aGEOGRAPHY
Situated in the middle of the Pacific Ocean, Hawaii is one of the most isolated 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 $150 to $300.
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 air transportation.
DEMOGRAPHICS
According to the 2023 American Community Survey (ACS) 1-year estimate, the estimated 2023 state population is 1,435,138 residents, the 30th most populous state in the U.S. Oahu is home to 68.9% (989,408 residents) of the state’s population, while 14.5% (207,615 residents) live on Hawaii Island, 11.4% (164,244 residents) in Maui County, and 5.1% (73,851 residents) in Kauai County. Compared to 2022 (1,440,196), the state's population decreased by 5,058 (0.35%).
Other sources reported a rebounding of the population in 2023, due to a change in state migration patterns in recent years. For example, the Economic Research Organization at the University of Hawaii (UHERO) revealed that there was a 2022 reversal in state population, due to a net gain in Hawaii-born residents returning home.[1],[2] The UHERO data reported a 0.2% increase in the state population, from January 2023 to January 2024.2
MULTI-ETHNIC POPULATION
Hawaii remains the most multi-ethnic state in the nation.[3] According to the ACS data, 28.2% of the state’s resident population reported two or more races, and the following single race proportions: White=21.9%; Asian=36.7%; and Native Hawaiian or Other Pacific Islander (NHOPI)=9.4%. The largest Asian single-race ethnic subgroups reported were Filipino (14.9%) and Japanese (11.2%), and the largest NHOPI single-race subgroup was the indigenous Native Hawaiians (5.6%). 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.
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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 nationally. 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 22.4% of the state population when reported as “Alone or in Combination,” as compared to just 5.6% when reported singly.
There is also variation among race subgroups, with an overall estimate of 35.6% of those in the “Asian Alone or in Combination”, reporting another race. Variation in the three largest Asian subgroups ranges from 15.8% Chinese to 40.5% Filipino. 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 |
314,534 |
21.9% |
0 |
|
White Alone or in Combination |
635,240 |
44.3% |
50.4% |
|
Native Hawaiian or Other Pacific Islander (NHOPI) Alone |
135,541 |
9.4% |
0 |
|
NHOPI Alone or in Combination |
388,921 |
27.1% |
65.2% |
|
Native Hawaiian Alone |
81,062 |
5.6% |
0 |
|
Native Hawaiian Alone or in Combination |
321,694 |
22.4% |
73.3% |
|
Asian Alone |
526,684 |
36.7% |
0 |
|
Asian Alone or in Combination |
817,525 |
57.0% |
35.6% |
|
Filipino Alone |
213,268 |
14.9% |
0 |
|
Filipino Alone or in Combination |
379,791 |
26.5% |
38.1% |
|
Japanese Alone |
161,089 |
11.2% |
0 |
|
Japanese Alone or in Combination |
306,991 |
21.4% |
36.7% |
|
Chinese Alone |
83,540 |
5.8% |
0 |
|
Chinese Alone or in Combination |
218,122 |
15.2% |
61.6% |
|
Source: U.S. Census Bureau. 2023. 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, resulting in a sizeable immigrant community. Based on the ACS, there were 255,755 immigrants in Hawaii, or nearly one in five (17.8%) residents, the 6th highest of all states. Hawaii immigrants were 57.6% women and 4.0% children (under 18 years old). The largest ethnic group of immigrants was Asians (74.6%), followed by NHOPI (8.2%) and White (8.8%).
Most immigrants in Hawaii (79.8%) report their primary spoken language as other than English, and 46.3% speak English, less than “very well.” About 21.4% reported possessing a bachelor’s degree, with 10.1% having earned a graduate or professional educational degree. Approximately 62.3% of immigrants who are 16 years and over, were employed in the labor force in 2023.
Compacts of Free Association (COFA)
COFA migrants migrate from the Federated States of Micronesia, Republic of Marshall Islands, and Republic of Palau. Under these unique intergovernmental agreements, COFA migrants are considered legally residing noncitizen nationals, who can live, work, and study in the U.S. indefinitely, without a VISA or green card. This status has been negotiated for decades, 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 for 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.
Among COFA migrants, there are reports of high morbidity rates of chronic diseases, communicable diseases, and other medical concerns, some of which 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 vary, from 16,680 to 28,000.[4] COFA migrants are consistently overrepresented among homeless surveys, and account for about 2-3% (400-600) of births annually in Hawaii. They have lower rates of prenatal care, higher rates of low-birth-weight infants, and higher numbers of neonatal intensive care unit (NICU) admissions.[5]
Languages Spoken
Because of its ethnic variety, limited English proficiency impacts access to healthcare for immigrant communities, and pose a challenge to service organizations serving these populations. An estimated 24.2% of Hawaii residents, ages 5 years and over, speaks a language other than English at home, compared to 22.5% nationally. An estimated 10.4% of Hawaii residents reported limited English proficiency (4th highest state ranking) compared to 8.7% nationally.
In School Year 2019-20, an estimated 18.0% (32,044) of the K-12 public school students are, or have been, identified as English Learners (EL).[6] The top five languages/dialects spoken by Hawaii public school students are: Ilokano, Chuukese, Marshallese, Tagalog, and Spanish.
Other subpopulations within Hawaii include the U.S. Armed Forces personnel and their family members. Due to the strategic location of Hawaii in the Indo-Pacific region, about 5.6% of the state’s land belongs to the military, making it the most densely militarized state in the U.S.[7] In 2023, Active Duty, National Guard, and Reserve Personnel comprise an estimated 3.8% of the state’s population (54,149 people).[8]
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 primarily for veterans, active-duty members and their family members.
Homeless
The 2024 Hawaii homeless study estimated that there were 2,347 sheltered homeless people in the state (1,728 on Oahu and 619 on the neighbor islands).[9] The Point-in-Time count for unsheltered homeless was 2,766 for Oahu and 1,276 on the neighbor islands. From 2023 to 2024, there was a 3.9% increase in sheltered homeless, and 17% increase in unsheltered homeless on Oahu. However, for neighbor islands, there was a 5.2% decline for sheltered homeless and 17.2% decline for unsheltered homeless from 2023 to 2024.
Other sources report a much larger increase in Hawaii homeless. For example, including the data from non-congregate shelter (e.g., Maui non-congregate shelter for Maui fire victims), the 2024 Annual Homelessness Assessment Report to Congress indicates an 87% increase of total homeless from 2023 (6,223) to 2024 (11,637).[10] Compared to other states, Hawaii had the second highest homeless rate in the U.S. (81 per 10,000 residents), which is more than three times the national rate.
The ACS data estimates indicate that there were 259,611 women of reproductive age (15-44 years old), a 3.3% decline from 2015 (268,648), and representing 18.1% of the entire state population. Vital statistics data for Hawaii show that the number of births have decreased between 2019 (16,835) and 2023 (14,848),[11] but there was a slight increase in number of births in 2024 (14,930).
There were 158,283 children ages 9 years or younger in Hawaii, representing a 10.8% decrease since 2015. This group represents 11.0% of the state population. There were 166,225 children ages10-19 years, representing a 1.9% increase from 2015. This group represents 11.6% of the state population.
Based on 2022-2023 data, an estimated 59,844 Children with Special Health Care Needs (CSHCN) reside in Hawaii, representing 20.0% of all children ages 0-17 years. This estimate is significantly below the national estimate of 26.2%. The 2022-2023 Hawaii estimate was similar to the 2021-2022 estimate (18.0%).
Older Population
As in other states, Hawaiihas a rapidly aging population. Persons, ages 65 years and over (303,352 total), comprised 21.1% of the Hawaii population, as compared to 16.6% in 2015. Nationwide, this elderly population was estimated at 17.7% in 2023, compared to 14.9% in 2015. There are now more older people, in proportion to younger ones residing in Hawaii, and this growth trend is expected to continue.
Maui Wildfires
On August 8, 2023, one of the deadliest natural disasters struck, when a fast-moving wildfire destroyed the historic town of Lahaina on Maui Island. The fire claimed 102 lives, injured many more, and displaced thousands of residents. Over 3,000 buildings were destroyed—86% were homes, exacerbating Maui’s already limited and costly housing crisis. More than 8,000 people were temporarily relocated to hotels and short-term rentals.
A year later, many Maui families still face housing instability, job losses, and emotional stress. Nearly half remain in temporary housing, contending with soaring rents—over 50% higher than before, along with fewer job opportunities.
Recent relief efforts include:
- The state-funded One ‘Ohana Fund, which provided $1.5 million to families who lost one or more loved ones in the fire.
- A $4 billion global settlement from six parties, including government entities, utilities, and landowners, to help support recovery and rebuilding.
- $1.6 billion in federal disaster recovery funding, with a focus on housing assistance for displaced residents.
ECONOMY
Tourism, real estate, construction sectors, and federal/military spending largely propel the economy in Hawaii. Initial COVID- 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, which was driven by rebounding U.S. incomes and pent-up demand. By 2023, Hawaii showed signs of a post-pandemic economic recovery, with generally stabilizing 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. As of December 2024, federal support for Maui already totaled around $4 billion, including support from the Federal Emergency Management Agency and the Small Business Administration.[12] Maui’s economic recovery remains slow, with an estimated loss of over 1,000 residents post 2023, due to out migration.
According to the Hawaii Department of Business, Economic Development and Tourism (DBEDT),[13] the state’s major economic indicators were mixed in the fourth quarter of 2024. Visitor arrivals, wage and salary jobs, private building authorizations, and state general fund tax revenues increased, compared to the fourth quarter of 2023. However, inflation was still relatively high and the civilian labor force, state general excise tax revenues, transient accommodations tax revenues, and awards from government contracts decreased.
Tourism
In 2024, total visitor arrivals by air increased by 21,083(0.2%), International arrivals increased by 106,683(6.8%) from the previous year.[14] Overall, the visitor census remained steady, with fewer visitors going to the neighbor islands, particularly Maui, while Oahu saw a slight increase. In 2024, visitor expenditures totaled $20,596.2 million, a decrease of $66.7 million( 0.3%) from the previous year.[15] This may reflect a decrease in length of stay for Oahu’s large visitor market, due to minimal growth in the tourism sector.
Unemployment
The unemployment rate in Hawaiihas largely stabilized to 3.0% in 2024, compared to the U.S. average of 4.0%[16] ranking Hawaii the 7th lowest among all states. In 2024, Maui County saw a decrease in unemployment (4th quarter; 3.6%) with increases in jobs and visitor arrivals, as the county slowly recovers from the impacts of the 2023 wildfires.
Job Market: Labor force vs Jobs
Labor market conditions statewide were mixed in 2024. The civilian labor force decreased, but civilian non-agricultural wage and salary jobs increased.[17] In 2024, the civilian labor force averaged 671,100 people, a decrease of 5,250 people (0.8%) from 2023.[18]
Conversely, Hawaii averaged 637,700 jobs in 2024, an increase of 5,500 jobs (0.9%) over 2023.[19] The job increase in 2024 was attributed to gains in jobs in both the private and government sectors. Compared to 2023, the largest average increases in 2024 were in:
- Construction, which reported a 9.2% increase in jobs.
- Health Care and Social Assistance, which reported a 3.1% increase in jobs.
- Accommodations, which reported a 1.8% increase in jobs
- Food Services and Drinking Places, which reported a 0.9% increase in jobs.[20]
The Government sector reported an annual average of 2.0% increase in jobs in 2024, compared to 2023.[21]
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 2023 average annual wage in Hawaii was $64,207, which was 11.2% lower than the U.S. average.[22] It reflected a 4.4% ($2,724) increase in average wages, compared to the 2022 U.S. average annual wage ($61,483).
In 2023, Hawaii ranked 26th among the 50 states.
Income
Per capita, personal income for Hawaii workers also increased 5.3% in 2023 ($65,888), compared to 2022 ($62,522).[23] As noted, income loss during COVID was offset by government stimulus/relief supports, including rental relief, which helped to prevent economic collapse for many island families.[24] In 2023, Hawaii per capita income was 5.1% lower than the national average ($69,418).After adjusting this income for the high cost of living, it was 12% lower than the unadjusted level.[25]
The aggregated income and wage indicators do not reflect 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 the state’s status, as having the highest cost of living in the U.S.
Poverty
Based on 2023 ACS estimates, the poverty rate in Hawaii was 10.1% (all ages in poverty), which is 2.4% lower than the U.S. rate (12.5%). This percentage represents an estimated 141,925 individuals living in poverty in Hawaii. Over 32,612 (11.4%) 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 9.0%; Maui 8.8%; Kauai 7.6%; and Hawaii 17.5%. Poverty rates remain higher among Native Hawaiians and Other Pacific Islanders (17.3%) and Blacks/African Americans (14.8%), compared to Whites (10.4%) or Asians (6.9%).
The official FPL obscures many families' struggles in Hawaii, due to the high cost of living and the relatively low average 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%).[26]
ALICE Report
The Hawaii United Way 2024 agency report on working residents living just above the poverty level unable to afford basic necessities, more accurately reflects the economic status of Hawaii families. The ALICE survey refers to families that are Asset-Limited, Income-Constrained, employed (ALICE).[27] The most recent Hawaii ALICE study in 2024 revealed that approximately 40% of Hawaii households in 2024 fell below the ALICE threshold, struggling to meet basic housing, childcare, food, transportation, and healthcare expenses. This includes 12% of households with income below the Federal Poverty Level (FPL), as well as those who are ALICE (29%).[28]
Although the proportion of Hawaii households living below the poverty line declined in 2024 (12%) from 2022 (14%), the proportion of Alice households remains the same in 2022 and 2024 (29%). This suggests that hardships remain for many island residents, post-COVID. Notably, the majority of Native Hawaiian (58%) and Filipino (52%) residents fell below the ALICE threshold, as did all households with children (50%). Maui county experienced an increase in Alice households in 2024 (43%), as compared to 2022 (34%), due to the aftermath of the Maui wildfires.
The report cites the major reasons for the high percentage of ALICE households:
- Low-wage jobs dominate the state’s economy.
- Cost of living consistently 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. Many parents are forced to work 2-3 jobs to make ends meet.
HIGH COST OF LIVING
Regional price parities data for 2023 indicates that Hawaii was the third highest in regional price parity (108.6), with California (112.6) and the District of Columbia (110.8) emerging as the highest.[29] Other sources ranked Hawaii as the most expensive state in the nation, in terms of cost of living.[30]
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 revenue for other essential household expenses. As a result, families are often forced to live in overcrowded, substandard housing, or are forced into homelessness, due to a lack of affordable housing options.
In March 2025, the median housing cost for a single-family dwelling on Oahu was $1,160,000, with a condominium averaging $500,000.[31] The median monthly owner mortgage cost in 2023 was $2,739, which is 43.9% higher than the U.S. average.
Among homeowners, 31.5% spent 35% or more of their household income on housing, which is significantly higher than the U.S. average of 21.9%, the highest in the nation. Not surprisingly, the homeownership rate in Hawaii in 2023 was ranked as among the lowest in the U.S. (46th among the 50 states) at 62.4%, which was lower than the U.S. average of 65.2%.
Rental Costs
High monthly housing rental costs are unaffordable for many working families in Hawaii. In 2023, an estimated 37.6% 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 $1,940, which was 38.0% higher than the U.S. average of $1,406. In 2023, Hawaii ranked 2rd highest in housing rental costs nationally.
Multigenerational Households
For many island families, cultural preferences and traditions have increased the number of multigenerational households, but also a necessity, due to high housing costs. In 2023, the percentage of multigenerational family households among all family households in Hawaii was 7.7% (38,197 out of 493,898 households), which is twice the U.S. average of 3.8% (4,933,856 out of 131,332,360 households). Hawaii has the nation's highest rate of multigenerational households, with some of the largest household sizes, especially evident among Pacific Island families. These household factors created challenges during COVID social distancing/isolation efforts, which contributed to significantly higher and disparate infection rates for certain ethnic groups.
Cost of Health Insurance
Overall, the cost of private employer-based health in Hawaii significantly increased for a family plan between 2013 and 2022, from $14,382 to $19,439.[32]
Hawaii health insurance is estimated to be 10.7% of average wages in 2022, compared to only 2.8% in 1974. Hawaii health plans offered through the federal ACA marketplace increased from $330 in 2017 for the average individual premium, to $493 monthly in 2025.[33] Hawaii is widely considered to have among the lowest healthcare insurance premium costs in the nation, but these rates continue to increase nearly every year.[34]
Health Services Infrastructure
There are approximately 100 healthcare facilities total in Hawaii.[35] Of the state’s 29 hospitals, 12 offer obstetric labor and delivery services. Three pediatric hospitals have Neonatal Intensive Care Units on Oahu, while other hospitals have lower levels of acute pediatric services.
Hawaii has 15 federally qualified health centers, 15 rural health clinics, and seven Native Hawaiian health system sites, located across the state. Most healthcare services, particularly specialty care providers/facilities, are concentrated in urban Honolulu on Oahu. Neighbor island residents routinely have to fly to Oahu to access specialty, medical, dental, and behavioral services. Maps of these facilities are in the Supporting Documents.
Healthcare Workforce
The state has 240 family and general licensed practitioners, 220 obstetricians and gynecologists, and 480 pediatricians.[36] Based on the 2023 population estimate, there are 15.3 per 100,000 obstetricians and gynecologists, which is significantly higher than the national rate (5.9 per 100,000 population). There are 33.4 pediatricians per 100,000 population, which is similar to the national estimate (10.4). The rate for family/general practitioners (16.7 per 100,000 population) is significantly lower than the national rate (33.4).
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.
COVID 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 chronic significant physician shortages.[37]
To address the workforce shortage, $30 million was allocated by the Hawaii Legislature in 2023 for the Hawaii Health Education Loan Repayment Program for healthcare providers, who agree to care for at least 30% public insurance recipients within their caseload. The federally-funded State Loan Repayment Program provides a total $800,000 loan repayment a year. These programs are anticipated to assist hundreds of medical residents in training, as well as other healthcare workers statewide every year.
Healthcare Shortage Designations
Shortage Designations represent an area's or population's needs, which are 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 as 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 that enable almost universal access for residents, and was one of the first six states that implemented a Medicaid program in 1966.
In 1974, Hawaii implemented its groundbreaking Prepaid Healthcare Act (PHCA), which mandated that most employers must offer health insurance a to all employees who work at least 20 hours a week, with mandated caps on employee contributions. The PHCA is largely credited for the state’s high level of insurance coverage and relative affordability. Hawaii is the only state with a federally-approved exemption from the federal Employee Retirement Income Security Act (ERISA), which sets the minimum standards for health plans within private industry.
In conjunction with the Affordable Care Act (ACA), Hawaii implemented further Medicaid expansions in 2017, adopting the federally-offered 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 24,606 enrollees in 2025.[38]
Under Medicaid expansion, coverage was increased to 138% of FPL. Prior to COVID,, the number of people enrolled rose significantly, from 292,423 in 2013 to about 345,231 in 2019.[39] 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, in order to ensure that health benefits remained available under Hawaii law. This included dependent coverage for children through 26 years of age, as well as prohibiting any preexisting condition exclusion or the use of gender in determining premiums. As a result of these efforts, Hawaii consistently reports low uninsured rates; at 3.2% in 2023.
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, while containing costs, via a managed care delivery system, with savings utilized to expand coverage. Under this federal waiver, Medicaid beneficiaries with disabilities and those over 65 receive services through a fee-for-services model.
- Medicaid eligibility levels for children in Hawaii are much higher than the national average and are consisitent with national levels for pregnant women and parents:Children ages 0-18 qualify, with family income up to 313% of the FPL.
- Pregnant women qualify, with family income up to 196% of the FPL.
- Parents/Caregiver relatives, qualify up to 105% of FPL and
- Other adults, under 65 years of age, qualify, up to 138% of the FPL.
Hawaii residents with low incomes and low asset/resource levels can qualify for Medicaid, if they’re 65 or older, or if they’re blind or disabled. These enrollees are covered under fee-for-service (FFS) Medicaid, rather than the managed-care Med-QUEST program.
In 2024, CMS approved Hawaii MEDQUEST’s request to provide continous eligibility for children, until the child’s 6th birthday, and 24 months of continuous eligibility for children, ages six to 19. In 2022, Hawaii extended postpartum coverage for 12 months, and the state reinstated preventative and restorative adult dental benefits to Medicaid adults in 2023. During COVID,Hawaii Medicaid enrollments increased by 37.0%, totalling over 448,193 enrollees in 2023 statewide.
Of the 408,590 individuals enrolled in Medicaid, 122,717 are children.[40] The Medicaid Program also serves 2,015 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. In 2024, a total of 32,414 COFA adults were enrolled with Med-QUEST.
The state’s CHIP program, a Medicaid expansion element, covers all Hawaii children under 19 years of age whose family incomes are up to 313% 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 health care coverage from five health plans: AlohaCare, HMSA, Kaiser Foundation Health Plan, 'Ohana Health Plan, and United Healthcare. All the health plans cover services statewide, except for the Kaiser Foundation Health Plan, which provides care 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 2024 Medicaid media campaign to ensure all eligible Medicaid enrollees remain covered is called, Stay Well, Stay Covered. It includes a website with enrollment information available in 14 languages.
GOVERNMENT
The state’s Executive Branch is organized into 17 cabinet-level agencies. HDOH and HDHS administer the major health programs. HDHS administers the Medicaid program, while HDOH serves as the state's lead 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). A chart of the state government is included in Section VI of this report.
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 served by District Health Offices, which 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; all of whom report 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. In 2022, Hawaii elected a new democratic Governor, Josh Green, MD. The Administration’s HDOH Director is Kenneth S. Fink, MD, MGA, MPH, with Ms. Debbie Kim Morikawa as the Deputy Director for HRA. Matthew J. Shim, PhD, MPH, remains the FHSD Chief/Title V Director.
STATUTORY AUTHORITY
As the Title V agency, FHSD falls within the purview of Title 19, Chapter 321 of the Hawaii Revised Statutes. A listing of statutes pertaining to the division programs are in the Supporting Documents.
LEGISLATURE
Over the past four years, the State Legislature has leveraged budget surpluses and federal COVID relief funds, in order to ease financial burdens on families.
Investments focused on affordable housing, raising the minimum wage, expanding tax credits, public preschool and childcare, rural hospitals, and healthcare workforce support. Lawmakers have also expanded access to reproductive healthcare and abortion services and strengthened gun safety laws, in response to shifting federal rulings.
In 2024, the Legislature approved over $1 billion for Maui wildfires recovery, and passed the largest tax cut in state history, which is projected to save taxpayers $5 billion by 2030. While the bill increases standard deductions and adjusts tax brackets, it has raised concerns about dwindling future state revenue and potential cuts to services.
In 2025, amid federal funding cuts and continued economic uncertainty, lawmakers prioritized budget stability for essential services. The 2024 tax cuts remained intact. The state boosted reserves and made strategic investments in housing, food security, healthcare, and early learning. Revenues were also enhanced by major pharmaceutical settlements: $150 million from opioid litigation and $700 million from a Plavix case. Key allocations included:
- $240 million for affordable housing
- $13.3 million for early learning expansion
- $200 million reserved to sustain programs vulnerable to federal cuts
Notable legislation:
- Free school meals for families earning up to 300% of the Federal Poverty Level, starting SY 2026–2027
- $900,000 to establish a statewide vaccine access program
- Expansion of youth mental health services
- A first-in-the-nation 0.75% “green fee” on hotel stays to fund climate resilience projects
Although the paid family and medical leave bill did not pass again this year, lawmakers approved funding for a feasibility study and created a task force to guide future efforts.
[1] UHERO Data Portal: Resident Population, accessed at
https://data.uhero.hawaii.edu/#/series?id=150383&data_list_id=25&sa=true&geo=HI&freq=Q&start=2014-07-01
[2] UHERO Who is Moving in and Out? Understanding Migration Trends in Hawaii: https://uhero.hawaii.edu/who-is-moving-in-and-out-understanding-migration-trends-in-hawaii/
[3] 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
[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] https://www.hawaiidxp.org/data-products/hawaii-english-language-learners-data-story/
[7] https://www.voronoiapp.com/other/How-Much-Land-does-the-US-Military-Control-in-Each-State-2
[8] Active Duty and Reserve Personnel by Service (Table 10.04) at https://dbedt.hawaii.gov/economic/databook/2023-individual/_10/
[9] For Oahu: https://www.partnersincareoahu.org/pitc;
for neighbor islands: https://www.btghawaii.org/reports/hic-&-pit/
[10] U.S. Department of Housing and Urban Development. The 2024 Annual Homelessness Assessment Report to Congress (Appendix A). https://www.huduser.gov/portal/datasets/ahar/2024-ahar-part-1-pit-estimates-of-homelessness-in-the-us.html
[11] Hawaii Health Data Warehouse, Number of Births Per Year: https://hhdw.org/data-sources/birth-data/
[12] https://www.civilbeat.org/2024/12/congress-is-poised-to-approve-another-1-6-billion-for-maui-fire-aid/?utm_source=Civil+Beat+Master+List&utm_campaign=31a2f8d1fb-EMAIL_CAMPAIGN_2024_11_05_01_52_COPY_01&utm_medium=email&utm_term=0_-4a7e232a85-402200135&mc_cid=31a2f8d1fb&mc_eid=ad662506c9
[13] State DBEDT, Report on the economic condition of Hawaii http://dbedt.hawaii.gov/economic/qser/
[14] International Visitor Arrivals-By Air (Tourism data tables: Table D-4). https://dbedt.hawaii.gov/economic/qser/tourism/
[15] Visitor expenditures by air (Tourism data tables: Table D-11). http://dbedt.hawaii.gov/economic/qser/tourism/
[16] 2023 unemployment rate is found at www.bls.gov/lau/lastrk24.htm,
[17] Note: Non-agricultural jobs do not include farm/ranch workers.
[18] State DBEDT, Labor Data Tables from 2025 1st quarter report (Tables A-1, A-2; annual average), https://dbedt.hawaii.gov/economic/qser/labor-force/
[19] State DBEDT, Labor Data Tables from 2025 1st quarter report (Table A-6, annual average).
[20] Labor Data Tables from 2025 1st quarter report (Tables A-7, A-16, A-18, A-19; annual average), https://dbedt.hawaii.gov/economic/qser/labor-force/
[21] Labor Data Tables from 2025 1st quarter report (Table A-21; annual average)
[22] U.S. Bureau of Labor Statistics, 2023 Annual Averages.
https://data.bls.gov/cew/apps/table_maker/v4/table_maker.htm#type=0&year=2023&qtr=A&own=0&ind=10&supp=1
[23]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.
[24] University of Hawaii Economic Research Organization (UHERO), Recovery Resumes but Omicron Looms, December 17, 2021. https://uhero.hawaii.edu/focus-areas/forecast-project/
[25]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/
[26] 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
[28]2024 Alice Report: https://www.auw.org/about/alice-initiative/alice-reports/
[29] Bureau of Economic Analysis, Regional Price Parities for States, 2023, https://www.bea.gov/news/2024/real-personal-consumption-expenditures-state-and-real-personal-income-state-and
[30]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
[31] Honolulu Board of Realtors https://www.hicentral.com/
[32] Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey Insurance Component Chartbook 2022, Appendix Exhibit 3.8. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://meps.ahrq.gov/data_files/publications/cb27/cb27.pdf
[33] KFF website https://www.kff.org/ Marketplace Average Benchmark Premiums
[34] Hawaii Insurance Division, Health Care, Health Insurance, PPT. https://cca.hawaii.gov/ins/files/2023/01/Health-Insurance-2022-State-of-Reform.pdf
[35] 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/
[36] Based on 2023 state data provided in Form 11.
[37] 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
[38] KKF.org Total Marketplace Enrollment.
[39] Based on the Department of Human Services, State of Hawaii, 2019 Annual Report found on http://humanservices.hawaii.gov/reports/annual-reports/
[40] Based on 2024 data provided by the State of Hawaii Department of Human Services, Med-QUEST Division
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