Hawaii’s residents have come to expect the safety net of government health insurance spread wide beneath them so that most people would have entree to the health care system. It’s one reason why, for the past quarter-century, Hawaii has had the distinction of being one of only a few states with nearly universal access to medical care.

Gov. Neil Abercrombie administration surely doesn’t want that assurance ending on his watch, notwithstanding its current struggles to deal with the state’s fiscal condition. Nor should anyone. So it was gratifying to see the state Department of Human Services take a scalpel rather than a cleaver to QUEST, the state’s health plan for the poor.

QUEST is the state’s variant of the federal Medicaid program, which gives an assist to the neediest people. For years Hawaii officials has defined the qualified population more liberally than most states do, setting the eligibility limit at households with incomes up to 200 percent of the federal poverty level. This works out to $42,650 for a family of three. Considering Hawaii’s high cost of living, it’s made sense to depart from national norms on this score. It’s pretty tough for a family to make ends meet on that amount here.

However, enrollment in QUEST has skyrocketed by 34 percent since June 2008 — which could be expected in the wake of a steep economic downturn. As a result, the state’s tab is rising faster than tax receipts can pay, so cuts, to the tune of $150 million over the next two years, had to be made.

The changes, pending federal approval expected in mid-2012: Eliminate an estimated 3,000 adults from the rolls by raising the eligibility bar back to the level mandated by the feds: Households with incomes at 133 percent of the poverty level will be admitted. These are families of three earning a total of $28,356 a year.

In addition to the poorest families, the cuts left untouched are those the department rightly considers its other core beneficiaries: children, pregnant women, the elderly, blind and disabled. And after consultation with social service advocates and the federal Centers for Medicare and Medicaid Services, DHS backed off an earlier plan to cap inpatient hospital stays for medical reasons at 10 days a year. That would have made Hawaii the nation’s most restrictive state on that score. The current plan, to set the hospital limit at 30 days form medical and surgical services and 30 days for behavioral-health stays, seems at least reasonable.

Patricia McManaman, the department’s director, expressed confidence that the changes will satisfy "99-plus percent of the needs of the community." The hope of social services advocates such as state Sen. Suzanne Chun Oakland (D, Kalihi-Liliha), is that the state expenditures on QUEST will fall back to more normal levels as the economy improves.

We hope they’re right. But many economic projections seem tentative at best, and the impact is anything but crystal-clear. Careful monitoring by state officials will be necessary to gauge who, in fact, is falling through the cracks.

More immediately, adults who could be vulnerable to the cutbacks need sufficient notice to make plans. The DHS plan includes letters to be mailed and public forums, but with the transient conditions of the working poor, social service agencies should be involved in public outreach, too.

There’s also never been a more critical juncture for the nonprofit sector to see if some additional charity outreach services — such as wellness checks and screenings — can be made available to those in the gap group.

The health care landscape is rapidly changing, given the expansion in coverage that federal health care reform is expected to bring after 2014. Over time the hope is that reform will help knit together a more efficient system, one that can provide basic care to more people at a lower cost.

That bright day is a long way off, however. For now the best we can expect is a patchwork quilt of a solution. Hawaii has made a start at stitching one up.