deferred Action for Childhood Arrivals)

As of March 2020, 340 active DACA recipients live in Hawaii, with 368 people granted DACA status since 2012.[4] As of 2019, 11% of those DACA-eligible immigrants in Hawaii applied for DACA status.

 

Compacts of Free Association (COFA)

COFA migrants come from the Federated States of Micronesia, Republic of Marshall Islands, and Republic of Palau. Under these unique agreements, COFA migrants are legally residing noncitizen nationals who can live, work, and study in the U.S. indefinitely without a VISA or green card. This status was negotiated in exchange for exclusive U.S. military control of strategic areas in the region. The passage of the 1996 Welfare Reform Act removed COFA eligibility to key entitlement programs (Medicaid, Social Security, disability, and housing programs), with the state assuming most of the costs for services. However, in December 2020, Medicaid benefits were restored to COFA migrants.

 

Among COFA migrants, there are reports of high morbidity rates due to chronic diseases, communicable diseases (tuberculosis), and other medical concerns (cancer) that may be related to U.S. nuclear tests conducted in their Pacific nations. Challenges also exist due to language and cultural barriers within the population. Estimates of the COFA population in Hawaii range from 16,680 to 28,000.[5] COFA migrants are consistently overrepresented among homeless surveys and account for about 2-3% (400-600) of births annually in Hawaii, with low utilization rates of prenatal care and high rates of low birth weight and Neonatal Intensive Care Unit (NICU) admissions.[6]

 

In 2019, the Title V agency served an estimated 4,371 COFA migrants at a cost of $2.7 million. Programs reporting service to COFA clients included: WIC; state-funded Primary Care (for uninsured/underinsured); Maternal, Infant, and Early Childhood Home Visiting Program; Family Planning; Perinatal Support Services; and Early Intervention Services.

 

Languages Spoken

Because of the ethnic diversity in Hawaii, limited English proficiency may impact access to healthcare for immigrant communities and poses a challenge to service organizations targeting these populations. According to the 2021 ACS, an estimated 25.8% of Hawaii residents ages 5 years and over spoke a language other than English at home, compared to 21.6% nationally. An estimated 11.1% of Hawaii residents reported limited English proficiency (4th highest state ranking) compared to 8.3% nationally.

 

In School Year 2019-20, an estimated 18.0% (32,044) of the state's public school students are or have been English Learners (EL).[7] The top five languages spoken by Hawaii public school students are Ilokano, Chuukese, Marshallese, Tagalog, and Spanish.

 

Hispanics

Hawaii has areas with a growing Hispanic population. Anecdotally, recent Hispanic workers to the state helped address labor shortages in agriculture (coffee and pineapple farms) and the service and construction industries, primarily in Maui and Hawaii counties. Service organizations report that they originate from Mexico, Guatemala, and Honduras.[8]

 

Disaggregated Data

The state’s unique characteristics, particularly the diversity in race, ethnicity, language, and cultural practices, underscores the need for disaggregated data. When diverse groups are combined, critical differences can be hidden. Disaggregating data can inform and expand understanding of the experiences of population subgroups and help evaluate whether programs are effective at meeting the needs of these groups. It can also help develop policies and programs that are culturally/linguistically accessible. Further, differences in culture and language are important considerations when implementing Evidenced-Based Interventions, especially when the evidence was established with populations different from those in Hawaii.

 

Military

Other subpopulations within the state include the U.S. Armed Forces personnel and their family members. In 2021, Active Duty, National Guard, and Reserve Personnel comprised an estimated 3.6% of the state’s population (51,575 people).[9] There are several major military health facilities to serve this population on Oahu. The Tripler Army Medical Center is the federal tertiary care hospital for 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 clinics for active-duty members and their family members.

 

Homeless

The 2022 Hawaii Point-in-Time homeless study estimates the number of sheltered homeless in the state was 2,224 (1,896 on Oahu and 628 on the neighbor islands).[10] Data for unsheltered homeless was 2,355 for Oahu and 1,224 on the neighbor islands. There was a 13.8% decrease in sheltered homeless compared to 2021 for Oahu and a 1.3% decrease for sheltered homeless for neighbor islands. Compared to other states, Hawaii had the fourth highest homeless rate in the U.S. (41 per 10,000 residents), more than twice the national rate (18 per 10,000).[11]

 

Maternal and Child Population

Based on 2021 ACS data, the estimates show that there were 264,324 women of reproductive age (15-44 years old), a 1.6% decline from 2015 (268,648), representing 18.3% of the entire state population. Vital statistics data show the number of births continued to decrease between 2019 (16,810), 2020 (15,780), 2021 (15,608), and 2022 (15,354).

 

Estimates show there were 164,877 children 9 years of age or younger in Hawaii, representing a 7.1% decrease from 2015. This group represents 11.4% of the state population. There were 168,774 children 10-19 years of age in Hawaii, representing a 3.4% increase from 2015. This group represents 11.7% of the state population.

 

Based on the 2020-2021 National Survey of Children’s Health, there are an estimated 39,320 Children with Special Health Care Needs (CSHCN), 13.2% of all children ages 0-17 years. This is significantly below the national estimate of 19.5%. The 2020-2021 Hawaii estimate was slightly lower, though not statically significant, compared to the 2019-2020 estimate (14.5%).

 

Older Population

Hawaii's population is aging. Based on 2021 population estimates, persons aged 65 years and over comprised 19.6% of the population, compared to 16.6% in 2015. Nationwide, this population comprised 16.8% in 2021 compared to 14.9% in 2015. There are more older people in proportion to younger ones.

 

ECONOMY

Tourism, real estate, construction sectors, and military spending largely drive the economy in Hawaii. Initial COVID shutdowns in 2020 resulted in the virtual closure of the Hawaii tourism market, causing an unprecedented contraction of the state’s economy. Equally unexpected, the economy made an astounding rebound in 2021 with the return of U.S. domestic travelers, driven by healthy U.S. incomes and pent-up demand. According to the Hawaii Department of Business, Economic Development and Tourism (DBEDT),[12] in 2023 the state’s major economic indicators were largely positive in the fourth quarter of 2022. Visitor arrivals, wage and salary jobs, state general fund tax revenues, and private building authorizations increased in 2022 compared to 2021.

 

Tourism

In 2020, during the COVID-19 pandemic, total visitor arrivals decreased by 7,556,762, or 73.8%. However, in 2021, Hawaii experienced a sudden surge in visitor numbers in the second quarter, aided by the availability of COVID vaccines, reduced disease counts, and loosening of safety restrictions across the U.S. By the fourth quarter of 2021, domestic visitor arrivals and international visitor arrivals both increased.

 

Tourism continued to recover in 2022. Total visitor arrivals by air increased by 2,374,674 or 35.0 % compared to 2021 (a 7.7 % increase in domestic flights and a 295.1 % increase in international flights).[13] Visitor expenditures also increased. In 2022, visitor expenditures totaled $19.2 million, an increase of 46.7 % from the previous year.

 

Unemployment

The unemployment rate in Hawaii soared during the early COVID-19 pandemic shutdown from 2.4% in March 2020, the lowest rate in the nation, to 23.8% in April 2020, the highest rate. The 2020 average annual unemployment rate was 11.6% but decreased to 5.7% in 2021 as the economy rebounded. The unemployment rate decreased to 3.5% in 2022 compared to the U.S. average of 3.6%[14] ranking Hawaii the 27th lowest among the 50 states.

 

Job Market

Labor market conditions were mainly positive in 2022: Hawaii averaged 625,200 non-agricultural jobs, an increase of 25,600 jobs or 4.3 % over 2021. The job increase in 2022 was due to increases in both the private and government sectors. The largest increases were in Food Services and Drinking Places, which added 9,500 jobs (16.2% increase), followed by Accommodation, which added 6,300 jobs (19.0%).[15] Natural Resources, Mining, and Construction increased by 1,600 jobs (4.4%), and the Government sector added 2,200 jobs (1.8%) compared to 2021.

 

Wages

According to 2020 data from the U.S. Bureau of Labor Statistics, the average annual wage for employees in Hawaii was $57,934, roughly a 10% increase over 2019 despite COVID shutdowns. Economists believed this was largely due to direct federal stimulus payments/supports, including supplemental unemployment insurance benefits.

 

In 2021, wages overall continued to increase to a smaller extent. The U.S. Bureau of Labor Statistics reported that the 2021 average annual wage in Hawaii was $59,644, 11.8% lower than the U.S. average.[16] However, this is about a 3.0% ($1,710) increase compared to the 2020 average annual wage ($57,934). Hawaii ranked 24th among the 50 states.

 

Income

Per capita, personal income for Hawaii also increased in 2021 ($60,947) from 2020 by 6.7% ($57,109).[17]As noted, income loss from the economic shutdown was offset by government stimulus/relief supports.[18] Federal income and housing support programs were crucial in preventing economic collapse for some families and communities.

 

Per capita income in Hawaii was 5% lower than the national average. After adjusting for cost of living, the per capital income was 12% lower than the unadjusted level.[19] Aggregated income wages do not measure the disparate effect on high- and low-income workers. During the pandemic, professional workers continued to work safely and remotely through 2021, while many lower-income households were dependent on face-to-face service jobs, the hardest hit by COVID. This led to disproportionate economic hardship for these families. This divergence in economic impacts (social and health) reflected preexisting structural inequalities.

 

State Budget/Revenues

The state general fund revenue for 2022 ($9.44M) increased by 16.0% over 2021 ($8.13M), and 47.2% over 2020 ($6.42M).[20] This reflected robust tax collections from tourism’s rapid recovery, renewed consumer spending, and additional tax collections due to inflation. The transient accommodations tax on visitors reflected the largest increase.

 

Based on this, the State Council on Revenues (which sets the state's budget ceiling) lowered its forecast on revenue growth from 5.5% to 2.0% for fiscal year (FY) 2023.[21] Also, it lowered its forecast from 5.0% to 4.0% for FY 2024. The 3.5% decrease in the FY 2023 revision is due to a legislatively mandated taxpayer refund, expected to reduce revenues by $334 million in FY 2023 and lower estimated taxes from individual filers. Lower capital gains income due to poor performance in the stock market and a cooling real estate market is likely to cause lower estimated tax payments.

 

The council acknowledged the risks that may inhibit the economic recovery include new variants of the COVID-19 virus: inflation and the response from the Federal Reserve, high oil and commodity prices, economic disruptions from the war in Ukraine, severe labor shortages, supply chain disruptions, sustained travel hesitancy from Asian markets, and the reduction in Federal stimulus spending.

 

Poverty

Based on 2021 ACS estimates, the poverty rate in Hawaii was 11.2% (all ages in poverty), 1.6% lower than the U.S. rate (12.8%). This represents an estimated 156,735 individuals living in poverty in the state. Over 40,502 (13.6%) of those under 18 years old live in households below the Federal Poverty Level (FPL). Poverty rates were variable across counties: Honolulu 10.2%; Maui 12.1%; Kauai 11.7%; and Hawaii 14.8%. Poverty rates were higher among Native Hawaiians/Other Pacific Islanders (16.5%) and Blacks/African Americans (14.3%), compared to Whites (11.9%) or Asians (7.6%).

 

The official FPL obscures many families' struggles in Hawaii because of the high cost of living and the generally low wage structure, given the dependence on 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 (2019-2021) poverty rate was 10.5% in Hawaii using the supplemental poverty measure, 0.4% higher than the official poverty rate (10.1%).[22]

 

ALICE Report

The Hawaii United Way agency tracks working residents living just above the poverty level who cannot afford basic necessities through a survey titled Asset Limited, Income Constrained, Employed (ALICE).[23] The most recent Hawaii ALICE study in 2022 found that more Hawaii households fell below the ALICE threshold compared to 2018 before COVID. An estimated 44% of ALICE households lived in Hawaii (compared to 42% in 2018) and struggled to meet housing, childcare, food, transportation, and healthcare expenses. These were in addition to the 11% of households below the FPL. Additionally, the percentage of households with income below the FPL increased from 9% in 2018.[24] This suggests hardship deepened for many island residents during the pandemic, and the post-pandemic inflation made it more difficult to cover everyday expenses. A majority of Native Hawaiian (60%) and Filipino (59%) residents fell below the ALICE threshold, along with households with children (54%).

 

The report cites the major reasons for the high percentage of ALICE households is:

• Low-wage jobs dominate the economy.
• Cost of living outpaces wages.

Nearly 62% of all jobs in Hawaii pay less than $20 per hour, with more than two-thirds paying less than $15 per hour. It is difficult for ALICE households in Hawaii to find affordable housing, job opportunities, and community resources. Although public and private assistance helps, it does not provide financial stability. ALICE households are often forced to make difficult financial choices with limited resources, such as forgoing healthcare, childcare, healthy food, or car insurance.

 

The report also confirmed that in addition to financial challenges, mental health issues (anxiety, depression) emerged as one of the major concerns for ALICE households.

 

HIGH COST OF LIVING

Data for 2021 shows that in Hawaii, the price level of goods and services was about 13% higher than the U.S. average, making it the most expensive state in the country.[25]

 

Housing Costs

The primary driver for the high cost of living is housing costs, which are the highest in the U.S. Housing costs create a burden for families, resulting in less income for other critical household expenses. Some families are forced to live in overcrowded, substandard housing or are forced into homelessness.

 

In April 2023, the median housing cost for a single-family dwelling on Oahu was $999,995, and for a condominium was $500,000.[26] Based on ACS 2021 one-year estimates, the median monthly owner mortgage cost in 2021 was $2,584, 54.5% higher than the U.S. average. Among these homeowners, 33.9% spent 35% or more of their household income on housing, higher than the U.S. average of 21.0%. Hawaii ranked the highest in the nation for this indicator. Not surprisingly, the homeownership rate in Hawaii in 2021 was one of the lowest in the U.S. (46th among the 50 states) at 62.6%, which was lower than the U.S. average of 65.4%.

 

Rental Costs

The high cost of fair market rent may be out of reach for working families. Based on the ACS 2021 estimate, 37.4% of occupied housing units in Hawaii were renter-occupied (compared to 34.6% nationally). The median monthly gross rent for the renter-occupied units was $1,774, 49.0% higher than the U.S. average of $1,191. Hawaii has the highest cost of rent among the 50 states.

 

Multigenerational Households

For some groups, cultural preference and tradition have led to multigenerational households; for others, it is a consequence of high housing costs. Based on 2021 ACS estimates, the percentage of multigenerational family households among all family households in Hawaii was 8.2% (40,229 out of 490,080 households), which was higher than the U.S. average of 3.8% (4,858,150 out of 127,544,730 households). Hawaii has the highest rate among the 50 states and also some of the largest household sizes, especially among Samoan, Marshallese, and Tongan families. These conditions complicated COVID-19 social distancing/isolation efforts and contributed to disparities in infection rates for these groups.

 

Cost of Health Insurance

Overall, the cost of private employer-based health in Hawaii steadily increased for a family plan between 2013 and 2021 ($14,382 to $18,539).[27] Hawaii health plans offered through the federal marketplace also increased slightly from $330 for the average premium to $484 in 2022.[28]

 

Health Services Infrastructure

There are about 100 health facilities in Hawaii.[29] Of the state’s 29 hospitals, 12 are labor and delivery hospitals. Three pediatric hospitals have Neonatal Intensive Care Units on Oahu, while other hospitals have fewer acute pediatric services. Hawaii has 15 federally qualified health centers, 15 rural health clinics, and seven Native Hawaiian health system sites. Most healthcare services, particularly specialty care providers/facilities, are concentrated in urban Honolulu on Oahu. Neighborhood island residents commonly fly to Oahu to access medical, dental, and behavioral services. Maps of these facilities are in the Supporting Documents.

 

Healthcare Workforce

The state has 300 family and general practitioners, 210 obstetricians and gynecologists, and 230 pediatricians.[30] Based on the 2021 population estimate, there are 14.6 per 100,000 obstetricians and gynecologists, which is higher than the national rate (6.5 per 100,000 population), though non-significant. There are 16.0 pediatricians per 100,000 population, which is similar to the national estimate (10.1). The rate for family/general practitioners (20.8 per 100,000 population) is similar to the national rate (31.0). Despite the high ratio of providers to population, many of the state’s medical and specialty providers are located on Oahu, and most of the state’s rural communities are designated as shortage and/or medically underserved areas.

 

The COVID pandemic worsened healthcare workforce needs in the state. The Hawaii Physician Workforce Assessment Project reported that the state is short 776 doctors, with the greatest need in primary care specialties. The greatest need is on the neighbor islands, with Maui and Hawaii County experiencing a physician shortage of 40%.[31] In 2022, nearly 3,900 position vacancies were reported across 89 patient-facing professions, an average job vacancy rate of 17% compared to 10% in 2019.[32] The state’s smallest islands, Lanai and Molokai, have the highest percentage of job vacancies.

 

Healthcare Shortage Designations

Shortage Designations represent an area's or population's needs based on several factors, including health professional presence, socioeconomic and demographic data, language barriers, health indicators, access to health care, and travel time to the nearest available provider. As described previously, most shortage areas populate the rural neighbor islands and rural/low-income urban areas on Oahu. The entire state is designated a mental health shortage area. Maps of shortage areas in Hawaii are included in the Supporting Documents.

 

Health Professional Shortage Areas

A Health Professional Shortage Area (HPSA) is a geographic area, population, or facility with a shortage of primary care, dental, or mental health providers. HPSA designations cover nearly all major islands and the rural northern half of Oahu. Dental health HPSA designations include Maui, Molokai, Lanai, Hawaii Island, and the Kalihi-Palama district of Oahu due to its low-income population.

 

Medically Underserved Areas

A Medically Underserved Area (MUA) is a geographic location with insufficient health resources (staffing/facilities/services) to meet the population's medical needs. MUAs include Kauai, Molokai, Hawaii Island, rural/high-poverty areas on Oahu, and the East area of Maui.

 

Medically Underserved Population

A Medically Underserved Population (MUP) is the population of an urban or rural area designated as having a shortage of health resources (personnel, facilities, services) or a population group having a shortage of such services. MUPs include Lanai, West Maui, and a part of Oahu that includes the community of Wahiawa. Not all these populations overlap with MUA or professional shortage areas.

 

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 Healthcare 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 adopted Medicaid expansion and transitioned to the federally run exchange in 2017. Hawaii is one of the few states where enrollment in health plans through the exchange increased from 18,938 in 2017 to 22,327 in 2022.[33]

 

Under Medicaid expansion, coverage increased to 138% of FPL. Prior to the COVID public health emergency, the number of people enrolled rose significantly from 292,423 in 2013 to about 345,231 in 2019.[34] 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.

 

In 2018, state lawmakers integrated several components of the ACA into the PHCA to ensure the benefits remained available under Hawaii law: including dependent coverage for children until 26 years and prohibiting a preexisting condition exclusion and the use of gender to determine premiums.

 

Through these efforts, Hawaii consistently reports low uninsured rates:3.9% in 2021.

 

MEDICAID

The Department of Human Services (DHS) Med-QUEST Division (MQD) administers the state Medicaid program (QUEST). The QUEST program is designed to provide Quality care, Universal access, Efficient utilization, Stabilizing costs, and Transform the way healthcare is provided to recipients. QUEST's objectives are: to expand medical coverage to populations previously ineligible for Medicaid and to contain costs by shifting to a managed care delivery system. Savings realized would be used to expand coverage. Under this waiver, Medicaid beneficiaries, excluding those with disabilities and over 65, received their services through managed care.

 

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

• Children ages 0-18 qualify with family income up to 300% of the FPL.
• Pregnant women qualify with family income up to 191% of the FPL.
• Parents and other adults qualify with family income up to 133% of the FPL.

 

During the COVID public health emergency, Medicaid was not permitted to disenroll individuals from coverage. Hawaii Medicaid enrollments increased by 37.0% for the duration of the pandemic, with over 448,193 enrollees statewide from March 2020 to July 2023. The County of Maui had the largest increase (41.2%) in enrollment compared to Kauai County (37.8%), Honolulu County (38.1%), and Hawaii County (31.3%).

 

Of the 448,193 individuals enrolled in Medicaid, 157,386 are children.[35] The Medicaid Program also provided coverage for 3,397 pregnant women. Additionally, the program continues to support medically needy children who require nursing home level of care.

 

Adult COFA who make up a large proportion of the Pacific Islander population in Hawaii were ineligible for federal Medicaid coverage since 1996. In December 2020, federal Medicaid eligibility was finally restored to COFA migrants. As of February 7, 2022, there were 9,257 COFA adults enrolled with Med-QUEST.

 

The state’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.

 

Medicaid beneficiaries can choose 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 provide services statewide, except for the Kaiser Foundation Health Plan, which operates only on the islands of Oahu and Maui.

 

Medicaid Unwinding. The state Medicaid program has launched a media campaign to ensure all eligible Medicaid enrollees stay covered: Stay Well, Stay Covered, which includes a website with information available in 14 languages. Eligibility redeterminations began April 1, 2023, and will continue into 2024. Enrollees can keep their coverage until their renewal date but must be found eligible to keep coverage any further. The first renewal notices began in April for people whose renewal is scheduled for May. The first round of disenrollments begins in June for those who were either found to be no longer eligible or who failed to respond to a renewal notice.

 

Unhoused enrollee renewals will be processed at the end of the unwinding period. And dual-eligible enrollees (eligible for Medicare and Medicaid) who become eligible for Medicare between April and September 2023 will not go through a Medicaid eligibility redetermination until six months after their Medicare begins.

 

For those no longer eligible for Medicaid, a 16-month special enrollment period is available on HealthCare.gov.

 

GOVERNMENT

The state’s Executive Branch of government is organized into 16 cabinet-level agencies. The major health programs are administered by DOH and by 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).

 

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 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; the director of health reports directly to the governor. DOH is divided into three major administrations: Health Resources Administration (HRA), Behavioral Health (BHA), and Environmental Health (EHA). There are six major divisions within HRA, including the Family Health Services Division (FHSD), responsible for administrating all Title V funding. The three branches within FHSD are Maternal and Child Health; Women, Infants, and Children (WIC) Services; and Children with Special Health Needs.

 

Hawaii remains a strong Democratic state with very few Republicans that hold public office. Hawaii elected a new democratic Governor, Josh Green, MD, in 2022. Green served as the Lt. Governor in the past administration during COVID. The new DOH Director is Kenneth S. Fink, MD, MGA, MPH; Debbie Kim Morikawa is the new Deputy Director for HRA. Matthew J. Shim, PhD, MPH, remains the current FHSD Chief/Title V Director.

 

STATUTORY AUTHORITY

The Title V agency, FHSD falls within the purview of Title 19 Chapter 321 of the Hawaii Revised Statues. For a listing of statutes pertaining to the division programs, see the Supporting Documents.

 

Legislature

In 2022, the legislature used a $2B surplus to appropriate funds toward alleviating financial hardships for resident families, including:

• $1B for affordable housing
• Raised the minimum wage
• Passed several tax credits to help low-income and working families: Earned Income, Child/Dependent Care, Food/Excise tax credits
• Extended Medicaid coverage for postpartum care to 12 months and restored comprehensive adult dental care
• Increased preschool subsidies and funds for public preschool classrooms.

 

With another $1.7B surplus, the 2023 Legislature expanded supports for residents, including:

• Funds to expand emergency housing and wrap-around services for homeless
• Funds to support housing for teachers and those with disabilities
• Funds to upgrade/expand neighbor island hospitals
• $30M in loan forgiveness to recruit/retain healthcare workers
• Expansion of preschool and childcare supports and workforce training
• Doubling the earned income tax credit (although other key tax credits, paid family, and sick leave policies failed).

 

The Legislature also strengthened and expanded protections for reproductive healthcare access and abortion services, as well as gun safety laws, in response to recent Supreme Court rulings.

 

Despite these bright spots, this year’s legislature saw members openly criticize the session for a lack of transparency and the underfunding of food security programs and education while funding salary raises for legislators.

 

COVID-19 and Response

Hawaii managed the COVID-19 pandemic better than many other states. This was reflected in consistently low COVID case numbers, hospitalizations, and deaths. The state’s success relied on the ability to restrict all travel early in the pandemic and the state's close adherence to Centers for Disease Control (CDC) safety guidelines and cautious loosening of safety restrictions. The governor issued over 20 COVID-related emergency proclamations that mandated shutdowns of non-essential services; stay-at-home orders; self-quarantine for all travel within and entering the state; limitations on gatherings; mandated mask-wearing; and physical distancing to reduce disease spread. With community partners, the state also implemented COVID-19 testing, contact tracing, and systematic vaccination rollout. The state cautiously relaxed COVID restrictions in March 2022, making Hawaii the last state to end an indoor mask mandate.

 

The community spread of COVID-19 remains low yet steady through June 2023, with 296,454 cumulative cases and 1,884 deaths since the beginning of the pandemic. Positive case numbers are considered underestimated since many residents now test from home. Fatalities are largely among the elderly now (80%). COVID disparities continue with Native Hawaiians, Filipinos, and Pacific Islanders experiencing higher infection and death rates. Roughly 25% of the state's population has not contracted COVID (43.5% for those 65 and older).

 

As of June 2023, 78.8% of the state’s population was fully vaccinated, a relatively high vaccination rate. Those receiving a booster or bivalent shots are 23%, similar to the U.S. average. In 2022, the state transitioned from a COVID emergency response to disease management. DOH collects and publicly releases COVID data weekly, although the CDC discontinued reporting, making national comparisons more difficult. DOH continues to issue advisories on current COVID-19 recommendations and works with key partners to ensure that accurate guidance and culturally tailored messaging are shared.

 

Hawaii continues to monitor significant consequences of the pandemic, including long COVID, mental health issues, other comorbidities, and socioeconomic determinants that pose healthcare challenges.

[1] Due to the impact of COVID-19, 2020 Census data for population estimates is unavailable. Instead of providing the standard 1-year data products, the Census Bureau released experimental estimates from the 1-year data. Therefore, population comparison with 2019 will be provided here.

 

[2] with no single-race majority.

Diversity Index by State: 2020, Racial and Ethnic Diversity in the United States, U.S. Census Bureau, accessed at Racial and Ethnic Diversity in the U.S.: 2010 Census and 2020 Census

[3] Pew Research Center. (2016). https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state/

[4] American Immigration Council. (2020).

   https://www.americanimmigrationcouncil.org/sites/default/files/research/immigrants_in_hawaii.pdf

[5] State of Hawaii Department of Business, Economic Development, & Tourism Research and Economic Analysis Division 2020. https://files.hawaii.gov/dbedt/economic/reports/COFA_Migrants_in_Hawaii_Final.pdf

[6] COFA reports (2018) https://www.doi.gov/oia/reports/Compact-Impact-Reports.

[7] https://www.hawaiidxp.org/data-products/hawaii-english-language-learners-data-story/

[8] Civil Beat. The Fastest-Growing Ethnic Group In Hawaii Is Also The Most Invisible - Honolulu Civil Beat

[9] Active Duty and Reserve Personnel by Service (Table 10.04) at  https://dbedt.hawaii.gov/economic/databook/2021-individual/_10/

[10] For Oahu: https://www.partnersincareoahu.org/pit;

for neighbor islands, https://www.btghawaii.org/reports/housing-inventory-counts-point-in-time/

[11] U.S. Department of Housing and Urban Development. The 2022 Annual Homelessness Assessment Report to Congress. https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf

 

[12] State DBEDT, Report on the economic condition of Hawaii http://dbedt.hawaii.gov/economic/qser/

[13] http://dbedt.hawaii.gov/economic/qser/tourism/

[14](2022 unemployment rate is found at www.bls.gov/lau/lastrk22.htm,

[15] State DBEDT, Report on labor force https://dbedt.hawaii.gov/economic/qser/labor-force/

[16] U.S. Bureau of Labor Statistics, 2021 Annual Averages. https://data.bls.gov/cew/apps/table_maker/v4/table_maker.htm#type=0&year=2021&qtr=A&own=0&ind=10&supp=1

[17]Per Capita personal income is total personal income divided by total population. State Personal Income Summary is obtained from the U.S. Bureau of Economic Analysis: www.bea.gov/data/income-saving/personal-income-by-state.

[18] University of Hawaii Economic Research Organization (UHERO), Recovery Resumes but Omicron Looms, December 17, 2021. https://uhero.hawaii.edu/focus-areas/forecast-project/

[19]UHERO, Forecast for the State of Hawaii, May 12, 2023. https://uhero.hawaii.edu/focus-areas/forecast-project/

[20] State DBEDT, 2023 first Quarter: General Fund Tax Revenues and Major Components (Table C-1),  Research & Economic Analysis | QSER Archive (hawaii.gov)

[21] General fund forecast on March 8, 2023, http://tax.hawaii.gov/useful/a9_1cor/

[22] Poverty in the United States. Number and Percentage of People in Poverty by States (Table B-5)  https://www.census.gov/library/publications/2022/demo/p60-277.html

[23] https://www.auw.org/alice-initiative

[24]2022 Alice Report: https://www.boh.com/siteassets/files/community/alice-report-2022.pdf

[25] Bureau of Economic Analysis, Regional Price Parities in UHERO Forecast for the State of Hawaii, May 12, 2023. P.13 https://uhero.hawaii.edu/focus-areas/forecast-project/

[26] Honolulu Board of Realtors https://www.hicentral.com/

[27] Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey Insurance Component, accessed through the KFF website https://www.kff.org/

[28] KFF website https://www.kff.org/ Marketplace Average Benchmark Premiums

[29] Based on the facility address provided on https://health.hawaii.gov/shpda/agency-resources-and-publications/health-care-utilization-reports-and-survey-instructions/2021-data/

[30] Based on 2021 state data provided in Form 11.

[31] The University of Hawai'i, Annual Report on Findings from the Hawai'i Physician Workforce Assessment Project, December 2022. https://www.hawaii.edu/govrel/docs/reports/2023/act18-sslh2009_2023_physician-workforce_annual-report_508.pdf

[32] Healthcare Association of Hawaii, Hawai‘i Healthcare Workforce Initiative 2022 Report. https://static1.squarespace.com/static/5d703ec20712890001abe61f/t/6371dd4102fbca73ff8d0539/1668406609446/HAH_HWI2022Report-111122_LR.pdf

[33] KKF.org Health Insurance Marketplace Enrollment.

[34] Based on the Department of Human Services, State of Hawaii, 2019 Annual Report found on http://humanservices.hawaii.gov/reports/annual-reports/

[35] Based on 2023 data provided by the State of Hawaii Department of Human Services, Med-QUEST Division