Diabetes is hitting Hawaii hard. Due in part to the dice-roll of genetics, Native Hawaiians and other Pacific Islanders are two times more likely to have diabetes than other ethnic groups here. And Japanese-Americans and other Asians develop diabetes with much lower BMIs (body mass index) than other high-risk populations.

Altogether, prediabetes and type 2 diabetes affect nearly 600,000 people here — that’s close to half of the state’s population. Diabetes is a major risk factor for kidney disease, with up to 40 percent of adults wth type 2 diabetes eventually suffering kidney failure.

That’s a staggering concern, one compounded by our lonely geography and other issues that could complicate patient accessibility to vital services such as kidney dialysis treatment.

Hawaii has about 3,600 dialysis patients, with the count rising by 700 a year. Most of them tap Medicaid and Medicare health coverage. While Medicaid covers all costs for the poorest patients, Medicare patients are often left with out-of-pocket costs, from monthly premiums to bills for a portion of medical expenses, which can add up to several thousand dollars a year.

So it’s unfortunate that the state’s largest health insurer, Hawaii Medical Service Association (HMSA), is changing its policy, effective Feb. 1, to ban certain third parties, such as the American Kidney Fund, from paying medical premiums for patients.

Last year, the American Kidney Fund provided grants for all types of health coverage, including Medicare and ACA (Affordable Care Act), for about 800 of Hawaii’s dialysis patients. A spokeswoman for the nonprofit — one of the nation’s largest — has said it is now fighting in Congress for patients’ rights to “continue receiving nonprofit assistance to pay their health insurance bills.”

There ought to be a way to enable such nonprofits to help cash-strapped patients. However, the federal government agreement under which the Kidney Fund has operated since mid-1990 appears to be in need of tweaking. It allows dialysis clinics to donate to the nonprofit as well as treat patients whose insurance premiums are paid by the charity, and then collect money from the insurers for those patients’ treatments.

In recent years, questions have surfaced regarding whether this agreement is touching off a gaming of the ACA. In some cases, various insurers and others have argued, it has prompted a practice of enrolling people who are eligible for Medicaid or Medicare in private health coverage available under the new law.

The private health care plans pay the clinics up to four times more than Medicaid — potentially adding up to an additional $200,000 per patient per year — for the same dialysis treatment, according to a New York Times report.

At HMSA, officials estimate that such “excessive and unnecessary” costs are adding up to an estimated $20 million a year, with about 120 members — primarily enrolled in individual ACA plans — holding policies that are being paid for by nonprofits such as the Kidney Fund.

In addition to the third-party ban come February, HMSA is now saddling its roughly 18,000 members holding Obamacare policies with the estimated $20 million bill. The state recently approved a 19.8 percent rate hike for HMSA, slated to take effect in 2018. About half of the increase, the insurer maintains, is linked to premiums paid by third-party nonprofits.

HMSA’s actions prompt questions about whether dialysis clinics and patients will be able to make ends meet in the absence of a working third-party agreement. Hawaii has more than 30 such clinics, with plans underway to open as many as a half-dozen new ones each year over the next five years. A shortage amid rising demand could quickly result in an array of patient care snags.

In cases of end-stage renal failure, unless a transplant is an option, a patient becomes dependent on dialysis, which functions as a kidney stand-in.

Cost of care can’t be ignored, of course, but the bottom line for HMSA and other insurers in the islands must be sufficient and accessible health care.