At 94 percent coverage, Hawaii is a national leader in access to quality health care. With political will, public support and a viable plan, Hawaii can become the first state to achieve 100 percent health insurance coverage and serve as a model for the rest of the nation.
How did we come so far? First, with the Prepaid Healthcare Act of 1974, Hawaii set the first minimum standards for health care offered by employers. If an employee works 20 hours per week for four consecutive weeks, health insurance must be offered.
Second, in 1994 the federal-state Medicaid program was modified to become Med-Quest, which leveraged budgets to support quality care, universal access, efficient utilization, stable costs and a transformation health care delivery.
Third, Hawaii benefited from the Affordable Care Act, signed into law in 2010. The late U.S. Sen. Daniel Inouye inserted a provision that exempts Hawaii from act provisions that might lead to lesser care for its citizens.
Fourth, Hawaii has benefited from the long economic expansion since the Great Recession of 2008 and now boasts unemployment hovering at 2.6 percent, just above its historic low of 2 percent. This translates into lots of jobs with employer-sponsored health care.
Fifth, as the state Legislature watched efforts to repeal the ACA during the past two years, it committed to a backstop such that if the ACA was lost, isle residents would not lose coverage.
Yet there is more to be done. Hawaii can be the first state to cross the finish line with quality universal coverage for virtually all Hawaii residents and lead the way for other states. Managed properly, it will not break the bank. To be successful, the plan must be simple, clear and decisive. Change must be deliberate, and the transition must be brisk but should not demolish private health care or the ACA.
What won’t work? Medicare for all won’t. Truth be known, Medicare doesn’t do health care much better than Hawaii builds rail. To suddenly overload a health care system that functions marginally at best will risk an administrative and humanitarian disaster.
Such a move also would pose an enormous challenge in managing costs where there is no room for error. Current trends are already unsustainable. Medicare and Medicaid plus Social Security already comprise more than half the federal budget. The Hospital Insurance Trust Fund, which finances Medicare payments, will fall into the red in 2026.
What will work? Currently, uninsured lives in Hawaii number range from 60,000 to 100,000. Any plan must be clear, business-friendly and offer quality care while containing costs. It also must provide targeted and compassionate care to high utilizers and prioritize closing the gap on health disparities. Comprehensive preventive care measures must sit at the core of any insurance plan. Measures that address risks associated with cardiovascular disease, obesity, diabetes and cancer are paramount. There also must be a catastrophic fund established to address medical bankruptcies.
A phased-in Medicaid buy-in option built on the structural foundation of the ACA is the way to go at the state level. There would remain a graded menu of health care plans associated with graded premium costs. Businesses also must be better incentivized with tax benefits for covering all employees.
What to do in the absence of the health care mandate? This was the tax penalty for the unworried well who simply did not want to pay for insurance. The courts struck down this provision resulting in more uninsured and higher premiums for others. Now, instead, there must be a tax incentive for opting in, particularly for contractors and small-business owners who are otherwise unmotivated to participate
Finally, the physician shortage in Hawaii must be addressed. Medicaid and Medicare pay less than private insurance, so a larger percentage of patients who would buy into these plans will reduce overall reimbursement. Meanwhile, tuition for a medical education continues to increase, with 76 percent of graduates carrying debt at a median level of nearly $200,000. To ensure a willing workforce, community service programs that offer debt forgiveness must expand significantly. Those in service are assigned to areas most in need. Nurse practitioner and physician assistant programs must continue to expand.
Insuring everyone is the conscionable thing to do. Hawaii is already ahead of the rest of the county. Let’s finish the job and show the nation how it can be done.
Ira Zunin is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
