GEOGRAPHY
Situated in the middle of the Pacific Ocean, Hawaii is one of the most isolated yet populated 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 coast of the United States. Hawaii is the only island state, the 11th smallest state in the nation by population size, and the 4th smallest in land area. Most of the state's 1.4 million residents reside on Oahu, where the state capital of Honolulu is located.
The state comprises seven populated islands in four major counties: Hawaii, Maui, Oahu, and Kauai. The county is the lowest civil subdivision in the state, with the counties providing basic public services such as fire and police protection. Cities or towns in other states usually perform these services. The Hawaii State government is also responsible for functions usually performed by counties or cities in other states. For example, Hawaii is the only state with a single unified public school system. Similarly, Hawaii has no city- and county-specific health departments and depends on state district health offices to provide public health services for the three neighbor island counties. The neighbor island counties are Hawaii, Kauai (includes Niihau, which is privately owned with restricted access), and Maui (includes Molokai, Lanai, and Kahoolawe, which is unpopulated).
Only 10% of the state's total land area is classified as urban. Oahu is the most urbanized, with a third of its land area and 96% of its population in urban communities. Most tertiary healthcare facilities, specialty and subspecialty services, and healthcare providers are on Oahu. Consequently, neighbor island and rural Oahu residents often travel to Honolulu for these services. Interisland passenger travel to and from Oahu is entirely by air. Air flights are frequent but comparatively expensive. Airfare costs can be volatile based on varying fuel costs. This creates a financial barrier for neighbor island residents since roundtrip airfare ranges between $130 to $200.
Geographic access to healthcare is further limited since public transportation is inadequate in many areas of the state other than the Honolulu metropolitan area. Over the past five years, the islands of Maui, Kauai, and Hawaii have established limited public bus services, but their use by residents is largely sporadic. Residents in rural communities, like the neighbor islands, rely on automobiles to travel to major population centers on their island, where healthcare services are more likely to be available. Because of the mountainous nature of the islands, road networks are sparse and, in some places, limited to a single highway along the coastline. Timely access to emergency care on neighbor islands often requires costly helicopters or fixed-wing aircrafts.
DEMOGRAPHICS
According to the 2022 American Community Survey (ACS) 1-year estimate, the estimated 2022 state population is 1,440,196 residents, the 30th most populous state in the U.S. Oahu is home to 69.1% (995,638 residents) of the state’s population, while 14.3% (206,315 residents) live on Hawaii Island, 11.4% (164,365 residents) in Maui County, and 5.1% (73,810 residents) in Kauai County. Compared to 2021 (1,441,553),[1] The state's population decreased by 1,357 (0.09%). Other sources reported a larger decline over the years. For example, the Decennial Census estimated a 7,346 (0.5%) population decline from 2021 to 2022 and an 11,782 (0.8%) decline from 2020.[2] The Economic Research Organization at the University of Hawaii (UHERO) reported that Hawaii’s population losses have been concentrated on Oahu and Maui, with many residents moving to less expensive/more affordable locations elsewhere.[3]
ETHNIC DIVERSITY
Hawaii is the most ethnically diverse state in the nation.[4] According to the 2022 American Community Survey (ACS) data, 28.7% of Hawaii’s resident population reported two or more races, and the following single race proportions: White=22.2%; Asian=35.2%; and Native Hawaiian or Other Pacific Islander (NHOPI)=10.0%. The largest Asian single-race ethnic subgroups reported were Filipino (13.8%) and Japanese (10.6%), and the largest NHOPI single-race subgroup was the indigenous Native Hawaiians (5.8%). The individual Asian and NHOPI subgroups from the U.S. Census are listed in the table below, showing the heterogeneity of these aggregated ethnic groupings.
|
Reporting is further complicated by the growing category of those with two or more race groups. They are not included in the single-race groups commonly reported. Hawaii State Department of Health (HDOH) guidance instructs race data to be reported as “Alone” or “Alone or in Combination” with another group. For example, Native Hawaiians accounted for 22.8% of the state population when reported as “Alone or in Combination,” compared to just 5.8% when reported singly. There is also variation among race subgroups, with an overall estimate of 37.7% of those in the “Asian Alone or in Combination” reporting another race. Variation in the three largest Asian subgroups ranges from 39.6% Filipino to 61.3% Chinese. The other Asian subgroups are likely newer immigrants when compared to these three and have smaller numbers reporting more than one race.
|
Race |
Resident Population in the State (N) |
Percent of State Population (%) |
Proportion Reporting at least one other Race (5) |
|
White Alone |
319,118 |
22.2% |
0 |
|
White Alone or in Combination |
631,327 |
43.8% |
49.5% |
|
Native Hawaiian or Other Pacific Islander (NHOPI) Alone |
143,444 |
10.0% |
0 |
|
NHOPI Alone or in Combination |
404,442 |
28.1% |
64.5% |
|
Native Hawaiian Alone |
83,655 |
5.8% |
0 |
|
Native Hawaiian Alone or in Combination |
328,724 |
22.8% |
72.5% |
|
Asian Alone |
506,753 |
35.2% |
0 |
|
Asian Alone or in Combination |
812,862 |
56.4% |
37.7% |
|
Filipino Alone |
198,648 |
13.8% |
0 |
|
Filipino Alone or in Combination |
367,525 |
25.5% |
39.6% |
|
Japanese Alone |
152,062 |
10.6% |
0 |
|
Japanese Alone or in Combination |
299,756 |
20.8% |
38.3% |
|
Chinese Alone |
92,576 |
6.4% |
0 |
|
Chinese Alone or in Combination |
239,216 |
16.6% |
61.3% |
|
Source: U.S. Census Bureau. 2022. ACS Calculations by Hawaii HDOH, FHSD. |
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Hawaii is a gateway to the U.S. for immigrants traveling from Asia and the Pacific, reflecting a sizeable immigrant community. Based on the 2022 ACS, there were 246,683 immigrants in Hawaii, or nearly one in five (17.1%) residents, the 6th highest of all states. Hawaii immigrants were 57.2% women and 4.5% children (under 18 years old). The largest ethnic group of immigrants was Asians (72.6%), followed by NHOPI (9.9%) and White (9.6%).
Most immigrants in Hawaii (81.8%) speak a language other than English as their primary language, and 49.0% speak English less than “very well.” About 20.9% reported possessing a bachelor’s degree, with 9.0% having earned a graduate or professional degree. Approximately 59.5% of immigrants 16 years and over were employed in the labor force in 2022.
Undocumented Immigrant Estimates
In 2016, an estimated 45,000 undocumented immigrants were in Hawaii (3.3.% of the population).[5] The majority were from the Philippines. Hawaii was the only state where undocumented women (55%) outnumbered men. The following table summarizes the characteristics of Hawaii's undocumented immigrant population compared to the U.S.
|
Unauthorized Immigrant (UI) Characteristics |
Hawaii |
US |
|
Unauthorized population |
45,000 (3.3% of population) |
10.7 million (3.3% of population) |
|
Proportion of all immigrants undocumented |
17.0% |
24.0% |
|
Proportion of adults in the U.S. for 5 years or less |
34% |
18% |
|
K-12 students with unauthorized immigrant parent(s) |
7.0% |
7.6% |
|
Proportion of labor force that is unauthorized |
4.5% |
4.8% |
|
Industries & occupations with most unauthorized immigrant workers |
Leisure/hospitality, service; Agriculture/farming |
Construction, Service, Farming |
DACA (Deferred Action for Childhood Arrivals)
As of March 2020, 340 active DACA recipients resided in Hawaii, with 368 people granted DACA status since 2012.[6] As of 2019, 11% of those DACA-eligible immigrants in Hawaii applied for DACA status.
Compacts of Free Association (COFA)
COFA migrants come from the Federated States of Micronesia, Republic of Marshall Islands, and Republic of Palau. Under these unique agreements, COFA migrants are legally residing noncitizen nationals who can live, work, and study in the U.S. indefinitely without a VISA or green card. This status was negotiated in exchange for exclusive U.S. military use of strategic areas in the region. The passage of the 1996 Welfare Reform Act removed COFA eligibility to key entitlement programs (Medicaid, Social Security, disability, and housing programs), with the state assuming most of the costs for services. However, in December 2020, Medicaid benefits were federally restored to COFA migrants once again.
Among COFA migrants, there are reports of high morbidity rates due to chronic diseases, communicable diseases, and other medical concerns that may be related to U.S. nuclear tests conducted within Micronesia in the 1950s and 60s. Health disparities are exacerbated by chronic unmet care needs, lower socioeconomic status, and cultural beliefs and behaviors with the most recent arrivals. Estimates of the COFA population in Hawaii range from 16,680 to 28,000.[7] COFA migrants are consistently overrepresented among homeless surveys and account for about 2-3% (400-600) of births annually in Hawaii, with lower rates of prenatal care, higher rates of low birth weight infants, and greater numbers of Neonatal Intensive Care Unit admissions.[8]
Languages Spoken
Because of the ethnic diversity in Hawaii, limited English proficiency may impact access to healthcare for immigrant communities and pose a challenge to service organizations targeting these populations. According to the 2022 ACS, an estimated 24.2% of Hawaii residents ages 5 years and over spoke a language other than English at home, compared to 22.0% nationally. An estimated 10.3% of Hawaii residents reported limited English proficiency (4th highest state ranking) compared to 8.4% nationally.
In School Year 2019-20, an estimated 18.0% (32,044) of the public school students are or have been English Learners (EL).[9] The top five languages spoken by Hawaii public school students are Ilokano, Chuukese, Marshallese, Tagalog, and Spanish.
Hispanics
Hawaii has experienced a growing Hispanic population, particularly in rural, predominantly agricultural areas. Anecdotally, recent Hispanic workers in the state have lessened the labor shortages in agriculture (coffee and pineapple farms) and in tourism-related and construction industries located primarily in Maui and Hawaii counties. Service organizations report that their migrant workers have relocated primarily from Mexico, Guatemala, and Honduras.[10]
Disaggregated Data
The state’s unique characteristics, particularly the diversity in race, ethnicity, language, and cultural practices, underscores the serious 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 assist in evaluating whether programs are effective at meeting the needs of these groups. It can also help develop policies and programs that are culturally/linguistically appropriate since differences in culture and language are important considerations when implementing any Evidenced-Based Interventions.
Other subpopulations within Hawaii include the U.S. Armed Forces personnel and their family members. In 2022, Active Duty, National Guard, and Reserve Personnel comprised an estimated 3.5% of the state’s population (50,031 people).[11] Several major military health facilities serve this population on Oahu. The Tripler Army Medical Center is the federal tertiary care hospital for the Pacific Basin. It supports 264,000 local active-duty and retired military personnel, their families, and veteran beneficiaries. Medical services are also available on military bases, offering clinical services for active-duty members and their family members.
Homeless
The 2023 Hawaii homeless study estimates that there were 2,316 sheltered homeless people in the state (1,663 on Oahu and 653 on the neighbor islands).[12] Data for unsheltered homeless was 2,365 for Oahu and 1,542 on the neighbor islands. From 2022 to 2023, a 4.2% increase was documented in sheltered homeless on Oahu, with a 4.0% increase for sheltered homeless on neighbor islands. Compared to other states, Hawaii had the 4th highest homeless rate in the U.S. (43 per 10,000 residents), more than twice the national rate (19 per 10,000).[13]
The 2022 ACS data estimates indicate that there were 260,713 women of reproductive age (15-44 years old), a 3.0% decline from 2015 (268,648), representing 18.1% of the entire state population. Vital statistics data for Hawaii show the number of births have continued to decrease between 2019 (16,810) and 2023 (14,820).
ACS data also indicates there were 161,160 children 9 years of age or younger in Hawaii, representing a 9.2% decrease from 2015. This group represents 11.2% of the state population. There were 165,846 children 10-19 years of age, representing a 1.6% increase from 2015. This group represents 11.5% of the state population.
Based on 2021-2022 data, an estimated 41,437 Children with Special Health Care Needs (CSHCN) reside in Hawaii, representing 13.9% of all children ages 0-17 years. This 13.9% is significantly below the national estimate of 20.0%. The 2021-2022 Hawaii estimate was similar to the 2020-2021 estimate (13.2%).
Older Population
As in other places, Hawaii's population is rapidly aging. Based on 2022 population estimates, persons aged 65 years and over (294,654 total) comprised 20.4% of the Hawaii population, compared to 16.6% in 2015. Nationwide, this population comprised 17.3% in 2022, compared to 14.9% in 2015. There are now more older people in proportion to younger ones residing in Hawaii, and this trend is expected to continue.
Maui Wildfires
One of the deadliest natural disasters in U.S. history occurred on August 8, 2023, when a swiftly-moving wildfire unexpectedly razed drought-prone West Maui, completely destroying the historic town of Lahaina. The fire tragically took the lives of 102 people, injuring many more and leaving several thousand without a home or means of support. The wildfire burned 2,170 acres and destroyed more than 3,000 buildings, including schools, 5,000 cars, and 100 sea vessels. Approximately 86% were residential homes, of which half were rentals. Housing on Maui, as elsewhere in the state, is very limited and costly, with the fire aftermath creating an extreme emergency for affected families and individuals.
The American Red Cross, Hawaii Emergency Management Agency, and FEMA temporarily relocated thousands of displaced families to dozens of hotels and hundreds of short-term rentals on Maui, ultimately housing more than 8,000 displaced individuals in more than 2,400 units across 40 properties in just 14 days. The town of Lahaina is considered rural by federal definitions, making this area eligible for federal grants. The consequences of the wildfires continue to impact all aspects of life for the community, county, and the entire state. Some of the more measurable impacts will be discussed throughout the report.
ECONOMY
Tourism, real estate, construction sectors, and federal/military spending largely drive the economy in Hawaii. Initial COVID-19 shutdowns in 2020 resulted in the virtual closure of the Hawaii tourism market, causing an unprecedented decline in the state’s economy. Equally unexpected, the economy made an astounding rebound in 2022 with the return of U.S. domestic travelers driven by healthy U.S. incomes and pent-up demand. According to the Hawaii Department of Business, Economic Development and Tourism (DBEDT),[14] the state’s major economic indicators were mixed in the fourth quarter of 2023. Wage and salary jobs and state general fund tax revenues increased, but visitor arrivals and private building authorizations decreased in 2023 compared to 2022. In the first half of 2023, Hawaii showed signs of a post-pandemic economic recovery with generally stabilized economic indicators.
The August 2023 Maui Wildfires altered the state's trajectory when economic activity slowed significantly after the fires. Maui County experienced the immediate loss of thousands of jobs, housing, and businesses, particularly in the high-end West Maui tourist destination. Lahaina town in West Maui has a rich history, serving as the Hawaiian kingdom's capital and an active center of commerce. Property losses from the 2023 fire were estimated at $6 billion, including 834 registered businesses that were closed that had previously generated $900 million in annual sales revenue.
Tourism
After the virtual shutdown of tourism during the 2020-22 pandemic, there was an eventual robust return of domestic visitor numbers to Hawaii. In 2023, the visitor industry continued to flourish despite the impact of the Maui wildfires. International visitor arrivals continued to increase, although the lucrative Japanese visitor market remained well below pre-pandemic levels due to the weak Japanese yen. Domestic visitor arrivals slowed, reflecting a waning of post-pandemic rebound travel. In 2023, the total annual international flight arrivals increased to 643,692 visitors, 71.1% of 2022 arrivals. In 2023, visitor expenditures totaled $20,708 million, which reflected an increase of 5.4% from the previous year.[15]
In the wake of the August 2023 wildfires, Maui visitor arrivals plunged by nearly three-quarters as travelers reacted to the news of the fires. Conflicting messaging about Maui’s capacity and ability to host tourists amid the tragedy affecting their residents was evident. As a result, Maui lost more than $13 million of visitor spending each day in the weeks following the fire. The October 2023 official reopening of the unaffected West Maui resort areas renewed tourism response with a strong rebound. Other counties experienced more visitors opting for alternative vacation destinations during this post-disaster period.[16]
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 nationally. Hawaii’s unemployment rate has largely stabilized since 2020 to 3.0% in 2023, compared to the U.S. average of 3.6%[17] ranking Hawaii the 17th lowest among all states.
The impacts of the Maui fires on local employment were rapid and severe, with 9,000 uninsurance claims filed in September 2023 following the fire, compared to 130 in July 2023. Across Maui, local businesses also struggled due to the lower visitor numbers, with the initial impact post-wildfires pushing the Maui jobless rate to 11% in the fourth quarter of 2023.
Job Market
Labor market conditions statewide were mixed in 2023. The civilian labor force decreased, but civilian non-agricultural wage and salary jobs increased.[18] In the fourth quarter of 2023, the civilian labor force averaged 675,000 people, a decrease of 5,200 people (0.8%) compared to the same quarter of 2022.[19] Conversely, Hawaii averaged 637,700 jobs in the fourth quarter of 2023, an increase of 5,000 jobs (0.8%) over the same quarter in 2022. The job increase in the fourth quarter of 2023 was attributed to gains in jobs in both the private and government sectors. Compared to the same quarter in 2022, the largest increases in 2023 were in:
- Health Care and Social Assistance, which reported a 1.8% increase in jobs.
- Food Services and Drinking Places, which reported a 1.7% increase in jobs.
- Private Educational Services, which reported a 6.1% increase in jobs.
- Professional and Business Services, which reported a 1.0% increase in jobs.[20]
The Government sector reported a 2.6% increase in jobs in the fourth quarter of 2023 when compared to the same quarter of 2022.
Wages
During the COVID period from 2020-22, the average annual wage for employees in Hawaii increased, largely attributed to direct federal stimulus payments, including supplemental unemployment insurance benefits. The U.S. Bureau of Labor Statistics reported that Hawaii's 2022 average annual wage was $61,483, 12.1% lower than the U.S. average.[21] It reflected a 3.1% ($1,839) increase in Hawaii's average wages, when compared to the 2021 average annual wage ($59,644). In 2022, Hawaii ranked 27th among the 50 states.
Income
Per capita, personal income for Hawaii workers also increased slightly in 2022 ($61,813) compared to 2021 ($61,481).[22] As noted, income loss during COVID was offset by government stimulus/relief supports, including rental relief, essentially preventing economic collapse for many island families.[23] In 2022, Hawaii per capita income was 5.6% lower than the national average ($65,473), and after adjusting for the high cost of living, it was 12% lower than the unadjusted level.[24] The aggregated income and wage indicators do not measure the markedly disparate effect on high- versus lower-income workers. Wage and income measures also do not accurately reflect residents’ economic status since the increases are nullified by Hawaii’s status as having the highest cost of living in the U.S.
Poverty
Based on 2022 ACS estimates, the poverty rate in Hawaii was 10.2% (all ages in poverty), which is 2.4% lower than the U.S. rate (12.6%). This percentage represents an estimated 142,378 individuals living in poverty in the state. Over 36,568 (12.6%) of children and adolescents under 18 years old live in households that are below the Federal Poverty Level (FPL). Poverty rates remain variable across counties: Honolulu 9.7%; Maui 8.2%; Kauai 6.6%; and Hawaii 15.1%. Poverty rates remain higher among Native Hawaiians and Other Pacific Islanders (19.1%) and Blacks/African Americans (11.6%) when compared to Whites (9.8%) or Asians (7.0%).
The official FPL obscures many families' struggles in Hawaii due to the high cost of living and the relatively low minimum wage structure, given many families’ dependence on low-paying service industry jobs in tourism. The Census Supplemental Poverty Measure reports that the three-year average (2019-2021) poverty rate in Hawaii was actually 10.5% when using the supplemental poverty measure, which was 0.4% higher than the official FPL (10.1%).[25]
ALICE Report
The Hawaii United Way agency report on working residents living just above the poverty level who cannot afford basic necessities more accurately reflects Hawaii's family economic status. The ALICE survey refers to families that are Asset-Limited, Income-Constrained, Employed (ALICE).[26] The most recent Hawaii ALICE study in 2022 revealed that more Hawaii households fell below the ALICE threshold compared to 2018 prior to COVID. An estimated 44% of Hawaii ALICE households in 2022 (compared to 42% in 2018) struggled to meet basic housing, childcare, food, transportation, and healthcare expenses. These ALICE households were in addition to the 11% of households below the FPL. Additionally, the percentage of households with income below the FPL increased from 9% in 2018.[27] This suggests hardship deepened for many island residents during the pandemic. Strikingly, the majority of Native Hawaiian (60%) and Filipino (59%) residents fell below the ALICE threshold, as did all households with children (54%).
The report cites the major reasons for the high percentage of ALICE households:
- Low-wage jobs dominate the economy.
- Cost of living increasingly outpaces wages.
Nearly 62% of all jobs in Hawaii pay less than $20 per hour, with more than two-thirds paying less than $15 per hour. It is difficult for ALICE households in Hawaii to find affordable housing, job opportunities, and community resources. Although public and private assistance helps, it does not provide financial stability. ALICE households are often forced to make difficult financial choices with limited resources, such as forgoing healthcare, childcare, healthy food, or car insurance.
HIGH COST OF LIVING
Regional price parities data for 2022 shows that Hawaii was the third highest in regional price parity (110.8), with California (112.5) and the District of Columbia (112.8) emerging as the highest.[28] Other sources ranked Hawaii as the most expensive state in the nation in terms of cost of living.[29]
Housing Costs
One primary driver for the high cost of living is escalating housing costs, the highest in the U.S. Housing costs in Hawaii create an inordinate burden for families, resulting in significantly less income for other essential household expenses. As a result, families are often forced to live in overcrowded, substandard housing or are forced into homelessness for lack of affordable housing options.
In April 2024, the median housing cost for a single-family dwelling on Oahu was $1,100,000, with a condominium averaging $528,000.[30] The median monthly owner mortgage cost in 2022 was $2,683, 51.2% higher than the U.S. average. Among homeowners, 33.1% spent 35% or more of their household income on housing, higher than the U.S. average of 21.3%. Hawaii ranked the highest in the nation for this indicator. Not surprisingly, the homeownership rate in Hawaii in 2022 was ranked as among the lowest in the U.S. (45th among the 50 states) at 62.6%, which was lower than the U.S. average of 65.2%.
Rental Costs
The high rent cost is out of reach for many working families in Hawaii. In 2022, an estimated 37.4% of occupied housing units in Hawaii were renter-occupied (compared to 34.8% nationally). The median monthly gross rent for the renter-occupied units was $1,813, 39.5% higher than the U.S. average of $1,300. In 2022, Hawaii ranked 3rd highest in rent cost nationally.
Multigenerational Households
For many island families, cultural preferences and traditions have increased the number of multigenerational households, but this is a reality due to high housing costs. In 2022, the percentage of multigenerational family households among all family households in Hawaii was 7.4% (36,716 out of 494,827 households), which was double the U.S. average of 3.7% (4,858,937 out of 125,031,991 households). Hawaii has the nation's highest rate of multigenerational households and some of the largest household sizes, especially among Pacific Island families. These household factors created challenges during COVID-19 social distancing/isolation efforts, which contributed to higher disparate infection rates for some ethnic groups.
Cost of Health Insurance
Overall, the cost of private employer-based health in Hawaii steadily increased for a family plan between 2013 and 2021, from $14,382 to $18,539.[31] Hawaii health plans offered through the federal marketplace increased from $330 in 2017 for the average individual premium to $469 in 2023.[32] Hawaii is widely considered to have among the lowest healthcare insurance premium costs in the nation, but the costs continue to increase nearly every year.[33]
Health Services Infrastructure
There are about 100 healthcare facilities in Hawaii.[34] Of the state’s 29 hospitals, 12 offer labor and delivery services. Three pediatric hospitals have Neonatal Intensive Care Units on Oahu, while other hospitals have fewer acute pediatric services. Hawaii has 15 federally qualified health centers, 15 rural health clinics, and seven Native Hawaiian health system sites across the state. Most healthcare services, particularly specialty care providers/facilities, are concentrated in urban Honolulu on Oahu. Neighbor island residents fly to Oahu to access medical, dental, and behavioral services. Maps of these facilities are in the Supporting Documents.
Healthcare Workforce
The state has 210 family and general practitioners, 210 obstetricians and gynecologists, and 320 pediatricians.[35] Based on the 2022 population estimate, there are 14.6 per 100,000 obstetricians and gynecologists, which is higher than the national rate (6.4 per 100,000 population), though non-significant. There are 22.2 pediatricians per 100,000 population, which is similar to the national estimate (10.0). The rate for family/general practitioners (14.6 per 100,000 population) is significantly lower than the national rate (30.3). Despite the high ratio of providers to population, many of the state’s medical and specialty providers are located on Oahu, and most of the state’s rural communities are designated as shortage and/or medically underserved areas.
The COVID-19 pandemic exacerbated already existing healthcare workforce shortages in Hawaii. The 2023 Physician Workforce Assessment reported that Hawaii should have 757 more doctors, with the greatest need in primary care specialties. The greatest needs are on the neighbor islands, with Maui (43%) and Hawaii County (41%) experiencing significant physician shortages.[36]
To address the workforce shortage, $30 million was allocated in 2023 for the Hawaii Health Education Loan Repayment Program for healthcare providers who agree to at least 30% public insurance recipients for their caseload. The federally funded State Loan Repayment Program provides $800,000 loan repayment a year. The programs are anticipated to assist hundreds of medical residents in training and other healthcare workers statewide every year.
Healthcare Shortage Designations
Shortage Designations represent an area's or population's needs based on several factors, including current health workforce numbers, socioeconomic and demographic data, language barriers, health indicators, access to healthcare, and travel time to the nearest available provider. Most shortage areas are on the rural neighbor islands and rural/low-income urban areas on Oahu. The entire state of Hawaii is currently designated a mental health shortage area. Maps of shortage areas in Hawaii are included in the Supporting Documents.
HEALTH INSURANCE
Hawaii has a long history of supporting health insurance initiatives universally available to residents, and was one of 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 and mandated caps on employee contributions. The PHCA is largely credited for Hawaii's high level of insurance coverage and affordability. Hawaii is the only state with a federally enacted exemption from the federal Employee Retirement Income Security Act (ERISA), which sets the minimum standards for health plans for private industry.
In conjunction with the Affordable Care Act (ACA), Hawaii implemented further Medicaid expansion in 2017, utilizing the federally run ACA exchange. Hawaii is one of the few states where enrollment in health plans through the ACA exchange increased, from 18,938 enrollees in 2017 to 22,327 enrollees in 2022.[37]
Under Medicaid expansion, coverage was 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.[38] This mirrors the national average of roughly 25% Medicaid coverage of the state population. In Hawaii, Medicaid provides health coverage for more than 40% of the state’s children.
In 2018, state lawmakers integrated several components of the ACA into the PHCA to ensure that health benefits remained available under Hawaii law. This included dependent coverage for children through 26 years of age and prohibiting any preexisting condition exclusion or the use of gender to determine premiums.
Through these efforts, Hawaii consistently reports low uninsured rates:3.9% in 2021.
MEDICAID
The Department of Human Services (HDHS) Med-QUEST Division (MQD) administers the state Medicaid program (QUEST). QUEST stands for Quality care, Universal access, Efficient utilization, Stabilizing costs, and Transform the way healthcare is provided to recipients. QUEST's objectives are to expand medical coverage to more residents and contain costs by shifting to a managed care delivery system, with savings realized to expand coverage. Under this federal waiver, Medicaid beneficiaries with disabilities and those over 65 receive services through fee for services.
Medicaid eligibility levels for children in Hawaii are much higher than the national average and are about average with national levels for pregnant women and parents.
- Children ages 0-18 qualify, with family income up to 308% 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.
These eligibility limits do not include a built-in 5% income disregard used for income-based (MAGI) Medicaid eligibility determinations. During the COVID public health emergency, Hawaii’s Medicaid enrollments increased by 37.0%, with over 448,193 enrollees statewide. In 2022, Hawaii extended postpartum coverage for 12 months, and the state recently reinstated preventative adult dental benefits to Medicaid adults in 2023.
Of the 466,328 individuals enrolled in Medicaid, 133,996 are children.[39] The Medicaid Program also covered 2,529 pregnant women. Additionally, the program continues to support medically needy children who require nursing home care.
Federal Medicaid eligibility was restored to COFA migrants in 2020. As of February 2022, 9,257 COFA adults were enrolled with Med-QUEST.
The state’s CHIP program, a Medicaid expansion, covers all Hawaii children under 19 years of age with family incomes up to 308% of the FPL. There is no waiting period for CHIP eligibility. All immigrant children who are Legal Permanent Residents or citizens of a COFA nation are eligible to be enrolled in the Medicaid program.
Medicaid beneficiaries can choose medical plans from five health plans: AlohaCare, HMSA, Kaiser Foundation Health Plan, 'Ohana Health Plan, and United Healthcare. All the health plans provide services statewide, except for the Kaiser Foundation Health Plan, which operates only on the islands of Oahu and Maui.
Medicaid Redeterminations. Hawaii began disenrolling ineligible Med-QUEST members in May 2023. Due to the Maui wildfires, Hawaii paused all eligibility redeterminations through the end of 2023. Redeterminations resumed for Maui residents in April 2024 and for West Maui residents in June 2024.
The Medicaid media campaign to ensure all eligible Medicaid enrollees remain covered is called Stay Well, Stay Covered. It includes a website with information available in 14 languages.
GOVERNMENT
The state’s Executive Branch is organized into 16 cabinet-level agencies. HDOH and HDHS administer the major health programs. HDHS administers the Medicaid program, while HDOH serves as the state's public health agency. HDHS also houses the major social service/entitlement programs (Child Welfare, Temporary Assistance for needy families, Supplemental Nutrition Assistance Program, and Vocational Rehabilitation).
HDOH is the state's sole public health agency, as Hawaii has no local health departments. The state's three neighbor island counties (Hawaii, Maui, and Kauai) are represented by District Health Offices that oversee HDOH services at the county level. The central Title V programs on Oahu handle contractor services on the neighbor islands.
The governor appoints all state department directors; the director of health reports directly to the governor. HDOH is divided into three major administrations: Health Resources Administration (HRA), Behavioral Health, and Environmental Health. There are six major divisions within HRA, including the Family Health Services Division (FHSD), which is responsible for administrating all Title V funding. The three branches within FHSD are Maternal and Child Health; Women, Infants, and Children (WIC) Services; and Children with Special Health Needs.
Hawaii remains a largely Democratic-leaning state, with few Republicans holding public office. Hawaii elected a new democratic Governor, Josh Green, MD. The new HDOH Director is Kenneth S. Fink, MD, MGA, MPH, with Debbie Kim Morikawa as the Deputy Director for HRA. Matthew J. Shim, PhD, MPH, remains the 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. A listing of statutes pertaining to the division programs are in the Supporting Documents.
LEGISLATURE
Over the past three years, the State Legislature utilized large budget surpluses bolstered by federal COVID relief funds to augment and support programs to alleviate financial hardships for resident families, including affordable housing development; raising the minimum wage; tax credits for low-income and working families; and major investments in public preschool classrooms, childcare supports, expansion of rural hospital facilities, and loan payment for hundreds of healthcare workers.
The Legislature also strengthened and expanded protections for reproductive healthcare access and abortion services, as well as gun safety laws in response to recent Supreme Court rulings.
In 2024, the Legislature approved over $1 billion for Maui recovery and passed the largest tax cut in state history, expected to save Hawaii taxpayers more than $5 billion by 2030. The bill will double the standard deduction that state taxpayers can claim for the 2024 tax year and then adjust income tax brackets and standard deductions upward in a series of steps in later years as Hawaii’s minimum wage gradually increases. The sweeping tax legislation has raised concerns that the bill may adversely affect state revenues, potentially resulting in substantial downsizing of government programs and services.
COVID Update
Hawaii managed the COVID-19 pandemic challenges more effectively than other states, as reflected in the low COVID-19 case numbers, fewer hospitalizations, and fewer deaths. The state's success relied on restricting all travel early in the pandemic and closely adhering to Centers for Disease Control safety guidelines. Hawaii was the last state to end an indoor mask mandate nationally. The HDOH is one of a few states that continues to maintain and keep the public informed via a COVID dashboard, with weekly confirmed cases, hospitalizations, deaths, and vaccinations. https://health.hawaii.gov/coronavirusdisease2019/
[1] Due to the impact of COVID-19, 2020 Census data for population estimates is unavailable. Instead of providing the standard 1-year data products, the Census Bureau released experimental estimates from the 1-year data and later released 5-year aggregated data. Therefore, a comparison with 2020 data is not available for ACS data.
[2] State Population Totals and Components of Change: 2020-2023 https://www.census.gov/data/tables/time-series/demo/popest/2020s-state-total.html
[3] UHERO Forecast for the State of Hawaii (p.18) https://uhero.hawaii.edu/uhero-forecast-for-the-state-of-hawai%ca%bbi-near-term-slowing-expected-as-pandemic-recovery-ends/
[4] with no single-race majority.
Diversity Index by State: 2020, Racial and Ethnic Diversity in the United States, U.S. Census Bureau, accessed at Racial and Ethnic Diversity in the U.S.: 2010 Census and 2020 Census
[5] Pew Research Center. (2016). https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state/
[6] American Immigration Council. (2020).
https://www.americanimmigrationcouncil.org/sites/default/files/research/immigrants_in_hawaii.pdf
[7] 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
[8] COFA reports (2018) https://www.doi.gov/oia/reports/Compact-Impact-Reports.
[9] https://www.hawaiidxp.org/data-products/hawaii-english-language-learners-data-story/
[10] Civil Beat. The Fastest-Growing Ethnic Group In Hawaii Is Also The Most Invisible - Honolulu Civil Beat
[11] Active Duty and Reserve Personnel by Service (Table 10.04) at https://dbedt.hawaii.gov/economic/databook/2022-individual/_10/
[12] For Oahu: https://www.partnersincareoahu.org/pit;
for neighbor islands, https://www.btghawaii.org/reports/housing-inventory-counts-point-in-time/
[13] U.S. Department of Housing and Urban Development. The 2023 Annual Homelessness Assessment Report to Congress. https://www.huduser.gov/portal/sites/default/files/pdf/2023-AHAR-Part-1.pdf
[14] State DBEDT, Report on the economic condition of Hawaii http://dbedt.hawaii.gov/economic/qser/
[15] Visitor expenditures by air (Tourism data tables: Table D-11). http://dbedt.hawaii.gov/economic/qser/tourism/
[16] UHERO (University of Hawaii Economic Research Organization, Expansion Intact, But Counties Poised for Slower Growth, May 19, 2024 https://uhero.hawaii.edu/wp-content/uploads/2024/05/24Q2_Forecast.pdf
[17] 2023 unemployment rate is found at www.bls.gov/lau/lastrk23.htm,
[18] Note: Non-agricultural jobs do not include farm/ranch workers.
[19] State DBEDT, 2024 1st quarter report on labor force https://dbedt.hawaii.gov/economic/qser/labor-force/
[20] Labor Data Tables from 2024 1st quarter report, https://dbedt.hawaii.gov/economic/qser/labor-force/
[21] U.S. Bureau of Labor Statistics, 2022 Annual Averages.
[22]Personal income, population, per capita personal income table (SAINC1-51) obtained from Bureau of Economic Analysis https://apps.bea.gov/itable/?ReqID=70&step=1&_gl=1*1qzqwko*_ga*MTE2Nzk0NTM0OC4xNjY0MzIwNjg3*_ga_J4698JNNFT*MTcxNTIwNDU3Mi4xMC4xLjE3MTUyMDU3MDguNjAuMC4w.
[23] University of Hawaii Economic Research Organization (UHERO), Recovery Resumes but Omicron Looms, December 17, 2021. https://uhero.hawaii.edu/focus-areas/forecast-project/
[24]UHERO, Forecast for the State of Hawaii, May 12, 2023. Hawaii’s high cost of living (p.13), forecast document downloaded from
https://uhero.hawaii.edu/uhero-forecast-for-the-state-of-hawai%ca%bbi-promise-and-peril-for-the-hawaii-economy/
[25] Poverty in the United States. Number and Percentage of People in Poverty by States (Table B-5) https://www.census.gov/library/publications/2022/demo/p60-277.html
[27]2022 Alice Report: https://www.boh.com/siteassets/files/community/alice-report-2022.pdf
[28] Bureau of Economic Analysis, Regional Price Parities for States, 2022, https://www.bea.gov/news/2023/real-personal-consumption-expenditures-state-and-real-personal-income-state-and
[29]Forbes Advisor: Examining the Cost of Living by State in 2024: https://www.forbes.com/advisor/mortgages/cost-of-living-by-state/; Missouri Economic Research and Information Center: https://meric.mo.gov/data/cost-living-data-series
[30] Honolulu Board of Realtors https://www.hicentral.com/
[31] Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey Insurance Component, accessed through the KFF website https://www.kff.org/
[32] KFF website https://www.kff.org/ Marketplace Average Benchmark Premiums
[33] Hawaii Insurance Division, Health Care, Health Insurance, PPT. https://cca.hawaii.gov/ins/files/2023/01/Health-Insurance-2022-State-of-Reform.pdf
[34] Based on the facility address provided on https://health.hawaii.gov/shpda/agency-resources-and-publications/health-care-utilization-reports-and-survey-instructions/2022-data/
[35] Based on 2022 state data provided in Form 11.
[36] Annual Report on Findings from the Hawai'i Physician Workforce Assessment Project, December 2023 https://www.hawaii.edu/govrel/docs/reports/2023/act18-sslh2009_2023_physician-workforce_annual-report_508.pdf
[37] KKF.org Health Insurance Marketplace Enrollment.
[38] Based on the Department of Human Services, State of Hawaii, 2019 Annual Report found on http://humanservices.hawaii.gov/reports/annual-reports/
[39] Based on 2024 data provided by the State of Hawaii Department of Human Services, Med-QUEST Division
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