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 healthcare 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 to and from Oahu Island 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 healthcare 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 is home of 69.0% (980,080 residents) of the state’s population, while 14.1% (200,983 residents) live on the Big Island, 11.8% (167,207 residents) in Maui County, and 5.1% (72,133 residents) in Kauai County. Compared to 2017 (1,427,538), there was a 7,047 (0.5%) population decline in the state.
ETHNIC DIVERSITY
Hawaii is one of the most ethnically diverse states in the U.S. with no single race majority. According to the 2018 American Community Survey (ACS), 24.3% of the population reported two or more races, and the following single race proportions: White=24.3%; Asian=37.6%; and, Native Hawaiian or Other Pacific Islander (NHOPI)=10.2%. The largest Asian single race subgroups were Filipino (15.5%), and Japanese (11.5%) and the largest NHOPI single race sub-group was Native Hawaiian (6.4%). The individual Asian and NHOPI subgroups 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 |
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Race Group |
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Detailed Sub Group |
Asian |
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Filipino |
Japanese |
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Chinese |
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Korean |
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Vietnamese |
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Asian Indian |
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Thai |
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Laotian |
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Taiwanese |
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Cambodian |
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Indonesian |
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Native Hawaiian |
Polynesian |
Native Hawaiian |
Samoan |
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Tongan |
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Tokelauan |
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Tahitian |
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Micronesian |
Guamanian or Chamorro |
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Marshallese |
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Kosraean |
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Chuukese |
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Palauan |
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Yapese |
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Saipanese |
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I-Kiribati |
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Melanesian |
Fijian |
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Papua New Guinean |
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Ni-Vanuatu |
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Soloman Islander |
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Sources: US Census Bureau. The Asian Population: 2010. 2010 Census Briefs. Issued March 2012; C2010BR-11. |
Table: Total Numbers within Selected Race Groupings by Alone and Alone or in Combination status, Percent of State Population, and Percent Reporting at least one
Other Race, Hawaii, American Community Survey.
Race Group |
Resident Population in the State of Hawaii (N) |
Percent of State Population (%) |
Proportion Reporting at least one other Race (5) |
White Alone |
345,652 |
24.3% |
0 |
White Alone or in Combination |
600,675 |
42.3% |
42.4% |
Native Hawaiian or |
144,971 |
10.2% |
0 |
NHOPI Alone or in Combination |
383,172 |
27.0% |
62.2% |
Native Hawaiian Alone |
91,442 |
6.4% |
0 |
Native Hawaiian Alone or |
315,616 |
22.2% |
69.2% |
Asian Alone |
534,479 |
37.6% |
0 |
Asian Alone or in Combination |
807,332 |
56.8% |
33.8% |
Filipino Alone |
220,315 |
15.5% |
0 |
Filipino Alone or |
367,952 |
25.9% |
33.6% |
Japanese Alone |
163,174 |
11.5% |
0 |
Japanese Alone or |
313,596 |
22.1% |
36.9% |
Chinese Alone |
82,123 |
5.8% |
0 |
Chinese Alone or |
210,573 |
14.8% |
60.9% |
Source: U.S. Census Bureau. 2018. American Community Survey Calculations by Hawaii Department of Health, Family Health Services Division
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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 22.2% of the state population when reported as “alone or in combination”, compared to just 6.4% when Native Hawaiian is reported singly. There is also variation among race subgroups an overall estimate of 33.8% of those in the Asian Alone or in combination reporting another race but variation in the 3 largest subgroups range from 33.6% in Filipino to 60.9% in Chinese. The other Asian subgroups 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.
Hawaii is considered a gateway to the U.S. for immigrants from Asia and the Pacific and has a sizeable immigrant community. As of 2018, there were 266,147 immigrants in Hawaii, or nearly one-in-five (18.7%) of all residents. This is the 6th-highest of all states. The ACS reports 54.5% of Hawaii’s immigrants are women and 5.8% are children (under 18 years old). The top countries of origin are:
- Philippines (45%),
- China (9%),
- Japan (8%), and
- the Marshall Islands (4%).
Most immigrants in Hawaii report speaking English well or very well (78%) and 28% have a college degree. Immigrants comprise an estimated 23% of Hawaii’s labor force in 2018 and 26% of immigrants reported they were self-employed or owned their own businesses.
Undocumented Immigrant Estimates
According to the Pew Research Center, there are an estimated 45,000 undocumented immigrants in Hawaii (3.3.% of the population).[1] The majority are from the Philippines. Hawaii is the only state where undocumented women (55%) outnumber 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 that are undocumented |
17.0% |
24.0% |
Proportion of adults that have been in the US 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 and occupations with most unauthorized immigrant workers |
Leisure/hospitality, service; Agriculture/farming |
Construction, Service, Farming |
DACA (Deferred Action for Childhood Arrivals)
As of 2019, 340 active DACA recipients live in Hawaii, with 1,201 people granted DACA status since 2012.[2] An estimated 11% of those eligible in Hawaii applied for DACA.
Compact of Free Association (COFA)
COFA migrants includes those from the 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, work, and study in the U.S. indefinitely. This status was negotiated in exchange for the U.S. military to control 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.
There are reports of high rates of morbidity due to chronic disease, 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 (i.e. cancer). Challenges also exist due to language and cultural barriers within the population. In 2018, there were approximately 16,680 COFA migrants in Hawaii. 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 2019, the Title V agency served an estimated 4,371 COFA migrants at a cost of $2.7M. Programs reporting COFA clients served included WIC, State-funded Primary Care program (for uninsured/underinsured), Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, Family Planning, Perinatal Support Services, and Early Intervention Services.
Languages Spoken
Because of Hawaii’s ethnic diversity, limited English proficiency may impact access to healthcare for immigrant communities. An estimated 26.1% Hawaii resident ages 5 years and over spoke a language other than English at home, compared to 21.5% nationally. An estimated 12.1% of Hawaii residents reported limited English proficiency (4th highest state ranking), compared to 8.5% nationally. The most common languages spoken at home other than English include Other Pacific Island languages, Tagalog, Japanese, and Spanish, followed by Chinese, Korean, and Vietnamese.[4]
In School Year 2015-16, 8.3% (13,619) of the state's public-school students were enrolled in English Language Learner Program.[i] The top five languages spoken by Hawaii public school students are Ilokano, Chuukese, Marshallese, Tagalog, and Spanish.
Military
Other sub-populations within the state include U.S. Armed Forces personnel and their family members which, in 2018, comprise an estimated 7.4% of the state’s population (105,669 people).[5] 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 family members.
Homelessness
Hawaii’s 2019 Point-in-Time homeless study estimates the total number of homeless individuals statewide at 6,448. The proportion of unsheltered individuals (56.4%) was higher than sheltered individuals (43.6%). The trend of homeless declined from 6,530 in 2018. About 31.5% (2,028) of the homeless were part of families, including 18.2% (1,176) children under age 18 years.[6]
Maternal and Child Population
The 2018 estimates show that there were 264,071 women of reproductive age (15-44 years old) a 0.7% 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 2018 population estimates show that there were 171,871 children 9 years of age or younger in Hawaii, which represents a 0.6% increase from 2010. This group represents 12.1% of the state population. There were 159,029 children 10-19 years of age in Hawaii, which represents a 3.0% decrease from 2010. This group represents 11.4% of the state population.
Based on the 2018 National Survey of Children with Special Healthcare Needs (CSHCN), there are an estimated 38,816 CSHCN, representing 12.8% of all children ages 0-17 years old.
Older Population
Hawaii's population, like the U.S., is aging. Based on 2018 population estimates, persons age 65 years and over comprised 18.4% of the population, compared to 14.3% in 2010. Nationwide, this population comprised 16.0% in 2018 compared to 13.0% in 2010. There are more older people in proportion to younger ones.
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 2020 outlook report suggested positive growth for Hawaii’s economy in 2020-21, based on national and global economies, the performance of Hawaii’s tourism industry, labor market conditions, and the growth of personal income and tax revenues.[7] Hawaii’s economy, as measured by real gross domestic product (GDP), was projected to show a 0.5 percent increase in 2020 pre-COVID. The real GDP growth forecast for 2021 is 1.5 percent, 0.2 of a percentage points above the previous forecast. The per capita real GDP in Hawaii was $55,418 in 2018 (in 2012 dollars), $972 or 1.8% higher than the U.S. average.[8] 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. The annual average unemployment rate in Hawaii was 2.7% in 2019, 1.0% points lower than the U.S. average of 3.7%.[9] Hawaii ranked the 5th lowest among the 50 states.
State Budget
The State Council on Revenues lowered its forecast for growth in the State General Fund tax revenue in FY 2020 from 4.1% to 3.8%.[10] The Council's decision to lower the estimate was based on the deterioration of the economic outlook due to the COVID-19 virus. The Council lowered the FY 2021 forecast from 4.0% to 0.0% in an expectation of an economic downturn. The Council raised the forecast for FY 2022 to 5.0% and forecasted that General Fund growth would be 4.0% for FY 2023-2026, if the effects of the COVID-19 virus would not be long-term.
Tourism
In 2019, Hawaii experienced another record-breaking year for tourism with 10.4 million travelers coming to the islands and visitor expenditures of $17.8 billion. Spending by visitors generated $2.07 billion in state tax revenue in 2019, an increase of $28.5 million (1.4%) from 2018. Hawaii’s tourism is expected to decrease in 2020 due to the impact of COVID-19.
Poverty
Based on 2018 estimates, Hawaii’s poverty rate was 8.8% (all ages in poverty), lower than the U.S. rate of 13.1%. This represents an estimated 122,143 individuals living in poverty in the state; over 35,368 or 11.9% 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 7.8%; Maui 7.1%; Kauai 6.4%; and Hawaii 16.2%.
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 2018 poverty rate for Hawaii was 12.8%, 1.0 percentage points higher than the official poverty rate of 11.8%.[11]
Wages
Average annual wages for employees in Hawaii was $50,977 in 2018, $6,289 or 10.9% lower than the U.S. average of $57,266. 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 $48,376 in 2018, $8,822 or 15.4% lower than the U.S. average, ranking Hawaii 30th.
ALICE Report
Hawaii’s United Way Agency tracks working residents who live just above poverty and unable to afford basic necessities through a survey titled - Asset Limited, Income Constrained, Employed (ALICE).[12] In 2018, there were an estimated 33% of ALICE households in Hawaii that struggled to meet expenses for housing, child care, food, transportation, and healthcare. These are in addition to the 11% of households below the Federal Poverty level. The reason for the high percentage of ALICE households are:
- low wage jobs dominate the economy and
- cost of living outpacing wages.
Nearly 62% of all jobs in Hawaii pay less than $20 per hour, with more than two-thirds of those paying less than $15 per hour. These jobs were projected to grow far faster than higher paying jobs over the next decade. The ALICE report calculated the average annual household survival budget for a family of four is $72,336, significantly more than the double the US family poverty level of $27,890. It is difficult for ALICE households in Hawaii to find affordable housing, job opportunities, and community resources in the same place. Public and private assistance helps but does not provide financial stability. When ALICE households cannot make ends meet, they are forced to make difficult choices such as forgoing health care, childcare, healthy food, or car insurance. These “savings” threaten their health, safety, and future – and they reduce productivity and raise insurance premiums and taxes for all residents.
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,” 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. The high cost of living may explain why the state experienced a slight population decline over the past three years (despite greater births than deaths).
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 critical household expenses, and for some families living in overcrowded, substandard housing, and homelessness.
In April 2019, the median housing cost for a single-family dwelling on Oahu was $810,000 and for a condominium was $435,000. The median monthly owner mortgage cost in 2018 was $2,354, $788 or 50.3% 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 20.9%. Hawaii ranked the 3rd highest in the nation for this indicator. Not surprisingly, the homeownership rate in Hawaii in 2018 was one of the lowest in the U.S. (47th among the 50 states) at 58.3%, which was lower than the U.S. average of 63.9%.
Rental Costs
For working families, the high cost of fair market rent is out of reach. In 2018 an estimated 41.7% of Hawaii residents rent (compared to 36.1% nationally). The median monthly gross rent for the renter-occupied units (excluding units not paying rent) was $1,613, $555 or 52.5% higher than the U.S. average of $1,058. Hawaii has the highest cost among the 50 states.
Multi-generational Households
Another consequence of high housing cost is the high number of multigenerational households. Based on 2018 ACS 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 5.3%. Hawaii has 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,[13] the average increase for health insurance group plan premium rate 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
There are about 100 health facilities in the state.[14] Of the State’s 29 hospitals: 12 are labor and delivery hospitals. There are 3 pediatric hospitals with Neonatal Intensive Care Units on Oahu while other hospitals have less acute pediatric services. Hawaii has 15 federally qualified health centers, 11 rural health clinics, 7 Native Hawaiian health systems sites. Maps of these facilities are in the “Supporting Documents” section.
There are 420 family and general practitioners, 210 obstetricians and gynecologists, and 190 pediatricians in the State.[15] Based on the 2018 population estimate (1,420,491), there are 14.8 per 100,000 population obstetricians and gynecologists, which is significantly higher than the national rate (5.7 per 100,000 population). There are 13.4 pediatricians per 100,000 population, which is like the national estimate (8.7). The rate for family/general practitioners (29.6 per 100,000 population) is similar to the national rate (34.9). Despite Hawaii’s high ratio of providers to population many of the state’s medical and specialty providers are located on Oahu and many of the State’s rural areas are designated as shortage of medically underserved.
Healthcare Shortage Designations
Shortage Designations are a representation of an area’s or population’s need based on several factors, including health professional presence, socio-economic and demographic data, language barriers, health indicators, population’s access to health care, and travel time to nearest available provider. Maps of Hawaii’s shortage areas 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. Hawaii’s primary care HPSA cover nearly all major islands and include Kauai, Maui, Molokai, Lanai, the Big Island, and the rural northern half of Oahu. Hawaii’s mental health HPSA include the six major islands of Kauai, Maui, Molokai, Lanai, the Big Island, and Oahu. Hawaii’s dental health HPSA include Maui, Molokai, Lanai, the Big 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 which has insufficient health resources (manpower/facilities/services) to meet the medical needs of the resident population. Hawaii’s MUA include Kauai, Molokai, the Big Island, and the East area of Maui, which includes Hana.
Medically Underserved Population
A Medically Underserved Population (MUP) is the population of an urban or rural area designated as an area with a shortage of health resources (manpower, facilities, services), or a population group having a shortage of such services. Hawaii’s MUP include Lanai, West Maui, and a part of Oahu that includes the community of Wahiawa.
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 implemented a state-run health insurance marketplace and adopted Medicaid expansion. The marketplace transitioned to a 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. 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 increased every year. In 2018, 20,193 people enrolled, a 2% increase over the previous year (19,799). The major gains in coverage 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 enrolled in private insurance and about 50,000 people enrolled in Medicaid.
With the possible repeal of the ACA, state lawmakers in 2018 integrated some of the significant pieces of the legislation into the Prepaid Healthcare Act. Act 111 ensures the following benefits remained available under Hawaii law:
- Ensuring dependent coverage for adult children until the age of 26 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 of 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, 2019, receive 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 Department of Human Services (DHS) Med-QUEST Division (MQD). QUEST administers the State Medicaid program. QUEST is an acronym that stands for: Quality Care, ensuring Universal Access, encouraging Efficient utilization, Stabilizing costs, and Transforming the way healthcare 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 133% of FPL.
As of August 2019, The Hawaii Medicaid Progam provided coverage to 341,346 individuals with 107,444 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 COFA migrants; 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 provide services to beneficiaries statewide, except for Kaiser Foundation Health Plan, which operates 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 deliver 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 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).
The 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; 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 Deputy Director for HRA. Matthew Shim, PhD, is the FHSD Chief/Title V Director.
STATUTORY AUTHORITY
The Title V agency, Family Health Services Division (FHSD) falls within the purview of Title 19 Chapter 321 of the Hawaii Revised Statues. For listing of statutes pertaining to the Division and programs see Supporting Documents.
COVID Pandemic
In March 2020, Hawaii implemented strict preventive measures including stay at home orders, travel restrictions on out-of-state and inter-island travel (14-day quarantine), closure of business, schools, and public spaces (including parks and beaches), limitations on social gatherings, and wearing of masks. Hawaii’s isolation and the shutdown orders succeeded in halting the spread of the coronavirus in Hawaii. In July Hawaii reported a total of 1400 cases and 25 deaths.
However, the economic impacts of these measures are devasting to the state economy largely dependent on tourism. Hawaii is getting 99.5% less travelers, with daily visitors declining from about 30,000 to between 600 and 800 on average. The unemployment rate went from the lowest in the U.S. to the highest 23.5%. Although Hawaii received $7.7 billion in federal COVID aid it will not make up for an anticipated $2.3B in FY 2021 revenue shortfalls.[18]
COVID measures were relaxed in June and July and Hawaii is experiencing a surge in new COVID cases largely on Oahu, resulting in reinstituting emergency restrictions.
2020 Cost of Living Initiative
In response to several reports outlining the adverse impacts of the state’s high cost of living; in January 2020 the Governor, legislative and business leaders announced an unprecedented joint legislative package aimed to address financial hardships on Hawaii families. The package focused on increasing minimum wage, tax credits for working families, expanding affordable housing, improving aging school facilities, and expanding pre-K education statewide.
Unfortunately, with the advent of COVID the Legislature adjourned in March 2020, reconvened in June with an abbreviated session. Only a limited number of bills were heard with greater focus on the passage of the state budget and COVID-related items. Of the cost-of-living package, only school facilities and pre-K education bills passed.
[1] Pew Research Center. (2019). https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state/
[2] American Immigration Council. (2020). https://www.americanimmigrationcouncil.org/sites/default/files/research/immigrants_in_hawaii.pdf
[3] COFA reports (2018) https://www.doi.gov/oia/reports/Compact-Impact-Reports.
[4] 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/sy15-16part1/index.html
[5] Number of armed forces residents and military dependents at http://dbedt.hawaii.gov/economic/databook/2018-individual/_01/
[7] Report on Hawaii’s economy http://dbedt.hawaii.gov/economic/qser/
[9] 2019 unemployment rate is found at https://www.bls.gov/lau/lastrk19.htm
[10] General fund forecast on March 13,2020, http://tax.hawaii.gov/useful/a9_1cor/
[11] Supplemental Poverty Measure is found on https://www.census.gov/library/publications/2019/demo/p60-268.html
[13] Department of Commerce and Consumer Affairs news release http://cca.hawaii.gov/ins/news-release-insurance-commissioner-reduces-hmsas-rate-increase-request/
[14] Based on the facility address provided on https://health.hawaii.gov/shpda/agency-resources-and-publications/health-care-utilization-reports-and-survey-instructions/2018-data/
[15] Based on 2018 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 2019 enrollment report from https://medquest.hawaii.gov/en/resources/reports.html
[18] https://www.civilbeat.org/2020/07/hawaii-has-huge-stake-in-negotiations-over-federal-covid-19-aid/
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