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. Nationally, Hawaii is the 11th smallest state 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. 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 has 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, 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

The estimated 2019 state population is 1,415,872 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 14.2% (201,513 residents) live on the 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 one of the most ethnically diverse states in the U.S. with no single race majority. According to the 2019 American Community Survey (ACS), 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 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
Race Group		Detailed Subgroup
Asian		Filipino
		Japanese
		Chinese
		Korean
		Vietnamese
		Asian Indian
		Thai
		Laotian
		Taiwanese
		Cambodian
		Indonesian
Native Hawaiian or Other Pacific Islander	Polynesian	Native Hawaiian
		Samoan
		Tongan
		Tokelauan
		Tahitian
	Micronesian	Guamanian or Chamorro
		Marshallese
		Kosraean
		Chuukese
		Palauan
		Yapese
		Saipanese
		I-Kiribati
	Melanesian	Fijian
		Papua New Guinean
		Ni-Vanuatu
		Solomon Islander
Sources: US Census Bureau. The Asian Population: 2010. 2010 Census Briefs. Issued March 2012; C2010BR-11. US Census Bureau. The Native Hawaiian and Other Pacific Islander Population: 2010. 2010 Census Briefs. Issues May 2012; C2010BRF-12

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	341,211	24.1%	0
White Alone or in Combination	582,436	41.1%	41.5%
Native Hawaiian or Other Pacific Islander (NHOPI) Alone	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 in Combination	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 in Combination	371,528	26.2%	33.6%
Japanese Alone	172,049	12.2%	0
Japanese Alone or in Combination	306,129	21.6%	31.3%
Chinese Alone	81,209	5.7%	0
Chinese Alone or in Combination	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

 

 

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 25.1% 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 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 subgroups 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 group.

 

Immigration

Hawaii is considered a gateway to the U.S. for immigrants from Asia and the Pacific and has a sizeable immigrant community. As of 2019, 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. The ACS reports 58.9% of Hawaii’s immigrants are women and 5.9% are children (under 18 years old). The top countries of origin are:

• Philippines (46%),
• China (8%),
• Japan (7%), and
• 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 2018 5-year ACS, there are an estimated 41,000 undocumented immigrants in Hawaii (3.3.% of the population). 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	41,000 (3.3% of population)	10.7 million (3.3% of population)
Proportion of all immigrants that are undocumented	16.4%	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.[1] 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 (i.e., cancer) that may be related to U.S. nuclear tests conducted in the Pacific nations. 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.[2]

 

In 2019, the Title V agency served an estimated 4,371 COFA migrants at a cost of $2.7 million. 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 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.[3]

 

In School Year 2018-19, 9.8% (16,579) 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.[4]

 

The state’s unique characteristics, particularly the diversity in ethnicity, language, cultural practices, and significant immigrant population, underscores the need for disaggregated data. Disaggregating data can inform and expand understanding of the outcomes and experiences of subsets of the population and help evaluate whether programs are effective at meeting the needs of these groups. It can also help develop policy and programs that are appropriate and culturally/linguistically accessible. Further, differences in culture, language, age, and other demographic variables are important considerations when implementing Evidenced-Based Interventions (EBI). Adaptations to culturally tailor EBI may be needed especially when the evidence for the program was established with populations different from those in Hawaii.

 

Military

Other subpopulations within the state include U.S. Armed Forces personnel and their family members, which, in 2019, comprise an estimated 7.5% of the state’s population (105,937 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 2020 Point-in-Time homeless study estimates the total number of homeless individuals statewide at 6,458. The proportion of unsheltered individuals (56.5%) was higher than sheltered individuals (43.4%). After peaking in 2016, homeless rates dropped and have remained constant since 2018. About 31.6% (2,040) of the homeless were part of families, including 17.0% (1,101) children under the age 18 years.[6]

 

Maternal and Child Population

The 2019 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.

 

Preliminary data suggests that the number of births continued to decrease between 2019 and 2020. There was a steady increase in the number of births since the late 1990s with about 18,000 births every year in the state over the past 5 years.

 

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 National Survey of Children with Special Health Care Needs (CSHCN), there are an estimated 44,195 CSHCN, representing 14.7% 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 age 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. Like the rest of the U.S., the Hawaii economy has improved since the 2009 recession.

 

Economic Growth

Hawaii’s economy has been greatly impacted by the COVID-19 pandemic. The Hawaii State Department of Business, Economic Development and Tourism (DBEDT) first quarter 2021 outlook report[7] suggested that Hawaii’s major economic indicators were mainly negative in the fourth quarter of 2020. Visitor arrivals, wage and salary jobs, state general fund tax revenues, and private building authorizations all decreased in the quarter compared to the fourth quarter of 2019.

 

During the April-December 2020 period, the average unemployment rate (not seasonally adjusted) was 15.1 percent. Hawaii lost 110,600 non-agriculture payroll jobs during as compared with the same period a year ago. All industry sectors lost jobs except for federal government jobs. The accommodation and food services and drinking places accounted for 52.6 percent of the total job loss at 58,200. Overall, statewide non-agriculture payroll jobs decreased by 16.9 percent in the April-December 2020 period. Visitor arrivals to the State during the fourth quarter of 2020 totaled 496,186, a decrease of 80.2 percent from the same quarter in 2019. However, due to the longer average length of stay, the average daily visitor census decreased only 70.7 percent in the fourth quarter of 2020.

 

At the national level, the U.S. economic growth rate was at 0.3 percent during the first quarter; fell to negative 9.0 percent in the second quarter; improved to negative 2.8 percent in the third quarter; and improved further to negative 2.5 percent in the fourth quarter as compared to the same quarter in 2019. The per capita real GDP in Hawaii was $57,015 in 2019, $525 or 0.9% 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. Hawaii’s unemployment rate soared during the COVID-19 pandemic with the annual average unemployment rate in Hawaii at 11.6% in 2020, 3.6% points higher than the U.S. average of 8.1%.[9] Hawaii ranked from the 5th lowest among the 50 states in 2019 to the 2nd highest in 2020 due to the pandemic. Through 2021, Hawaii’s unemployment rate decreased to 7.3% as the economy rebounded with a sudden return of the tourism market.

 

State Budget

The State Council on Revenues increased its forecast for growth in state tax revenues for FY 2021 (July 2020-June 2021) from -6.5% to -2.5%.[10] For FY 2022, the council lowered its forecast for to 4.0% from 6.0%. The council forecasted that tax revenue growth will fall to 4.0% from 6.0% in FY 2023, remain at 4.0% in FY 2024, and decrease to 3.5% from 4.0% for FYs 2025-2027

 

The council acknowledged the COVID-19 virus continues to represent a serious risk to public health and the state’s economy. Future tax revenues are highly dependent on the trajectory of the virus, new variants, availability and efficacy of vaccines, rapid low-cost testing and the state, county, and federal governments’ ability to manage health risks while at the same time supporting economic activities. Given the prominent role of tourism in Hawaii’s economy, the number of visitors to the state will have major impacts on the economy and tax collections.

 

Tourism

Due to the COVID-19 pandemic, total visitor arrivals by air in 2020 decreased by 7,556,762 or 73.8 percent, and average daily census decreased 167,699 or 68.2 percent.[11] In the fourth quarter of 2020, the length of stay per visitor increased. Due to the longer length of stay, the average total daily visitor census decreased less than the decrease in visitor arrivals in the quarter. The total average daily visitor census was down 70.7 percent or 169,083 visitors per day in the fourth quarter of 2020 over the same quarter of 2019. Hawaii experienced a sudden surge in visitor numbers in the second quarter of 2021. The total average daily census was up 189,965 or 2,062.7 percent in the quarter, nearing pre-pandemic numbers because of vaccinations and the pent-up domestic travel demand. Foreign travel restrictions remain in place.

 

Poverty

Based on 2019 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 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 2019 poverty rate for Hawaii was 11.7%, 1.3 percentage points higher than the official poverty rate of 10.5%.[12]

 

Wages

The average annual wage for employees in Hawaii was $52,686 in 2019, $6,523 or 11.0% lower than the U.S. average of $59,209. 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 $50,062 in 2019, $9,140 or 15.4% lower than the U.S. average, ranking Hawaii 32nd.

 

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).[13] In 2018, there were 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 Federal Poverty Level. The reason for the high percentage of ALICE households is:

• Low-wage jobs dominate the economy, and
• 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. The ALICE report calculated the average annual household survival budget for a family of four is $72,336, more than double the U.S. family poverty level of $27,890. 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. Hawaii’s high 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 March 2021, the median housing cost for a single-family dwelling on Oahu was $950,000 and for a condominium was $451,000. 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, 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. In 2019 an estimated 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 among the 50 states.

 

Multigenerational Households

For some groups, cultural preference and tradition have led to multi-generational 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,[14] 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.[15] 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 systems sites. Maps of these facilities are in the Supporting Documents section.

 

There are 330 family and general practitioners, 200 obstetricians and gynecologists, and 180 pediatricians in the state.[16] Based on the 2019 population estimate (1,415,872), there are 14.1 per 100,000 population obstetricians and gynecologists, which is significantly higher than the national rate (5.7 per 100,000 population). There are 12.7 pediatricians per 100,000 population, which is like the national estimate (9.1). The rate for family/general practitioners (23.3 per 100,000 population) is similar to the national rate (33.3). 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, Hawaii Island, and the rural northern half of Oahu. Hawaii’s mental health HPSA include the six major islands of Kauai, Maui, Molokai, Lanai, Hawaii Island, and Oahu. Hawaii’s dental health HPSA 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 MUA 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 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 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. The number of people on the program rose significantly from 292,000 in 2013 to about 345,709 in 2018.[17] 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. Through its efforts, Hawaii consistently reports low uninsured rates and high overall health scores, although stark disparities remain.

 

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; and
• Prohibiting health insurance entities from using an individual's gender to determine premiums or contributions.

 

MEDICAID

The Department of Human Services (DHS) Med-QUEST Division (MQD). QUEST administers the State Medicaid program. 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 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

 

Hawaii Medicaid enrollments increased by 28% for the duration of the pandemic with over 92,000 new enrollees since March 2020 to March 2021. As of March 2021, the Medicaid Progam provided coverage to record number of 419,228 individuals with 156,580 of them being children through traditional, CHIP, and current and former fostercare eligibility rules.[18] 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.

 

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.

 

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).

 

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.

 

Democratic Governor David Ige was re-elected to a second term in 2018. During the pandemic, a new Director of Health was appointed, Elizabeth Char, M.D. The former FHSD Chief, Danette Wong Tomiyasu, MBA, is the Deputy Director for HRA. Matthew J. Shim, Ph.D., MPH, is the current 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-19 Impact 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.

 

Early in the pandemic, Gov. Ige acted to protect Hawaii residents from mortality and morbidity associated with the pandemic. The first proclamation declaring a state of emergency was enacted on March 4, 2020, preceding the federal government’s response to the pandemic on March 13, 2020. The governor’s response directed the state and counties to implement a mandatory stay-at-home order; self-quarantine for all persons entering the state and traveling between counties; limited non-essential business, restaurants and bars, and gatherings; and mandated safe practices including mask wearing and physical distancing to reduce the spread of COVID-19. The state also implemented active COVID-19 testing and contact tracing and, once available, implemented vaccinations to mitigate disease impacts.

 

COVID-19 cases and deaths, as a result of these actions, were minimized. The state reported a cumulative 36,250 confirmed COVID-19 cases statewide and 508 deaths as of June 26, 2021. Hawaii’s cumulative death rate of 38/100,000 has been the lowest in the country. Disparities were seen with Native Hawaiian, Filipino, and Pacific Islanders experiencing higher rates of infection and death. The Delta variant was first detected in Hawaii in June 2021. Hawaii, like most of the U.S., is now experiencing a surge in cases, resulting in reinstated emergency restrictions.

 

Hawaii’s vaccination program began with healthcare providers in December 2020, opened to all adults on April 19, 2021, and all persons 12 and older on May 12, 2021. Among the state’s population, 62.9% are fully vaccinated. There are differences by county: 64% Oahu, 56% Maui, 59% Hawaii, and 62% for Kauai.

 

The spread of COVID-19 dramatically impacted Hawaii's families and businesses. The pandemic impacted the mental and physical health of residents but also impacted employment. The state's preliminary unemployment rate rose sharply from 2.4% in March 2020 – one of the best in the nation – to 23.8% in April 2020. As businesses have reopened on a measured basis, the unemployment rate decreased to 14.3% in October 2020 and is currently at 8.0%. With so many unemployed, the State Unemployment Insurance (UI) Trust Fund was quickly depleted, and the State had to obtain a $1.0 billion loan for calendar year 2020 from the federal government to pay UI claims, for which the State will pay the interest.

 

In addition to an increase in unemployment applications, the state reported:

• 29% increase in Medicaid enrollment (1/19 – 7/21) and 94,795 enrollments as of 3/6/2020
• 52,235 recipient increase to the Supplemental Nutrition Assistance Program (SNAP) between 3/2020 and 6/2021
• 36.4% of residents concerned about paying usual household expenses

 

The Department of Health 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 federal funds intended to support urgent COVID-19 response efforts to bring the pandemic under control, replace lost revenue, strengthen support for vital public services, provide assistance to individuals and households, and help retain jobs. The sources of federal funds are:

• Families First Coronavirus Relief Act
• Coronavirus Aid, Relief and Economic Security Act (CARES)
• American Rescue Plan Act (ARPA)

 

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] American Immigration Council. (2020). https://www.americanimmigrationcouncil.org/sites/default/files/research/immigrants_in_hawaii.pdf

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

[3] 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

[4] Hawaii State Department of Education, Who are Hawai’i’s English Language Learners (ELS)? School year 2018-19. https://www.hawaiipublicschools.org/DOE%20Forms/EL%20Infographic.pdf

[5] Number of armed forces residents and military dependents at http://dbedt.hawaii.gov/economic/databook/2019-individual/_01/

[6] https://homelessness.hawaii.gov/point-in-time-count/

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

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

[9] 2020 unemployment rate is found at https://www.bls.gov/lau/lastrk20.htm

[10] General fund forecast on March 13,2020, http://tax.hawaii.gov/useful/a9_1cor/

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

[12] Supplemental Poverty Measure is found on https://www.census.gov/library/publications/2020/demo/p60-272.html

 

[13] https://www.auw.org/alice-study-financial-hardship-hawaii

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

[15] Based on the facility address provided on https://health.hawaii.gov/shpda/agency-resources-and-publications/health-care-utilization-reports-and-survey-instructions/2019-data/

[16] Based on 2019 state data provided in Form 11.

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

[18] Based on the 2019 enrollment report from https://medquest.hawaii.gov/en/resources/reports.html