Long before the Affordable Care Act, Hawaii implemented changes to promote health care access and affordability. Since the ACA took effect, The Aloha State’s approach to healthcare has continued to evolve. Hawaii opted for a state-based exchange during the first ACA open enrollment period; however, due to ongoing technology troubles, the state switched to a federally supported state-based marketplace and began using HealthCare.gov for 2016 enrollment. For 2017, Hawaii switched to a fully federally facilitated exchange.
All of Hawaii’s islands are part of a single rating area for determining premiums in the individual and group markets. This was a deliberate decision by Hawaii’s Insurance Division in order to keep premiums uniform from one island to another. Most states are divided up into various rating areas based on geography, with some areas having higher premiums than other areas; this is not the case in Hawaii, however.
Hawaii was the first state to win 1332 waiver approval from CMS. The waiver allowed Hawaii to no longer have a SHOP exchange for small businesses as of 2017 (the State Department of Labor and Industrial Relations has an FAQ page about the transition away from the SHOP exchange, which had very little utilization prior to 2017). CMS sent a letter to Hawaii Governor, David Ige in December 2016, explaining that the state’s 1332 waiver had been approved for five years, from 2017 through 2021.
Legislation to preserve ACA, further expand Medicaid, and possibly enact single-payer health care
Democrats have strong control over Hawaii’s legislature. The Hawaii House of Representatives has 45 Democrats and six Republicans in 2017; the Senate has 25 Democrats and no Republicans.
In response to uncertainty about the future of the ACA, Hawaii lawmakers are considering a bill (H.B.552) that would preserve the ACA’s primary provisions, regardless of whether the bill gets repealed or changed at the federal level.
H.B.552 would preserve the individual mandate and the essential health benefits requirements. It would also allow dependents to remain on parents’ health plan until age 26, and would continue the ACA’s ban on preexisting condition exclusions and gender-based premiums.
H.B.552 passed the House on March 3, 2017. The Senate passed it in April, but with additional amendments (SD2) that increase the level of consumer protections in the bill, but also drive up the cost. The Senate’s amendments would:
- Create a Medicaid Plus program that would provide coverage to Hawaii residents with income between 138.5 per cent and 250 per cent of the federal poverty level (the federal poverty level is higher in Hawaii; for an individual, 250 percent of the poverty level in Hawaii in 2017 is $34,650, and for a family of four, it’s $70,725). This program would cover adults only, as children in Hawaii are already eligible for Medicaid with household income up to 300 percent of the poverty level. People with income up to 250 percent of the poverty level would also be exempt from the state’s individual mandate.
- Create a trust fund to reimburse insurers for the costs of providing minimum essential insurance benefits.
As of April 13, H.B.552 had been returned to the House and the House disagreed with the Senate’s amendments. The bill was sent to a House Conference on April 17, for further consideration.
Hawaii health ratings
Hawaii is among the healthiest states in the nation according to the 2017 Scorecard on State Health System Performance. The Aloha State placed No. 3 (the same ranking it held in 2015), with first place rankings in the categories of Avoidable Hospital Use & Costs and Equity. While there is not a tremendous amount of room for improvement, Hawaii did fare poorest in the Prevention & Treatment category, where it ranked 14th in the 2017 report.
Hawaii tops America’s Health Rankings 2016, holding the top spot for the fifth year in a row. In all Hawaii earned top 10 rankings for 22 of 38 measures. Strong public health funding, low uninsured rates, small disparity in health status, and policy contributed to Hawaii’s success.
Two other resources provide helpful information about public health in Hawaii. The Trust for America’s Health examines key health indicators, public health preparedness, and funding indicators. See Key Health Data About Hawaii. If you want to learn about a specific area of the state, get county-by-county health rankings for Hawaii from The Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
How did Obamacare help Hawaii?
Hawaii has long supported broad access to medical insurance. The state’s historically low uninsured rate is largely the result of the Hawaii Prepaid Health Care Act, which was enacted in 1974 and requires most employers to provide health insurance to employees who work more than 20 hours a week. The Hawaii Prepaid Health Care Act has much stronger requirements for employer-provided coverage than the ACA. Hawaii’s 1332 waiver to eliminate the SHOP exchange was a direct result of the state’s success under the Hawaii Prepaid Health Care Act .
According to U.S. Census data, Hawaii’s uninsured rate was 6.7 percent in 2013 (far lower than the national average of 14.5 percent), and had fallen to 4 percent by 2015 (again, less than half the national average of 9.4 percent by that point).
Many states had much more significant drops in their uninsured rates, but they also started with a much higher percentage of the population without health insurance in 2013. As of 2015, only Massachusetts, Vermont, and the District of Columbia had lower uninsured rates than Hawaii.
Medicaid expansion under the ACA has certainly benefited low-income Hawaii residents, particularly those with low or no employment and no access to the employer-based health insurance that most Hawaii residents enjoy. From late 2013 to June 2016, net enrollment in Hawaii’s Medicaid/CHIP programs grew by 58,437 people – an increase of 20 percent.
2017 health insurance carriers, rates
- Hawaii Medical Service Association: 35 percent
- Kaiser Foundation Health Plan:9 percent
Subsidy-eligible enrollees who have coverage through Hawaii’s health insurance exchange are receiving significantly larger subsidies in 2017, which offset a large portion of rate increases impacting most 2017 plans. 80 percent of enrollees in 2017 are receiving subsidies, which bring their average premiums down from $477/month to $191/month.
Hawaii enrollment in QHPs: An upward trend
Due to both technical problems and a small market, just 8,592 Hawaiians signed up for qualified health plans during 2014 open enrollment. As a percentage of the estimated market, that’s just 14.9 percent – one of the lowest rates in the nation and about half the national average.
By 2016, however, Hawaii’s exchange enrollment had reached 14,564.Of these enrollees, 82 percent received financial assistance and 99 percent were considered new to the exchange since Hawaii changed its eligibility and enrollment platform.
And for 2017, there were 18,938 people who enrolled in the Hawaii exchange during open enrollment. That’s a 30 percent increase over the 2016 enrollment total, which is in contrast to much of the rest of the country. Across all states that use HealthCare.gov, there was an average decrease in enrollment for 2017, and Hawaii’s percentage increase was far larger than any other state’s.
Hawaii and the Affordable Care Act
Hawaii embraced the Affordable Care Act, acting to implement a state-run health insurance marketplace and expand Medicaid.
Both of Hawaii’s U.S. senators and its lone representative voted “yes” on the Affordable Care Act in 2010. Hawaii was one of the first states to authorize a state-run marketplace, with then-Governor Neil Abercrombie signing a bill into law in July 2011.
Despite the state’s early legislative action on a state-run marketplace, the Hawaii Health Connector operated poorly throughout the 2014 open enrollment period and continued to face financial difficulties in 2015. As a result, the exchange opted to become a supported state-based marketplace in 2016 (using HealthCare.gov’s enrollment platform but still maintaining a state-run exchange). For 2017, however, Hawaii no longer has a state-run exchange, and relies instead on the federally-facilitated marketplace. Although consumers had to re-enroll for 2016 (switching from Hawaii’s platform to HealthCare.gov), they didn’t have to do anything different with the switch for 2017, as they were already using the HealthCare.gov enrollment platform in 2016.
Gov. David Ige took office in December 2014, and although he is a Democrat who supports healthcare reform, he was critical of the Hawaii Health Connector’s myriad flaws and supported the switch to a supported state-based marketplace.
Ige’s position was that the ACA’s provisions regarding employer-based health insurance are much weaker than Hawaii’s, and his focus was on obtaining federal waivers to protect the state’s already robust employer-sponsored insurance market, while also serving the individuals who don’t have access to employer-sponsored insurance (via continued expansion of Medicaid and access to individual insurance through the supported state-based marketplace). His leadership helped to cement the 1332 waiver approval that Hawaii received in late 2016, allowing them to terminate the Hawaii SHOP exchange.
Hawaii is among the 32 states, including the District of Columbia, that have implemented Medicaid expansion. Prior to 2014, Kaiser estimated that 74 percent of the 102,000 uninsured, nonelderly Hawaiians would qualify for financial assistance under the Affordable Care Act.
About 58,000 of the uninsured were expected to qualify for Hawaii Medicaid or the Children’s Health Insurance Program (CHIP), and by June 2016, net enrollment in Hawaii’s Medicaid/CHIP programs had grown by 58,437 people – an increase of 20 percent.
Not all of the growth in Medicaid enrollment is due to the expanded eligibility guidelines, as some people were already eligible but didn’t enroll until the ACA’s education and outreach programs were implemented. But clearly, a significant proportion of Hawaii’s newly Medicaid-eligible population has enrolled in the state’s expanded Medicaid program.
Other Hawaii reform provisions
The ACA’s Consumer Operated and Oriented Plan (CO-OP) Program offered loans for the creation of nonprofit insurers as a strategy to increase competition in the individual and small-group markets. During 2014, 23 CO-OPs were operational (that number has dropped to just five as of 2017). However, none were in Hawaii.
Hawaii Medicare enrollment
Hawaii has the smallest percentage of Medicare recipients who are on Medicare as the result of a disability: 10 percent. The other 90 percent of recipients qualify for Hawaii Medicare based on age alone.
In 2009, the Aloha State ranked 43rd in overall Medicare spending with $1.5 billion per year. As of 2014, CMS reported Hawaii’s annual per enrollee spending to be $5,967, well under the national average of $8970.
Hawaii Medicare beneficiaries can select a Medicare Advantage plan instead of original Medicare if they want to gain some additional benefits. 46 percent of Hawaii Medicare recipients selected a Medicare Advantage plan in 2016 — the same percentage as 2015. Nationwide, 12 percent of Medicare recipients were enrolled in a Medicare Advantage plan.
Medicare Part D plans are also available to Hawaii Medicare beneficiaries who want stand-alone prescription drug coverage. About 26 percent have a stand-alone Rx plan compared with an average of 45 percent nationally.
State-level health reform in Hawaii
Here’s what’s happening in Hawaii at the state level with healthcare reform:
- HB 552 would preserve the ACA in Hawaii. Senate amendments to the bill would also expand Medicaid to 250 percent of the poverty level. The bill passed the House in March 2017, passed the Senate with amendments in April, and was then sent back to the House for reconsideration with the Senate’s amendments.
- SB 1120 would establish a single-payer system in Hawaii and prevent private insurance from duplicating the benefits of the single-payer system.
Other state-level health reform legislation includes: