Hawai‘i is no Paradise for Health Care

Tatyana Lum is a neuroscience and biology major with a Japanese minor and she is a 2023-24 health care ethics intern with the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.

Being born and raised on Oahu and pursuing pre-med, I’ve often been told some form of, “That’s awesome because Hawaii needs more physicians.” However, it wasn't until recently that I truly grasped the significance of those words.

Hawai‘i's rich multi-ethnic culture contributes to a unique tight-knit community and is recognized as one of the most diverse states in the country. Though Hawai‘i is often described as paradise and set the benchmark for the most affordable health care in the nation, its health care system has been in crisis well before COVID-19 and the Lahaina fires. 

These emergencies highlighted long-standing issues stemming from policies established decades ago, leaving the state ill-equipped to handle day-to-day operations, exacerbated by its isolation 2,400 miles from the mainland. Accessing health care poses a significant challenge for many residents, especially for Kānaka Maoli, ​​Native Hawaiians. COVID-19 exposed the broader inequalities in Hawaii's health care system, disproportionately impacting this community. 

Hawai‘i’s Health Care Crisis

Hawai‘i's high rates of chronic disease are associated with low health literacy, a challenge accentuated by its status as the most culturally and racially diverse state in the U.S. Cultural and language barriers, often overlooked as health care disparities, further hinder access to quality care, especially for socioeconomically challenged and underrepresented communities. In Hawai‘i, where one in four residents speak another language at home, surpassing the national average, communication hurdles with health care providers pose a common challenge for those with limited English proficiency (LEP). This frequently leads to unequal treatment due to impatience and cultural incompetence of health care workers. 

I’ve observed these profound and harmful effects of language barriers on family members with LEP as they struggle with effectively communicating with health care providers, resulting in insensitive treatment and poor quality of care. Despite Hawai‘i's Language Access Law, enacted in 2006, which mandates state agencies to have a language access plan, the lack of funding, enforcement, and cultural sensitivity training for health care professionals has hindered the full and appropriate implementation of these accommodations. 

Additionally, Hawai‘i’s reputation as the most affordable state for health care can be misleading, as only 3.6% of the total state being uninsured is due to employer mandates, Medicaid, and state-sponsored insurance programs. The Hawai‘i Prepaid Health Care Act of 1974 and the Affordable Care Act of 2010 require private employers to furnish health insurance to employees logging at least 20 hours per week. 

This legislative requirement was designed to improve the health and well-being of residents navigating Hawai‘i’s high cost of living, especially against the backdrop of a $12-per-hour minimum wage. Despite these efforts, social determinants of health and a persistent shortage of physicians exacerbated disparities, particularly among under-recognized minority groups like Native Hawaiians. 

The COVID-19 pandemic and the Lahaina fire further strained Hawai‘i’s severe staffing shortages and limited hospital beds. Statewide, Hawai‘i faces a shortage of almost 800 full-time equivalent physicians, partly due to lower pay caused by the state general excise taxation on medical services. Hawai‘i is one of just two states in the nation that taxes doctor visits and medical products, with the unique distinction of taxing Medicare and Medicaid patients. This tax burden creates significant hurdles for private practice to thrive, further discouraging residents from pursuing a career as a physician. 

Moreover, Hawai‘i ranks among the states with the fewest hospital beds per capita and experiences the 10th longest wait times in emergency rooms nationwide. This reality translates to prolonged delays in care for residents, often necessitating inter-island travel for specialized treatment. However, many outer-island hospitals function as basic community health care centers, offering limited subspecialty care. The devastating fire that ravaged the entire town of Lahaina on August 8-9, 2023, underscored the severity of health deficiencies, with only three health care clinics serving approximately 30,000 patients. 

Furthermore, COVID-19 exacerbated existing disparities, notably impacting Native Hawaiians, who suffered some of the highest case and death rates in the U.S. due to underlying chronic illnesses. Despite the 1997 mandate to disaggregate Native Hawaiian data from the broader “Asian” category, two decades later, over 30% of federal data sources failed to disaggregate Native Hawaiians. The historical underrepresentation in health data collection at the state level masks significant health disparities of Native Hawaiians, hindering their ability to advocate for necessary resources. These inequalities are deeply rooted in historical trauma and mistreatment spanning nearly two and a half centuries of ongoing colonization. 

Health Impacts of Colonization for Native Hawaiians

In 1778, Captain James Cook’s arrival marked Hawai‘i’s first encounter with the Western world. Within the first century, the Native Hawaiian population plummeted by 90% due to new diseases such as measles and smallpox. Missionaries imposed Western culture, Christianity, and English through boarding schools, forcibly removing Hawaiian children from their homes. With increased non-native contact, Native Hawaiians lost control of their land, governance, and economy. The illegal overthrow of the Kingdom of Hawai‘i on January 17, 1893, was orchestrated by a small group of businessmen who invaded Iolani Palace and led to the conditional surrender of Queen Lili'uokalani, the last Hawaiian monarch. Subsequent annexation by the U.S. on August 12, 1898, further eroded their rights and traditional practices and nearly extinguished the Hawaiian language. These historical injustices echo through Hawai‘i’s economic and psychosocial landscapes today, exacerbating barriers to health equity for Native Hawaiians. 

Today’s Health Equity Challenges for Native Hawaiians

The 2020 Census revealed that 47% of Native Hawaiians reside in Hawai'i, comprising roughly 21% of the state’s 1.4 million residents. However, about 15% of Native Hawaiians lack health insurance and have the highest poverty rate, both of which are inextricably linked to their numerous social and health disparities. Moreover, Native Hawaiians have the shortest life expectancy, about a decade shorter than other ethnic groups, and bear the highest mortality rate for cardiometabolic diseases, like heart diseases, hypertension, diabetes, and cancer. 

Many of these chronic illnesses often remain undiagnosed and untreated due to a lack of awareness among individuals, compounded by limited access to health care. These health issues are compounded by poor diets and obesity, worsened by food insecurity and low health literacy stemming from their low socioeconomic status. Historical mistreatment had fostered deep mistrust in the health care system and Western-based care, especially among kūpuna, the elders, who often turn to traditional healing practices. Native Hawaiians hold a holistic health perspective, intertwining family, land, community, and spirituality, relying on traditional healing practices. Like the broader population, many Native Hawaiian patients prioritize interpersonal relationships they have with their physicians. 

Going Forward

In conclusion, Hawai'i's unique demographic composition and geographical isolation present significant obstacles to achieving  health care equity. It’s crucial to address systemic flaws and structural racism within the health care system to ensure inclusivity and responsiveness to the diverse needs of individuals from various cultural backgrounds. 

To alleviate the physician shortage, initiatives such as exempting medical services from the state general excise tax and expanding opportunities for local students to engage in medical research and internships, fostering greater interest in pursuing careers in health care, are needed. Additionally, health care providers must understand not only the culture but also the cultural history of any patient, particularly in serving the Native Hawaiian population, to advance health equity. Community-based programs like Kula No Na Po'e Hawaii exemplify the potential of integrating cultural practices and values into patient care to enhance health literacy and overall well-being. Finally, disaggregating data at the state level is vital for identifying and addressing disparities effectively, providing communities with relevant insights for targeted interventions. Through the implementation of these strategies, we can work towards a more equitable and inclusive health care landscape for all Hawai'i residents.