Dreaming of a move to tropical Hawaii? If you’re serious about your dream, go beyond visions of a beach at sunset. Consider how public health and the rollout of the Affordable Care Act may affect your quality of life.
This brief summary of overall health and healthcare reform provides useful information for current residents as well as those who may join them in the future.
Hawaii health ratings
Hawaii is among the healthiest states in the nation according to the Scorecard on State Health System Performance 2014. The Aloha State is ranked No. 5, down from its No. 2 ranking in 2009. The Aloha State ranks in the top quartile when it comes to the following health measures: affordable hospital use and costs, healthy lives and equity. It falls into the second quartile for access and prevention and treatment. See Hawaii’s Scorecard to see how its performance on individual health measures contributed to its overall high score.
Hawaii tops America’s Health Rankings 2014, the most recent evaluation available from this organization. It’s held the No. 1 spot since 2012. Hawaii earns its high ranking for low smoking and obesity rates, high immunization rates among children, and a low rate of preventable hospitalizations. Hawaii does have some public health challenges, including a high prevalence of binge drinking, low immunization coverage among children, and high rates of infectious disease.
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.
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 Gov. 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, and consumers will use Healthcare.gov to enroll in plans for 2016. Enrollees who already have a plan in 2015 will need to re-enroll through Healthcare.gov for 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 is that the ACA’s provisions regarding employer-based health insurance are much weaker than Hawaii’s, and his focus is 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).
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.
According to the Gallup-Healthways Well-Being Index, Hawaii’s uninsured rate dropped just 0.2 percentage points between 2013 and mid-2014, but it was down to 5.2 percent by the first half of 2015, nearly two percentage points below where it started in 2013.
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. Prior to ACA implementation, Hawaii had the nation’s second lowest uninsured rate, at 7.1 percent. By mid-2015, six states had attained uninsured rates lower than Hawaii’s 5.2 percent, but Hawaii is certainly still very close to the top in terms of overall percentage of the population with health insurance in 2015.
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 August 2015, net enrollment in Hawaii’s Medicaid/CHIP programs grew by 46,288 people – an increase of 16 percent.
Hawaii enrollment in qualified health plans
Due to both technical problems and a small market, just 8,592 Hawaiians signed up for qualified health plans (QHPs) 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.
But in 2015, enrollment reached 35,600 by September, according to Hawaii Health Connector’s Executive Director, Jeff Kissel. The federal government had a much lower enrollment count in Hawaii, showing just 8,802 people with in-force private plan coverage through Hawaii’s exchange as of June 2015. But Kissel explained that there has been significant lag time in reporting enrollments from the carriers, and that the CMS data did not include enrollments with HMSA, the dominant carrier in the individual market.
For the 2016 open enrollment period, and going forward, Hawaii will be using Healthcare.gov as its enrollment platform, so presumably there will be less confusion in future years regarding the federal/state reconciliation of enrollment data.
Carriers that offer coverage in Hawaii’s individual market
Hawaii’s individual health insurance market has two carriers, and both offer coverage through the state’s exchange and outside it in the private market:
- Hawaii Medical Service Association (HMSA)
- Kaiser Permanente
Hawaii is among the 29 states and 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 2015, net enrollment in Hawaii’s Medicaid/CHIP programs had grown by 46,288 people over where it was in late 2013.
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 significantly 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 will fall to 11, possibly lower, by 2016). However, none were in Hawaii.
State-level health reform in Hawaii
Here’s what’s happening in Hawaii at the state level with healthcare reform:
SB 1028 was passed in May 2015 and signed into law by June. This state legislation granted $2 million in funding for Hawaii Health Connector, which was less than the $10 million requested. Due to funding issues and a lack of self-sustainment, the exchange was transitioned to Healthcare.gov for 2016.
Hawaii Medicare enrollment
Hawaii has the smallest percentage of Medicare recipients who are on Medicare as the result of a disability: 12 percent. The other 88 percent of recipients qualify for Hawaii Medicare based on age alone.
The Aloha State ranks 43rd in overall Medicare spending with $1.5 billion per year. Medicare pays about $7,651 annually per Hawaii enrollee.
Hawaii Medicare beneficiaries can select a Medicare Advantage plan instead of original Medicare if they want to gain some additional benefits. Forty-six percent of Hawaii Medicare recipients have selected a Medicare Advantage plan. Nationwide, 32 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 25 percent have a stand-alone Rx plan compared with an average of 43 percent nationally.