Hawaii spent $130 million and five years building a health insurance exchange to offer coverage under President Barack Obama’s Affordable Care Act.

The state eventually shut down the Hawaii Health Connector and moved the program to healthcare.gov, the federal exchange.

Now President-elect Donald Trump has pledged to repeal the Affordable Care Act, raising the question of what will happen to the more than 40,000 people in Hawaii who are covered under Obamacare.

“We have to be worried about how they’ll get health insurance,” said state Rep. Della Au Belatti, (D, Moiliili-Makiki-Tantalus), who is chairwoman of the House Health Committee. “We will struggle with that.”

On Friday, Trump moderated his earlier hard line against Obamacare, saying in an interview with the Wall Street Journal, “Either Obamacare will be amended, or repealed and replaced.” Trump also said he favored keeping two Obamacare provisions — the ban on denying coverage to patients with pre-existing conditions and the requirement that children can remain on their parents’ health plan until age 26. “I like those very much,” Trump told the Journal.

Thousands at risk

Abolishing the law could mean thousands of Hawaii residents will have to find health insurance elsewhere or go without. Hawaii officials are watching to see what steps Trump takes and how those may affect Obamacare enrollees.

“The transition to a new national administration is just beginning, and it is far too early in the process to speculate on potential changes to the Affordable Care Act,” said Laurel Johnston, Gov. David Ige’s deputy chief of staff.

When asked if the public should continue to enroll in Obamacare, an Ige spokeswoman said, “It’s business as usual.” The open enrollment period for 2017 started on Nov. 1.

“Nobody expected this (a potential repeal of the ACA). Wiping it out completely would have bad effects,” said state Rep. Angus McKelvey (D, Lahaina-Kaanapali-Honokohau), chairman of the House Consumer Protection & Commerce Committee. “I’m just hoping that cooler heads prevail.”

Most Hawaii residents have private health insurance through their employers, a requirement of the state’s 1974 Prepaid Health Care Act, which mandates employers cover full-time employees.

“So a pullback in Obamacare, because Hawaii has been at it for half a century, is unlikely to affect Hawaii nearly as much as it will affect every other state,” said Jeff Kissel, former head of the Hawaii Health Connector.

When asked if the state is preparing or looking at alternatives for Obamacare enrollees, an Ige spokeswoman said there are “no discussions yet, as it is too premature to tell what will happen.”

“We have to wait and see exactly what that repeal looks like, which means the law that is operative right now is the ACA as it has been enacted,” Belatti said. “People should continue to enroll, and people should continue to get heath insurance if they don’t have it because it’s something that protects them.”

Future unknown

Obamacare penalizes taxpayers who don’t have health care coverage. The current penalty, charged on your federal tax return, is $695 per adult or 2.5 percent of income — whichever is higher.

Hawaii’s uninsured rate dropped to about 5 percent from between 8 and 10 percent before the health care law.

“Right now we do not know a lot of details about what future policies might be. A repeal could result in coverage and financing changes, but the magnitude would depend,” said Robin Rudowitz, associate director for the Kaiser Family Foundation Commission on Medicaid and the Uninsured in Washington, D.C.

A repeal of Obamacare would mean more change for the health insurance industry, which has just gone through years of adapting to the new law.

“The entire health-care industry has been through seismic changes in a quest to provide more affordable, more accessible high-quality health care to more Americans. The journey has not been an easy one,” said Bernard Tyson, chairman and CEO of Kaiser Permanente, which in Hawaii is the largest health-maintenance organization, in a statement. “With the presidential election complete, our entire industry looks forward to learning more about how the next administration views access to health care and coverage. We are ready to participate and engage in discussions with the new administration on the path forward as an advocate for greater access, affordability and improved health outcomes for every American.”

Costs upsetting

Health insurers complained about the cost to their businesses, while consumers were angered by soaring premium rates imposed by health plans trying to recoup the losses from the newly insured.

Hawaii Medical Service Association — the state’s largest health insurer with about 20,000 individuals and 12,000 small group subscribers and dependents enrolled in ACA plans — and Kaiser reported earlier this year a combined $77.6 million in fees and taxes related to Obamacare.

Hawaii residents will see a substantial jump in their Obamacare premiums in 2017. The state Insurance Division, which regulates health plan rates, approved a 35 percent rate hike for HMSA members and a 25.9 percent increase for Kaiser Permanente Hawaii’s Affordable Care Act policies.

Kihei resident Kelli Lundgren, a 56-year-old self-employed Kaiser member, said the medical premiums for her policy — which also covers her 21-year-old son — are jumping 48 percent next year to $904.05 a month from $609.55.

“I do not receive an ACA supplement. This premium takes 15 percent of my annual income as self-employed, not enough for ACA assistance, and too much for the self-employed,” she said. “I’m frustrated with the U.S. health care system.”

Micronesian impact

An added issue for Hawaii is coverage for roughly 3,700 Micronesians under the Compact of Free Association, an agreement between the U.S. and three Pacific countries.

The Department of Human Services, which manages the Medicaid health insurance program for low-income residents, moved the Micronesians to Obamacare plans last year to save the state an estimated $27 million annually because the federal government would cover the cost of coverage.

“The real impact to watch out for are in the Medicaid expansion and COFA community,” said Jim Dixon, former attorney for the Hawaii Health Connector. “If Obamacare is completely repealed … you’ve got to deal with the COFA issues.”

The state also received federal funds under Obamacare to expand Medicaid rolls and bring thousands more people into the program. State officials would not say how much Hawaii received or how they plan to finance the additional Medicaid enrollments if Obamacare ends.

“There will be less money for subsidies for individuals and then less money for the expanded Medicaid,” said Kissel. “(The state is) somehow going to have to get a better handle on costs. They may be able to do it by becoming more efficient.”