GEOGRAPHY
Situated in nearly the center of the Pacific Ocean, 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 in other states are performed by cities or towns. Counties also elect a mayor and council. 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 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 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, and 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 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 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 the use of helicopters or fixed-wing aircrafts.
DEMOGRAPHICS
Due to the impact of COVID-19, 2020 Census data for population estimates is not available. Instead of providing the standard 1-year data products, the Census Bureau released experimental estimates from the 1-year data. This includes a limited number of data tables for the nation and states, but no county information. Therefore, information from 2019 data is provided here.
The estimated 2019 state population is 1,415,872 residents, the 30th most populous state in the U.S. Oahu is home for 69.0% (980,080 residents) of the state’s population, while 14.2% (201,513 residents) live on Hawaii Island, 11.8% (167,488 residents) in Maui County, and 5.1% (72,293 residents) in Kauai County. Compared to 2018 (1,420,491), there was a 4,619 (0.3%) population decline in the state.
ETHNIC DIVERSITY
Hawaii is the most ethnically diverse state in the nation,[1] with no single race majority. According to the 2019 American Community Survey (ACS) data, 22.3% of the population reported two or more races and the following single race proportions: White=24.1%; Asian=38.7%; and Native Hawaiian or Other Pacific Islander (NHOPI)=10.8%. The largest Asian single race subgroups were Filipino (15.7%) and Japanese (12.2%), and the largest NHOPI single race subgroup was the indigenous Native Hawaiians (6.4%). The individual Asian and NHOPI subgroups from the U.S. Census are listed in the table below, and shows the heterogeneity of these aggregated race groupings.
|
Reporting is further complicated by the growing category of those that report two or more race groups. They are not included in the single race groups commonly reported. Hawaii 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 25.1% of the state population when reported as “Alone or in Combination,” compared to just 6.4% when reported singly. There is also variation among race subgroups, with an overall estimate of 31.7% of those in the “Asian Alone or in Combination” reporting another race, but variation in the three largest Asian subgroups that range from 33.6% in Filipino to 60.0% 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.
|
Race Group |
Resident Population in the State of Hawaii (N) |
Percent of State Population (%) |
Proportion Reporting at least one other Race (5) |
|
White Alone |
341,211 |
24.1% |
0 |
|
White Alone or in Combination |
582,436 |
41.1% |
41.5% |
|
Native Hawaiian or |
152,601 |
10.8% |
0 |
|
NHOPI Alone or in Combination |
354,987 |
25.1% |
56.9% |
|
Native Hawaiian Alone |
90,070 |
6.4% |
0 |
|
Native Hawaiian Alone or |
284,996 |
20.1% |
65.9% |
|
Asian Alone |
547,843 |
38.7% |
0 |
|
Asian Alone or in Combination |
801,987 |
56.6% |
31.7% |
|
Filipino Alone |
221,724 |
15.7% |
0 |
|
Filipino Alone or |
371,528 |
26.2% |
33.6% |
|
Japanese Alone |
172,049 |
12.2% |
0 |
|
Japanese Alone or |
306,129 |
21.6% |
31.3% |
|
Chinese Alone |
81,209 |
5.7% |
0 |
|
Chinese Alone or |
203,531 |
14.4% |
60.0% |
|
Source: U.S. Census Bureau. 2019. American Community Survey Calculations by Hawaii Department of Health, Family Health Services Division. 2020 data is not available due to the impact of COVID-19. |
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Hawaii is considered a gateway to the U.S. for immigrants from Asia and the Pacific, and has a sizeable immigrant community. Based on the 2019 ACS, there were 273,012 immigrants in Hawaii, or nearly one-in-five (19.3%) of all residents. This is the 6th highest of all states. Hawaii’s immigrants were 58.9% women and 5.9% children (under 18 years old). The largest ethnic group of immigrants comprised of Asians (74.7%), followed by NHOPI (10.9%), and White (8.6%).
Most immigrants in Hawaii (81.6%) speak a language other than English, and 49.3% speak English less than “very well.” About 19.2% had a bachelor’s degree, and 7.6% had a graduate or professional degree. Approximately 60.3% of immigrants 16 years and over were employed in labor force in 2019.
Undocumented Immigrant Estimates
According to the Pew Research Center, in 2016, there were an estimated 45,000 undocumented immigrants in Hawaii (3.3.% of the population).[2] The majority were from the Philippines. Hawaii was 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 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 and 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.[3] As of 2019, 11% of those DACA-eligible immigrants in Hawaii had 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 freely live, work, and study in the U.S. without a VISA or green card, indefinitely. This status was negotiated in exchange for exclusive U.S. military control to 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 with the passage of federal legislation sponsored by Hawaii’s congressional delegation.
Among COFA migrants, there are reports of high rates of morbidity due to chronic diseases, communicable diseases (tuberculosis), and other medical concerns (i.e., 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 (U.S. Department of the Interior) on the low end to 28,000 on the high end (University of Hawaii).[4] COFA migrants are consistently overrepresented among homeless surveys (roughly 1,000 migrants) 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.[5]
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 Hawaii’s ethnic diversity, limited English proficiency may impact access to healthcare for immigrant communities. According to the 2019 ACS, an estimated 27.8% of Hawaii residents ages 5 years and over spoke a language other than English at home, compared to 22.0% nationally. An estimated 11.9% of Hawaii residents reported limited English proficiency (4th highest state ranking) compared to 8.2% 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.[6]
In School Year 2019-20, an estimated of 18.0% 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
Like much of the U.S., Hawaii has areas of growing Hispanic population. Anecdotally, recent Hispanic workers to the state have helped address labor shortages in agriculture (coffee and pineapple farms) as well as the service and construction industries, primarily in Maui and Hawaii counties. Service organizations report 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 policy and programs that are culturally/linguistically accessible. Further, differences in culture, language, and other demographic variables are important considerations when implementing Evidenced-Based Interventions (EBI), 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 which, in 2020, comprised an estimated 7.1% of the state’s population (100,594 people).[9] 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.
Homeless
Hawaii’s 2021 Point-in-Time homeless study estimates the number of sheltered homeless for Oahu was 1,853, and for the neighbor islands was 636, with a total of 2,489 sheltered homeless individuals in the state.[10] Data for unsheltered homeless individuals is not available for 2021. There was a 11.8% decrease in sheltered homeless when compared to 2020 data for Oahu (2,102) and about a 9.9% decrease in sheltered homeless for neighbor islands (706).
Based on 2019 data, the estimates show that there were 262,848 women of reproductive age (15-44 years old), a 2.1% decline from 2015, representing 18.5% of the entire state population. Vital statistics data show the number of births continued to decrease between 2019 (16,810), 2020 (15,780), and 2021 (15,608).
The 2019 population estimates show that there were 169,801 children 9 years of age or younger in Hawaii, which represents a 0.4% increase from 2010. This group represents 12.0% of the state population. There were 160,303 children 10-19 years of age in Hawaii, which represents a 5.2% decrease from 2010. This group represents 11.3% of the state population.
Based on the 2019-2020 National Survey of Children with Special Health Care Needs (CSHCN), there are an estimated 43,575 CSHCN, representing 14% of all children ages 0-17 years old.
Older Population
Hawaii's population, like the U.S., is aging. Based on 2019 population estimates, persons aged 65 years and over comprised 27.2% of the population, compared to 14.3% in 2010. Nationwide, this population comprised 16.4% in 2019 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. Initial COVID shutdowns in 2020 resulted in the virtual closure of Hawaii’s 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.
The recovery is reflected in the 2022 State of the Economy report published by the Hawaii Department of Business, Economic Development and Tourism (DBEDT),[11] showing the state’s major economic indicators were mainly positive in the fourth quarter of 2021. Visitor arrivals, wage and salary jobs, state general fund tax revenues, and private building authorizations all increased in the 2021 fourth quarter compared to the fourth quarter of 2020.
Tourism
In 2020, during the COVID-19 pandemic, total visitor arrivals decreased by 7,556,762, or 73.8%, and the average daily census decreased 167,699, or 68.2%. 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, to a lesser extent, international visitor arrivals both increased. The total number of visitor arrivals increased 1,420,798, or 285.8%, in the fourth quarter of 2021, compared to the same quarter of 2020.[12]
Despite the increases, visitor expenditures remained below pre-pandemic levels. In 2021, visitor expenditures totaled $12,995 million, a decrease of $4,662 million, or 26.4%, from 2019. The absence of the lucrative Asian market and short-lived visitor reductions during COVID variant surges account for the slower recovery.
Unemployment
Hawaii’s unemployment rate 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 in the nation. The 2020 average annual unemployment rate was 11.6% but decreased to 5.7% in 2021 (compared to the U.S. average of 5.3%) as the economy rebounded with the return of the tourism market.[13] Hawaii unemployment ranked the 15th lowest among the 50 states in 2021.
Job Market
Labor market conditions were mainly positive for 2021: Hawaii averaged 583,000 jobs, an increase of 46,300 jobs, or 8.6%, from 2020. The largest increase was in Accommodations (Hotels & Resorts), which increased by 90.2%, followed by Food Services and Drinking Places (25.6% increase). The construction sector increased 1,600 jobs, or 4.5%, compared with the same quarter of 2020.[14]
Wages
According to 2020 data from the U.S. Bureau of Labor Statistics, the average annual wage for employees in Hawaii was $57,934, $6,087, or 9.5%, lower than the U.S. average. Hawaii ranked 23rd among the 50 states. This was roughly a 10% increase over 2019 despite COVID shutdowns. Economists believe this is largely due to direct federal stimulus payments/supports, including supplemental unemployment insurance benefits.
Income
Per capita real income for Hawaii also increased in 2020 ($56,840) and 2021 ($60,389) by 3.5%, even as real earnings from jobs fell by more than 6%. As noted, income loss from the economic shutdown was offset by government stimulus/relief supports.[15] Federal income and housing support programs were crucial in preventing economic collapse for some families and communities.
Data Limitations: Standard income/wage indicators were not able to measure the disparate effect on high- and low- income workers. During the pandemic, professional workers were able to continue work in relative safety (remotely) through 2021, while many lower-income households were dependent on face-to-face service jobs that were hardest hit by COVID. This led to disproportionate economic hardship for these families. This divergence in economic (social and health) impacts reflected pre-existing structural inequalities.
State Budget/Revenues
The state general fund revenue for 2021 ($8.15M) increased by 27.0% over 2020 ($6.42M).[16] This reflected robust tax collections stemming from the rapid recovery of tourist arrivals, renewed consumer spending, additional tax collections due to inflation, and a significantly larger share of the transient accommodations tax on visitors. Based on this, the State Council on Revenues (Council) increased its forecast for revenue growth from 15.0% to 21.0% for fiscal year (FY) 2022.[17] However, it lowered its forecast from 6.9% to 6.0% for FY 2023.
The Council acknowledged the risks that may inhibit the economic recovery include new variants of the COVID-19 virus; an aggressive monetary policy response from the Federal Reserve to combat inflation; high oil and commodity prices; the economic disruptions associated with the war in Ukraine; supply chain disruptions; sustained travel restrictions in Asian markets due to the pandemic; and the reduction in Federal stimulus spending.
Poverty
Based on 2019 ACS estimates, Hawaii’s poverty rate was 9.3% (all ages in poverty), lower than the U.S. rate of 12.3%. This represents an estimated 128,722 individuals living in poverty in the state; over 36,461, or 12.4%, 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 8.1%; Maui 11.9%; Kauai 8.6%; and Hawaii 13.2%. These numbers do not reflect impacts of the pandemic on Hawaii’s individuals and households.
The official FPL obscures the struggles faced by many families 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 2019 poverty rate for Hawaii was 11.7%, 1.3% points higher than the official poverty rate of 10.5%.[18]
ALICE Report
Hawaii’s United Way agency tracks working residents who live just above the poverty level and are unable to afford basic necessities through a survey titled Asset Limited, Income Constrained, Employed (ALICE).[19] In 2018, there was an estimated 33% of ALICE households in Hawaii that struggled to meet expenses for housing, childcare, food, transportation, and healthcare. These are in addition to the 11% of households below the FPL. In 2020, the Hawaii Data Collaborative revised this estimate upward to 59% of households that were ALICE during the initial year of the pandemic.[20]
The reason 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 of those paying less than $15 per hour. These jobs were projected to grow far faster than higher paying jobs over the next decade. It is difficult for ALICE households in Hawaii to find affordable housing, job opportunities, and community resources. 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 healthcare, 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% higher than the national average. In a recent report by Forbes.com, “The Best and Worst States to Make a Living,” Hawaii ranked as the worst state to make a living. The cost of living is 67% higher than what the average American makes. 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. Housing costs create a burden for families, resulting in less income available for other critical household expenses. Some families are forced to live in overcrowded, substandard housing or are forced into homelessness.
In April 2022, the median housing cost for a single-family dwelling on Oahu was $1,105,000 and for a condominium was $510,000.[21] Based on ACS 2019 1-year estimate, the median monthly owner mortgage cost in 2019 was $2,472, $863, or 53.6%, higher than the U.S. average. Among these homeowners, 31.1% spent 35% or more of their household income on housing, which was higher than the U.S. average of 19.9%. Hawaii ranked the highest in the nation for this indicator. Not surprisingly, the homeownership rate in Hawaii in 2019 was one of the lowest in the U.S. (47th among the 50 states) at 60.2%, which was lower than the U.S. average of 64.1%.
Rental Costs
For working families, the high cost of fair market rent is out of reach. Based on the ACS 2019 1-year estimate, 39.8% of occupied housing units in Hawaii were renter-occupied housing units (compared to 35.8% nationally). The median monthly gross rent for the renter-occupied units (excluding units not paying rent) was $1,651, $554 or 50.5% higher than the U.S. average of $1,097. 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 2019 ACS estimates, the percentage of multigenerational family households among all family households in Hawaii was 10.7%, which was higher than the U.S. average of 5.9%. 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 complicate COVID-19 social distancing efforts and have contributed to disparities in infection rates for these groups.
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,[22] 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 Hawaii.[23] Of the state’s 29 hospitals, 12 are labor and delivery hospitals. There are three 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, and seven Native Hawaiian health system sites. Maps of these facilities are in the Supporting Documents section.
Healthcare Workforce
There are 350 family and general practitioners, 190 obstetricians and gynecologists, and 240 pediatricians in the state.[24] Based on the 2020 population estimate (1,407,006), there are 13.5 per 100,000 population obstetricians and gynecologists, which is significantly higher than the national rate (5.7 per 100,000 population). There are 17.1 pediatricians per 100,000 population, which is significantly higher than the national estimate (8.4). The rate for family/general practitioners (24.9 per 100,000 population) is similar to the national rate (29.9). Despite Hawaii’s 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.
COVID exacerbated Hawaii’s healthcare workforce shortages for the state’s rural counties but also created shortages for some professions on Oahu. During the COVID Delta and Omicron variant surges in 2021-2022, the state flew in hundreds of emergency healthcare workers to address shortfalls at hospitals and long-term care facilities. Strains on Hawaii’s healthcare workforce continued into 2022.
Healthcare Shortage Designations
Shortage Designations are a representation of an area’s or population’s need based on several factors, including health professional presence, socioeconomic and demographic data, language barriers, health indicators, 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 designations cover nearly all major islands, and include Kauai, Maui, Molokai, Lanai, Hawaii Island, and the rural northern half of Oahu. Hawaii’s mental health HPSA designations include the six major islands of Kauai, Maui, Molokai, Lanai, Hawaii Island, and Oahu. Hawaii’s 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 that has insufficient health resources (manpower/facilities/services) to meet the medical needs of the resident population. Hawaii’s MUAs include Kauai, Molokai, Hawaii 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 having a shortage of health resources (manpower, facilities, services) or a population group having a shortage of such services. Hawaii’s MUPs 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 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 every year. Under the ACA 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.[25] 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 some of the significant pieces of the ACA into the Prepaid Healthcare Act to ensure 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
- Prohibiting health insurance entities from using an individual's gender to determine premiums or contributions
Through these efforts, Hawaii consistently reports low uninsured rates: 4.5% in 2019.
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 to Transform the way healthcare is provided to recipients. QUEST objectives are: to expand medical coverage to 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 beneficiaries, 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 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 any individuals from coverage. Hawaii Medicaid enrollments increased by 36.3% for the duration of the pandemic, with over 445,815 new enrollees statewide from March 2020 to April 2022. The County of Maui had the largest increase (41.5%) in enrollment since March 2020, compared to other counties. Kauai County had a 38.3% increase in enrollment, Honolulu County had an increase of 37.2%, and Hawaii County had an increase of 30.1% in total enrollment since March 2020.
Of the 445,815 individuals enrolled in Medicaid, 163,096 are children through traditional, CHIP, and current and former foster care eligibility rules.[26] The Medicaid Program also provided coverage for 2,742 pregnant women. Additionally, the program continues to support medically needy children who require nursing home level of care.
Adult COFA migrants who make up a large proportion of the Pacific Islander population in Hawaii have not been eligible for federal Medicaid coverage since the 1996 Personal Responsibility and Work Opportunity Reconciliation Act. After December 27, 2020, following hard-fought efforts by many, federal Medicaid eligibility was finally restored to COFA citizens. As of February 7, 2022, there were 9,257 COFA adults enrolled with Med-QUEST.
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.
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 statewide, except for Kaiser Foundation Health Plan, which operates only on the islands of Oahu and Maui.
GOVERNMENT
Hawaii’s Executive Branch of government is organized into 16 cabinet-level agencies. The major health programs are administered by the 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).
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. 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), which is responsible for the administration of 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.
Governor David Ige’s second term ends in December 2022 when a new administration will be sworn in after the November General election. The DOH Director is Elizabeth Char, M.D. (appointed in 2021 during the pandemic); the former FHSD Chief, Danette Wong Tomiyasu, MBA, is the Deputy Director for HRA; and Matthew J. Shim, Ph.D., MPH, is 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 listing of statutes pertaining to the division programs, see the Supporting Documents.
Legislature
With a $2B surplus, the 2022 Legislature was one of the most significant sessions in state history, passing long-awaited bills to alleviate financial hardships on Hawaii’s families:
- Approved $1B for affordable housing, including $600M for the Hawaiian Homelands program, finance starts for low-income rental housing projects, and expanded public housing projects
- Raised the minimum wage to $18 by 2028
- Made the state Earned Income Tax credit for low-income families permanent
- Approved Medicaid funding to extend postpartum coverage to 12 months and restored adult dental preventive benefits
- Restored funding for preschool subsidies and funding to expand pre-kindergarten classrooms
- Passed a bill to collect data on the state’s childcare workforce, which is the first step in solving the current childcare crisis
Specific bills impacting FHSD programs included: mandating reporting of newborn hearing assessments to assure follow-up and convening stakeholders to establish consistent standards for hearing and vision screening and follow-up.
COVID-19 and Response
The COVID-19 pandemic has had far ranging impacts across Hawaii’s health, economic, education, and employment sectors. The complexities of protecting public health and improving the state’s economy remain challenging.
Governor Ige acted swiftly in 2020, issuing the first of 21 COVID-19 related emergency proclamations in March 2020 at the first signs of travel-related cases and preceding the federal government’s response to the pandemic. Mandatory shutdowns of non-essential services; stay-at-home orders; self-quarantine for all travel within and entering the state; limitations on gatherings; and mandated mask wearing and physical distancing were ordered to reduce disease spread. The state also implemented active COVID-19 testing, contact tracing, and once available, implemented vaccinations to mitigate disease impacts.
COVID-19 cases and deaths, as a result of these actions, were minimized. As of June 2022, the state reported a cumulative 283,574 confirmed COVID-19 cases and 1,462 deaths. Compared to June 2021, cases increased 585% and deaths increased 172%, reflecting the effects of the smaller but more lethal summer wave of the Delta variant and the winter surge of the Omicron variant. The most recent wave of Omicron subvariant infections has led to a wave of infections greater in magnitude than the Delta wave; however, hospitalizations and deaths are far lower than 2021 levels. Hawaii’s cumulative death rate of 99/100,000 is the lowest in the country (Statista, 2022). Whites and Pacific Islanders are overrepresented in total cases, while Pacific Islanders and Filipinos are much more likely to die of COVID-19.
The coordinated actions by Hawaii state, county, and private healthcare partners also contributed to Hawaii’s successful COVID-19 management by expanding the availability of testing, vaccinations, and therapeutics. As of July 2022, 79.3% of Hawaii’s population was fully vaccinated, the sixth highest rate in the U.S., with another 40% receiving a booster dose. An estimated 78% of youth 12-17 years old and 40% of children 5-11 years old have been fully vaccinated.
The DOH has worked tirelessly to protect and inform the public about prevention, treatment, and resources for those experiencing hardship. Materials, PSAs, and media releases included translations in languages of vulnerable communities and culturally tailored messaging. The state worked with an array of public, private, and community partners to support pandemic mitigation efforts and protect public health.
The state received and benefited from the largest federal fiscal support on record as COVID-19 stalled economic recovery. Federal support helped to bring the pandemic under control by replacing lost tax revenue, strengthening support for vital public services, providing assistance to individuals and households, and helping to retain jobs.
- Health and economic well-being have improved marginally since the beginning of the COVID-19 pandemic in both Hawaii and nationally, though these improvements are fragile and subject to change during infection surges.
- Households with children reporting difficulty paying for usual household expenses have remained steady over the pandemic for both Hawaii and the U.S., at roughly 40% of respondents.
- Food sufficiency and health insurance coverage tend to be better in Hawaii than nationally.
- While food insecurity has improved since June 2020, one in four families with children still report difficulty affording food purchases in April 2022.
- Childcare disruptions have become an increasing burden for parents returning to work, particularly since the Omicron wave of infections during winter 2021-22.
- The Delta and Omicron waves saw greater loss in income for households with children in Hawaii than nationally, though recently these differences have receded.
- Hawaii’s proportion of households with children where housing was insecure was slightly lower than the national estimate early in the pandemic, became substantially higher in late 2021 and early 2022, and has since returned to pre-pandemic levels.
- Rates of depressive symptoms have not improved over the past few years, and disparities in mental health status are striking, with those of two or more races far more likely to report poor mental health status than Asians or Whites.
- In both Hawaii and the U.S. as a whole, there has been a substantial and steady decrease in the proportion of adults in households with children using telehealth or delaying medical care due to the pandemic. These indicators suggest that residents are increasingly confident and able to access medical care compared to earlier in the pandemic.[27]
While no one can predict how long this worldwide health crisis will last, there is hope that continued mitigation efforts and increasing vaccination coverage will help the state recover from the pandemic.
[1] 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
[2] Pew Research Center. (2016). https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state/
[3] American Immigration Council. (2020).
https://www.americanimmigrationcouncil.org/sites/default/files/research/immigrants_in_hawaii.pdf
[4] 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
[5] COFA reports (2018) https://www.doi.gov/oia/reports/Compact-Impact-Reports.
[6] 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
[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] Number of armed forces residents and military dependents at https://dbedt.hawaii.gov/economic/databook/2020-individual/_01/
[10] For Oahu: https://www.partnersincareoahu.org/pit;
for neighbor islands, https://www.btghawaii.org/reports/housing-inventory-counts-point-in-time/
[11] State DBEDT, Report on Hawaii’s economy http://dbedt.hawaii.gov/economic/qser/
[12] http://dbedt.hawaii.gov/economic/qser/tourism/
[13] 2021 unemployment rate is found at https://www.bls.gov/lau/lastrk21.htm
[14] State DBEDT, Report on Hawaii’s economy http://dbedt.hawaii.gov/economic/qser/
[15] University of Hawaii Economic Research Organization (UHERO), Recovery Resumes but Omicron Looms, Dec 17, 2021. https://uhero.hawaii.edu/uhero-forecast-for-the-state-of-hawaii-recovery-resumes-but-omicron-looms/
[16] State DBEDT, 2022 Second Quarter, Quarterly Statistical & Economic Report, Research & Economic Analysis | QSER Archive (hawaii.gov)
[17] General fund forecast on March 13,2022, http://tax.hawaii.gov/useful/a9_1cor/
[18] Supplemental Poverty Measure is found on https://www.census.gov/library/publications/2020/demo/p60-272.html
[20] Hawaii Data Collaborative, Fifty-Nine Percent of Hawaii Households Estimated to Experience Significant Financial Hardship by the End of 2020. https://www.hawaiidata.org/news/2020/6/19/fifty-nine-percent-of-hawaii-households-estimated-to-experience-significant-financial-hardship-by-the-end-of-2020
[21] Honolulu Board of Realtors https://www.hicentral.com/
[22] Department of Commerce and Consumer Affairs news release http://cca.hawaii.gov/ins/news-release-insurance-commissioner-reduces-hmsas-rate-increase-request/
[23] Based on the facility address provided on https://health.hawaii.gov/shpda/agency-resources-and-publications/health-care-utilization-reports-and-survey-instructions/2020-data/
[24] Based on 2020 state data provided in Form 11.
[25] Based on Department of Human Services, State of Hawaii, 2019 Annual Report found on http://humanservices.hawaii.gov/reports/annual-reports/
[26] Based on 2022 data provided by State of Hawaii Department of Human Services, Med-QUEST Division
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