Healthcare policy in Hawaii

in  Hawaii

* Fiscal
* Budgets
* Hawaii state budget and finances
* Tax policy in Hawaii
* Finance
* Financial regulation in Hawaii
* Pensions
* Public pensions in Hawaii
* Pension health in Hawaii
* Civil liberties
* Affirmative action in Hawaii
* Campaign finance requirements in Hawaii
* Campaign finance requirements for Hawaii ballot measures
* Nonprofit regulation in Hawaii
* Education
* Charter schools in Hawaii
* Higher education in Hawaii
* Public education in Hawaii
* School choice in Hawaii
* Elections
* Ballot access
* Ballot access requirements for political candidates in Hawaii
* Ballot access requirements for political parties in Hawaii
* Political parties in Hawaii
* Ballot access requirements for presidential candidates in Hawaii
* Redistricting in Hawaii
* Voting in Hawaii
* Energy and Environment
* Energy policy in Hawaii
* Fracking in Hawaii
* Oil and gas extraction on federal land in Hawaii
* Endangered species in Hawaii
* Environmental policy in Hawaii
* Healthcare
* Healthcare policy in Hawaii
* Medicaid spending in Hawaii
* Effect of the Affordable Care Act in Hawaii
* Immigration
* Immigration in Hawaii

* * *

This article does not contain the most recently published data on this subject. If you would like to help our coverage grow, consider donating to Ballotpedia.

* * *

Healthcare policy in Hawaii

State overview
State population:
1,369,900
Percent uninsured:

Total healthcare spending:
$8,832,694,000
Percent of gross state product:
13.8%
Total Medicaid spending:
$1,492,674,686
Total Medicare spending:
$1,532,732,000
Median annual income:
$60,814
Average family premium:
$14,382
Average employee contribution:
$3,131
Percent of income:
5.1%
State healthcare policy
Alabama • Alaska • Arizona • Arkansas • California • Colorado • Connecticut • Delaware • Florida • Georgia • Hawaii • Idaho • Illinois • Indiana • Iowa • Kansas • Kentucky • Louisiana • Maine • Maryland • Massachusetts • Michigan • Minnesota • Mississippi • Missouri • Montana • Nebraska • Nevada • New Hampshire • New Jersey • New Mexico • New York • North Carolina • North Dakota • Ohio • Oklahoma • Oregon • Pennsylvania • Rhode Island • South Carolina • South Dakota • Tennessee • Texas • Utah • Vermont • Virginia • Washington • West Virginia • Wisconsin • Wyoming

* * *

* * *

Healthcare policy in the U.S. • Medicare • Medicaid • Obamacare overview
Years of data (most recent available as of August 2015):
•2013: State population, percent uninsured, median annual income, average family premium, average employee contribution, and percent of income.
•2012: Total Medicaid spending.
•2009: Total healthcare spending, percent of gross state product, and total Medicare spending.

## Contents

* 1 Background
* 2 General information
* 2.1 Demographics
* 2.2 Economic indicators
* 2.3 Insurance coverage
* 3 Spending and costs
* 4 Government spending
* 4.1 Medicaid and Medicare
* 4.1.1 Medicaid
* 4.1.2 Medicare
* 4.1.3 Dual eligibility
* 4.2 Prison healthcare
* 4.3 State employees
* 5 Private insurance
* 5.1 Premiums
* 5.2 Competitiveness
* 6 Other sectors
* 6.1 Pharmaceuticals
* 6.1.1 Monitoring programs
* 6.1.2 Right to try
* 6.2 Health information technology
* 7 Studies
* 7.1 Citizen health
* 8 Recent legislation
* 9 Ballot measures
* 10 Recent news
* 11 See also
* 12 External links
* 12.1 Additional reading
* 13 Footnotes

Healthcare policy in Hawaii involves the creation and implementation of laws, rules, and regulations for managing the state's healthcare system. The healthcare system consists of services provided by medical professionals to diagnose, treat, and prevent mental and physical illness and injury. The system also encompasses a wide range of related sectors, such as insurance, pharmaceuticals and health information technology.

According to the National Conference of State Legislatures, the 50 state legislatures collectively "make thousands of health policy decisions each year," not including the decisions made by local governments, which often oversee hospitals, and private bodies, such as insurers. These decisions can include budget appropriations, requirements for doctors obtaining their licenses, which services are covered by insurance, how personal health information is managed, and which immunizations children must receive, among many others.[1]

Healthcare policy affects not only the cost citizens must pay for care, but also their access to care and the quality of care received, which can influence their overall health. A top concern for policymakers is the rising cost of healthcare, which has placed an increasing strain on the disposable income of consumers as well as on state budgets.

Other issues in healthcare policy include

* state Medicaid expansion,
* health information technology and privacy,
* uninsured and underinsured portions of the population,
* a shortage of primary care physicians, and
* mental healthcare access and coverage.

## Background[edit]

See also: History of healthcare policy in the United States

In the early years of the United States, healthcare was provided by wives and mothers in the home, with occasional home visits by doctors. Medical colleges were established starting in the late 1700s, providing formal scientific training and licensing to physicians. The role of doctors became more authoritative and pronounced with further advancements in science and the growth of cities, which presented health hazards due to overcrowding, poor sanitation and attendant disease.[2][3][4]

University of Pennsylvania School of Medicine, the first medical college in the United States

In 1846 a group of physicians formed the American Medical Association (AMA) with the early mission of (and achievement of) state regulation of pharmaceuticals. As medicine grew more professionalized, private health insurance pools were established, and employers and unions began offering some medical benefits to workers. The model of payment known as "fee-for-service," in which doctors are paid for each treatment, test and office visit, emerged.[2]

Though once housing primarily poor, terminally ill patients, hospitals evolved to more closely resemble the institutions they are today. This was in part due to the development of antiseptics—allowing for more sanitary treatment conditions—and better education of physicians. It was also partly due to their role in the development of employer-sponsored insurance by offering plans for public school teachers, which allowed them to go to hospitals for more routine treatments. The employer-sponsored insurance model spread during World War II, when government wage controls prompted employers to offer health benefits rather than higher salaries in order to attract workers. This model grew more popular after the war when payments by employers toward employee health insurance were made tax-exempt.[2][5][6]

Throughout the mid-20th century, Congress established federal agencies dedicated to healthcare policy, including the National Institutes of Health and the Centers for Disease Control, the Food and Drug Administration, and the Department of Health and Human Services. The federal government also enacted a number of pieces of healthcare legislation during the second half of the century:

Queen's Medical Center in Honolulu, Hawaii

* Social Security Amendments of 1965, which established Medicare and Medicaid
* Health Maintenance Organization Act of 1973, which promoted prepaid group practice service plans known as health maintenance organizations (HMOs) as an alternative to fee-for-service plans
* Consolidated Omnibus Budget Reconciliation Act of 1985, which allowed employees to continue healthcare coverage if they would otherwise lose it (due to job loss, medical leave, etc.)
* Health Insurance Portability and Accountability Act of 1996, which limited the extent to which insurance companies could exclude people with preexisting conditions
* Patient Protection and Affordable Care Act of 2010, known as Obamacare, which established health insurance exchanges and required all citizens to obtain health insurance

Though there have been steady calls for a national health insurance program since the early 1900s, no such measure has been adopted in the United States.[2]

Today, the healthcare industry is an immense part of the nation's economy. Healthcare spending amounts to about one-sixth of the nation's gross domestic product and health expenditures account for about one-fourth to one-third of state budgets. Healthcare regulation and policy is complex, with nearly "every aspect of the field ... overseen by one regulatory body or another, and sometimes by several." Such regulations are enforced by federal, state and local governments, and even private organizations. The 2010 passage of Obamacare introduced experimentation and uncertainty into the industry, which will be watched closely over the next several years to gauge the lasting effects of its policies.[1][7][8][9]

Back to top↑

## General information[edit]

Terms and definitions

Hover over each term to display a definition.

* * *

Fee-for-service
Gross domestic product
Gross state product
Managed care
Medical durables
Medical nondurables
National health insurance
Premium
Scheduled drugs

* * *

The tables below compare demographic and economic statistics for Hawaii and surrounding states, since both factors significantly impact healthcare and healthcare policy. Also provided is general information on the insurance coverage of individuals in each state.

### Demographics[edit]

See also: State population demographics by age and gender

A major concern for the healthcare industry is the shifting demographic makeup of the nation and its states. Different groups of people--such as men and women, for example--tend to use different health services.In particular, persons aged 65 and older comprise an increasing share of the total population, with that share expected to reach 20.2 percent by 2050. This trend has had a part in the increase in demand for healthcare services and the related increase in costs. It will also influence the federal budget, as more and more seniors join Medicare.[10]

Hawaii’s percentage of individuals over the age of 65 was equal to that of Oregon, at 16 percent of the population. This was 2 percentage points higher than the national average in 2013.[11][12][13]

Age and gender demographics, 2013

State  | Total residents  | Children 0-18  | Adults 19-64  | 65+  | Male  | Female
Hawaii | 1,369,900 | 24% | 60% | 16% | 50% | 50%
California | 38,114,300 | 25% | 62% | 12% | 49% | 51%
Oregon | 3,941,300 | 23% | 61% | 16% | 50% | 50%
Washington | 6,862,300 | 25% | 60% | 15% | 49% | 51%
United States | 313,395,400 | 25% | 61% | 14% | 49% | 51%
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

### Economic indicators[edit]

See also: Economic indicators by state

Hawaii's GDP increased by 0.8 percent in 2014. Click the image to view a larger version.

Broadly defined, a healthy economy is typically one that has a "stable and strong rate of economic growth" (gross state product, in this case) and low unemployment, among many other factors. The economic health of a state can significantly affect its healthcare costs, insurance coverage, access to care, and citizens' physical and mental health. For instance, during economic downturns, employers may reduce insurance coverage for employees, while those who are laid off may lose coverage altogether. Individuals also tend to spend less on non-urgent care or postpone visits to the doctor when times are hard. These changes in turn may affect the decisions made by policymakers as they react to shifts in the industry. Additionally, a person's socioeconomic status has profound effects on their access to care and the quality of care received.[14][15][16]

Hawaii’s median annual household income was $60,814 from 2011 to 2013, highest among neighboring states. Hawaii also had the lowest unemployment rate as of September 2014.[17][18][19][20]

Note: Gross state product (GSP) on its own is not necessarily an indicator of economic health; GSP may also be influenced by state population size. Many factors must be looked at together to assess state economic health.

Various economic indicators by state

State  | Distribution of population by FPL* (2013)  | Median annual income† | Unemployment rate  | Total GSP (2013)‡
Under 100%  | 100-199%  | 200-399%  | 400%+  | Sept. 2013  | Sept. 2014
Hawaii | 11% | 16% | 35% | 38% | $60,814 | 4.7% | 4.2% | $75,235
California | 15% | 21% | 28% | 36% | $57,161 | 8.8% | 7.3% | $2,202,678
Oregon | 15% | 19% | 31% | 35% | $54,066 | 7.6% | 7.1% | $219,590
Washington | 12% | 19% | 28% | 41% | $60,520 | 6.9% | 5.7% | $408,049
United States | 15% | 19% | 30% | 36% | $52,047 | 7.2% | 5.9% | $16,701,415
* Federal Poverty Level. "The U.S. Census Bureau's poverty threshold for a family with two adults and one child was $18,751 in 2013. This is the official measurement of poverty used by the Federal Government."
† Median annual household income, 2011-2013.
‡ In millions of current dollars. "Gross State Product is a measurement of a state's output; it is the sum of value added from all industries in the state."
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

### Insurance coverage[edit]

See also: Health insurance coverage by source

In general, employers have been the dominant source of health insurance for individuals since the late 1940s and 1950s. This can be at least partially attributed to the income tax exemption granted to employers for payments made toward health insurance for employees. The second major sources of health insurance are the state and federal governments, which jointly provide Medicaid for low-income individuals while the federal government sponsors Medicare for the elderly and disabled.[21]

In 2013, about 53 percent of individuals in Hawaii were insured through their employers, a greater percentage than in any other West Coast state. The state also had the smallest percentage of residents without health insurance.[22]

Health insurance coverage by source, 2013

State  | Employer  | Other private  | Medicaid  | Medicare  | Other public  | Uninsured
Hawaii | 53% | 4% | 16% | 15% | 6% | 5%
California | 45% | 7% | 19% | 12% | 2% | 15%
Oregon | 48% | 6% | 15% | 16% | 1% | 13%
Washington | 49% | 7% | 13% | 15% | 4% | 11%
United States | 48% | 6% | 16% | 15% | 2% | 13%
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

The 1980s saw a peak in the percentage of people who were receiving health coverage through their employers, with a continuous decline in the rate thereafter. A study by researchers at the University of Minnesota’s State Health Access Data Assistance Center, which was funded by the Robert Wood Johnson Foundation, found that despite the tax exemption, fewer employers are choosing to offer health coverage to their employees, and when it is offered, fewer employees are enrolling.[21][23]

From 2000 to 2012, employer-sponsored insurance in Hawaii declined by 8.5 percentage points. Medicare enrollment grew by about 3.8 percentage points, which was greater growth than in any other West Coast state. Meanwhile, the uninsured rate declined by 0.3 percentage points, the only decline among other West Coast states.. Click 'show' on the table below to view more comparisons.[24]

Change in health insurance coverage by source, 2000-2012

State  | Change (in percentage points)
Medicaid enrollment  | Employer-sponsored insurance  | Medicare enrollment  | Uninsured rate
Hawaii | 2.8 | -8.5 | 3.8 | -0.3
California | 6.9 | -8.3 | 2.2 | 0.3
Oregon | 0.4 | -11.8 | 3 | 3.7
Washington | 4.5 | -5.3 | 1.6 | 0.5
United States | 5.8 | -10 | 2.2 | 2.3
Source: The Pew Charitable Trusts, "State Health Care Spending on Medicaid"
Back to top↑

## Spending and costs[edit]

See also: Total healthcare spending by state

Healthcare spending and costs have become a top priority for both state and federal legislators amid growing concern from consumers and employers. Healthcare spending as a percentage of the national gross domestic product (GDP) increased from 5 percent in 1960 to reach 17.4 percent in 2009, or over one-sixth of the nation's economy, where it remained steady through 2013. Total healthcare spending in both the public and private sectors amounted to $2.9 trillion in 2013. Federal, state and local governments were responsible for about 43 percent of that spending. Projections have shown that if healthcare spending continues to increase at its current rate, it will reach 19.3 percent of GDP in 2023.[25][26][27][28]

The rise in spending has been attributed partially to increased demand, but in large part to the increased price of delivering and receiving care.

“  |

Between January 1988 and January 2009, the consumer price index (CPI) rose 82 percent, while the medical component of CPI rose 175 percent.[29]

| ”

|
|

—National Conference of State Legislatures

Such costs mean less disposable income for consumers, greater expenses to hire new employees for employers, and difficulty writing budgets for lawmakers.[30][31]

In 2009, the most recent year for which state-level data are available, total healthcare spending nationwide was $2.5 trillion. In Hawaii, total healthcare spending amounted to $8.8 billion, 13.8 percent of gross state product (GSP). Total spending came out to about $6,856 per person, higher than that of any other West Coast state.[32][33][34]

Total healthcare spending*, 2009

State  | Total health spending (in millions)  | Percent of GSP  | Health spending per capita  | Avg. annual percent growth†
Hawaii | $8,833 | 13.8% | $6,856 | 6.2%
California | $230,090 | 12.6% | $6,238 | 5.9%
Oregon | $25,155 | 14.7% | $6,580 | 7.5%
Washington | $45,246 | 13.6% | $6,782 | 7.3%
United States‡ | $2,505,800 | 17.4% | $8,175 | 6.8%
* "Total Health Spending includes spending for all privately and publicly funded personal health care services and products (hospital care, physician services, nursing home care, prescription drugs, etc.) by state of residence. Hospital spending is included and reflects the total net revenue (gross charges less contractual adjustments, bad debts, and charity care)."
† 1991-2009
‡ Data come directly from the Centers for Medicare and Medicaid Services, "NHE Summary including share of GDP, CY 1960-2013"
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

The bulk of Hawaii’s total healthcare spending went towards hospital care, with the second largest portion going towards physician and professional services. This was on par with national trends.[35]

Back to top↑

## Government spending[edit]

See also: Hawaii state budget and finances

### Medicaid and Medicare[edit]

#### Medicaid[edit]

See also: Medicaid spending in Hawaii

During fiscal year 2012, combined federal and state spending for Medicaid, a government health insurance program primarily for low-income and disabled persons, was lower in Hawaii than in its neighboring states, totaling about $1.5 billion. Spending per enrollee amounted to $5,876, above only that of California. Medicaid spending was evenly split between the federal government and the state government, each contributing about 50 percent of the total amount. Between 2000 and 2012, Medicaid spending increased by 71 percent in Hawaii, or about 4.6 percent per year. This was a lower rate than in California but above growth rates in Oregon and Washington. Hawaii and Washington each dedicated about 12 percent of their 2012 budgets to Medicaid, a smaller portion than in California and Oregon.[36][37][38][39][40]

Medicaid spending, fiscal year 2012

State  | Total spending*† | Per enrollee*† | Total growth‡ | Compound annual growth rate‡ | Federal share* | State share* | Percent of state budget
Hawaii | $1,492,674,686 | $5,876 | 71% | 4.6% | 50% | 50% | 12.3%
California | $50,165,335,340 | $4,803 | 83% | 5.2% | 51% | 49% | 21.4%
Oregon | $4,587,105,504 | $7,314 | 66% | 4.3% | 63% | 37% | 18.2%
Washington | $7,560,049,390 | $6,190 | 45% | 3.1% | 50% | 50% | 12.1%
United States | $415,154,234,831 | $6,833 | 63% | 4.1% | 57% | 43% | N/A
* "Expenditures do not include administrative costs, accounting adjustments, or the U.S. Territories."
† Includes both state and federal expenditures.
‡ 2000-2012\. Includes payments for services, administrative expenses, and DSH payments.

Acute care services are those that are typically provided within a short time frame, such as inpatient hospital stays, lab tests and prescription drugs. Long-term care services, on the other hand, are those provided over a long period of time, such as home care and mental health treatment. Disproportionate Share Hospital (DSH) payments are funds given to hospitals that tend to serve more low-income and uninsured patients than other hospitals. Most of Hawaii’s Medicaid spending went towards acute care, at 92 percent, a greater portion than any other West Coast state. Hawaii was the only state among its neighbors where Medicaid made no payments to DSHs, leaving the remaining 7.5 percent for long-term care services.[41]

In 2010, there were 265,588 Hawaii residents enrolled in Medicaid. The majority of spending, 58 percent, was on the elderly and disabled, who made up 20 percent of Medicaid enrollees. This is typical of most states, since this group of enrollees is "more likely to have complex health care needs that require costly acute and long-term care services," according to the Pew Charitable Trusts. The portion of Medicaid enrollees who are elderly and disabled is a factor taken under significant consideration when state lawmakers make appropriations for the program each year.[42]

Distribution of Medicaid enrollment and payments, 2010

State  | Enrollment rates  | Payment for services
Total  | Elderly and disabled individuals  | Parents and children  | Total (in billions)  | Elderly and disabled individuals  | Parents and children
Hawaii | 265,588 | 20% | 80% | $1.4 | 58% | 42%
California | 11,428,811 | 18% | 82% | $39.3 | 68% | 32%
Oregon | 643,940 | 24% | 76% | $3.9 | 64% | 36%
Washington | 1,352,939 | 22% | 78% | $6.6 | 61% | 39%
United States | 66,390,642 | 24% | 76% | $369.3 | 64% | 36%
Source: The Pew Charitable Trusts, "State Health Care Spending on Medicaid"

#### Medicare[edit]

Medicare is a federal health insurance program for elderly persons over age 65 and younger individuals with certain disabilities. Medicare accounted for 14 percent of the federal budget in 2013. In 2009, the most recent year for which state spending data is available, total federal Medicare spending for enrollees in Hawaii amounted to $1.5 billion. Per enrollee, this amounted to $7,652, lowest among other West Coast states. Hawaii and Oregon both had a higher average annual rate of growth in total Medicare spending between 1991 and 2009 than their neighboring states, but Hawaii experienced the lowest rate of growth in per enrollee spending.[43][44][45][46]

Medicare spending and growth, 2009

State  | Total (in millions)  | Average annual growth rate* | Per enrollee  | Average annual growth rate*
Hawaii | $1,533 | 8.3% | $7,652 | 5.8%
California | $50,604 | 7.8% | $10,954 | 5.9%
Oregon | $4,967 | 8.3% | $8,247 | 6.4%
Washington | $7,971 | 8.2% | $8,497 | 5.9%
United States | $471,260 | 8.0% | $10,362 | 6.4%
* 1991-2009
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

In 2012, there were 217,678 individuals in Hawaii enrolled in Medicare, or 15.8 percent of the state population. Aged beneficiaries made up 88.1 percent of the total number, while 11.9 percent were disabled.[47][48][49]

Medicare beneficiaries, 2012

State  | Number  | Percent of population  | Eligibility category
Aged  | Disabled
Hawaii | 217,678 | 15.8% | 88.1% | 11.9%
California | 5,000,198 | 13.3% | 84.8% | 15.2%
Oregon | 653,905 | 16.9% | 83.4% | 16.6%
Washington | 1,029,529 | 15.1% | 82.7% | 17.3%
United States | 49,435,610 | 16.0% | 81.4% | 18.6%
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

#### Dual eligibility[edit]

Some individuals, such as low-income seniors, are eligible for both Medicare and Medicaid; these individuals are known as dual-eligible beneficiaries. For those enrolled in Medicare who are eligible, enrolling in Medicaid may provide some benefits not covered by Medicare, such as stays longer than 100 days at nursing facilities, prescription drugs, eyeglasses, and hearing aids. Medicaid may also be used to help pay for Medicare premiums. Total Medicaid spending for dual eligibles in Hawaii amounted to $606 million. Most payments were made toward acute care.[50][51]

Medicaid spending for dual eligibles by service, fiscal year 2011 (in millions)

State  | Medicare premiums  | Acute care  | Prescribed drugs  | Long-term care  | Total
Hawaii | $57 | $491 | $0 | $58 | $606
California | $2,248 | $7,235 | $245 | $8,949 | $18,677
Oregon | $142 | $300 | $8 | $1,094 | $1,545
Washington | $308 | $251 | $27 | $1,685 | $2,271
United States | $13,489 | $40,190 | $1,462 | $91,765 | $146,906
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"
Back to top↑

### Prison healthcare[edit]

See also: Prison healthcare

In 1976, the United States Supreme Court ruled that adequate healthcare for prisoners is a constitutional right and that the refusal to provide them with such violates the Eighth Amendment prohibiting cruel and unusual punishment. As such, state budget allocations for correctional facilities, like other healthcare expenditures, have continued to grow, especially as the prison population ages. Correctional healthcare spending nationwide totaled $7.7 billion in 2011, or $6,047 per inmate, which The Pew Charitable Trusts estimated to be about one-fifth of total prison spending. This was up from 2007, but down from a peak in 2009 as the average daily prison population decreased. States have experienced fiscal pressure to manage prison healthcare costs without compromising prisoners' right to quality care.[52]

“  |

The manner in which states manage prison health care services that meet these legal requirements affects not only inmates' health, but also the public's health and safety and taxpayers' total corrections bill.[29]

| ”

|
|

—The Pew Charitable Trusts

Total prison healthcare spending in Hawaii amounted to $23.9 million, or $4,513 per inmate, the lowest per inmate spending among other West Coast states. This was an increase of 8 percent over 2007 per inmate spending, which may be partially due to the 6 percent decline in the average daily prion population. Hawaii also had the smallest percentage of inmates that were age 55 and over, 6 percent.[52]

State spending on prison healthcare

State  | Category  | 2007  | 2008  | 2009  | 2010  | 2011  | Percent change
Hawaii | Total spending* | $23,573 | $24,350 | $26,335 | $22,569 | $23,934 | 2%
Daily prison population | 5,638 | 5,520 | 5,461 | 5,258 | 5,303 | -6%
Per inmate spending | $4,181 | $4,411 | $4,822 | $4,292 | $4,513 | 8%
Percent of inmates age 55+ | 6% | 6% | 6% | 6.1% | 6% | -1%
California | Total spending* | $1,688,342 | $2,277,690 | $2,577,835 | $2,218,926 | $2,137,045 | 27%
Daily prison population | 165,406 | 154,483 | 157,219 | 152,799 | 147,438 | -11%
Per inmate spending | $10,207 | $14,744 | $16,396 | $14,522 | $14,495 | 42%
Percent of inmates age 55+ | 5.7% | 6.4% | 7.1% | 7.9% | 8.8% | 54%
Oregon | Total spending* | $80,778 | $82,648 | $100,872 | $93,662 | $103,836 | 29%
Daily prison population | 13,264 | 13,766 | 13,620 | 13,819 | 14,116 | 6%
Per inmate spending | $6,090 | $6,004 | $7,406 | $6,778 | $7,356 | 21%
Percent of inmates age 55+ | 10.7% | 11.8% | 12.7% | 12.8% | 13.8% | 30%
Washington | Total spending* | $117,865 | $140,581 | $143,222 | $128,503 | $119,253 | 1%
Daily prison population | 16,108 | 16,280 | 16,564 | 16,995 | 16,997 | 6%
Per inmate spending | $7,317 | $8,635 | $8,646 | $7,561 | $7,016 | -4%
Percent of inmates age 55+ | N/A | N/A | N/A | N/A | N/A | N/A
* In thousands.
Source: The Pew Charitable Trusts, "State Prison Health Care Spending"

### State employees[edit]

See also: State employee health plans

State employee health insurance accounts for the second-largest portion of state healthcare spending, behind only Medicaid. The total cost of insurance for state workers was $30.7 billion nationwide in 2013, with $25.1 billion paid for by the states. Premium costs varied widely, with higher premiums found in states such as New Hampshire and Vermont compared to those in states like Arkansas and Mississippi. Part of this variation is due to demographic factors and provider prices, and part may be attributed to differences in health plan "richness," or the cost sharing between the insurer and health plan enrollees, such as deductibles and copayments.[53]

“  |

State health plans were generally "rich," paying on average 92 percent of the typical enrollees’ health care costs. By way of context, these plans would be designated "platinum" plans within the new health insurance marketplaces.[29]

| ”

|
|

—The Pew Charitable Trusts

Several states are experimenting with various cost-containment methods. "Pooled public employee health benefit programs" are one such strategy, which are mergers between state employee health plans and those of other, smaller public employers, such as city governments and school districts. The idea is to save on administrative costs for insurers and leverage the larger pool to negotiate lower premium rates. Evidence of cost savings is mixed, with the smaller public employers reaping most of the benefits. Programs for pooling public employee health plans have been implemented in 31 states; as of December 2014, Hawaii was one of them. According to the National Conference of State Legislatures, Hawaii allows city, town and county governments, public colleges and universities, and public school districts to join its healthcare plan.[54]

Hawaii is one of 46 states that “self-fund at least one of their employee health care plans,” meaning that rather than purchasing insurance, the state pays health insurance claims with state and employee out-of-pocket insurance contributions while an insurer administers the benefits. As of 2013, there were 24 states offering plans with a $0 deductible; Hawaii was one of these states, with 100 percent of state employees enrolled in such a plan.[53][54]

Net state employee health plan expenditures in Hawaii totaled $274.4 million in 2013. This was 39 percent increase from 2011, which was a much greater increase than any West Coast state. Nationwide, such expenditures declined by 1 percent over the same period.[53]

Note: Due to such variations as demographics, plan richness and provider rates, "higher spending is not necessarily an indication of waste, and lower spending is not necessarily a sign of efficiency."[53]

State employee health plan spending (in thousands)

State  | Total state expenditures (gross)  | Change  | Total state expenditures (net)  | Change
2011  | 2013  | 2011  | 2013
Hawaii | $388,456 | $475,080 | 22% | $196,731 | $274,419 | 39%
California | $2,394,406 | $2,594,322 | 8% | $1,854,783 | $2,008,166 | 8%
Oregon | $749,358 | $755,073 | 1% | $749,358 | $717,319 | -4%
Washington | $1,112,783 | $1,131,014 | 2% | $982,450 | $962,552 | -2%
United States | $30,311,259 | $30,692,147 | 1% | $25,263,863 | $25,071,413 | -1%
Note: "Gross expenditures include employer and employee premium contributions. Net expenditures include only employer premium contributions. All spending figures are in 2013 dollars."
Source: The Pew Charitable Trusts, "State Employee Health Plan Spending"

In 2013, state employee health plan premiums for single coverage were lower in Hawaii than in neighboring staes, while those for family coverage were the second lowest. The state paid on average 58 percent of the premiums, a much smaller portion than its neighboring states.[53]

Average state employee health plan monthly premiums, 2013

State  | Single  | Family  | Employer contribution percentage  | Employee contribution percentage
Total premium  | Employer contribution  | Employee contribution  | Total premium  | Employer contribution  | Employee contribution
Hawaii | $435 | $251 | $184 | $1,237 | $714 | $523 | 58% | 42%
California | $646 | $494 | $152 | $1,465 | $1,127 | $337 | 77% | 23%
Oregon | $1,030 | $978 | $51 | $1,366 | $1,298 | $68 | 95% | 5%
Washington | $536 | $459 | $77 | $1,187 | $1,008 | $179 | 85% | 15%
United States | $570 | $502 | $68 | $1,233 | $1,004 | $230 | 84% | 16%
Note: "Due to rounding, the sum of employer and employee contributions may differ from total premium."
Source: The Pew Charitable Trusts, "State Employee Health Plan Spending"
Back to top↑

## Private insurance[edit]

See also: Private health insurance

### Premiums[edit]

For private insurance, consumers typically either receive coverage through their employer or buy it on their own through the individual market. As healthcare costs have increased, so have insurance premiums. Between 2000 and 2014, insurance premiums for employer-sponsored plans, including state and local government plans, increased 144 percent for single coverage and 161 percent for family coverage. However, the rate of increase has slowed in more recent years. Between 2000 and 2007, premiums grew by 81 percent for single coverage and 88 percent for family coverage. Between 2007 and 2014, the rates of increase were 34.5 percent and 39 percent, respectively.[55]

Employers have reacted to these costs in a number of ways, one of which has been to shift more responsibility for premium contributions to their employees. The portion of premiums paid by employees for single coverage has increased by four percentage points, from 14 percent to 18 percent, since 2000, and by three percentage points, from 26 percent to 29 percent, for family coverage. Average deductibles for employees have also risen, doubling from $584 to $1,135 between 2006 and 2013.[55][56]

In Hawaii's private, employer-based insurance market, average premiums for employer-sponsored coverage amounted to $5,103 for single coverage and $14,382 for family coverage. These figures were below national averages. Employees contributed about $431 per year for single coverage and $3,131 for family coverage. As shown in the bar chart above, premiums in Hawaii's individual market were second-highest compared to West Coast states, averaging at about $268 per month, or $3,211 per year.[57][58][59]

Average annual premiums for private employer-based insurance, 2013

State  | Single  | Family
Employee contribution  | Employer contribution  | Total  | Employee contribution  | Employer contribution  | Total
Hawaii | $431 | $4,672 | $5,103 | $3,131 | $11,251 | $14,382
California | $1,091 | $4,490 | $5,581 | $4,518 | $12,173 | $16,691
Oregon | $804 | $4,645 | $5,449 | $4,327 | $11,529 | $15,856
Washington | $680 | $5,010 | $5,690 | $3,930 | $11,791 | $15,721
United States | $1,170 | $4,401 | $5,571 | $4,421 | $11,608 | $16,029
Note: "Figures may not sum exactly due to rounding."
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

In 2013, private sector employers in Hawaii contributed on average 91.6 percent to single coverage premiums and 78.2 percent to family coverage premiums. Click on the table below to view further details and state comparisons.[60][61]

Average annual premiums for private employer-based insurance, 2013 (percents)

State  | Single  | Family
Employee contribution  | Employer contribution  | Total  | Employee contribution  | Employer contribution  | Total
Hawaii | 8.4% | 91.6% | 100% | 21.8% | 78.2% | 100%
California | 19.5% | 80.5% | 100% | 27.1% | 72.9% | 100%
Oregon | 14.8% | 85.2% | 100% | 27.3% | 72.7% | 100%
Washington | 12% | 88% | 100% | 25% | 75% | 100%
United States | 21% | 79% | 100% | 27.6% | 72.4% | 100%
Note: Percentages calculated by Ballotpedia.
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

### Competitiveness[edit]

The Henry J. Kaiser Family Foundation measured the competitiveness of the private health insurance market in 2013, using the Herfindahl-Hirschman Index (HHI) as an indicator. The HHI takes into account how much of a market is controlled by each of the companies competing within it (market share) and is expressed in a value between zero and 10,000. The lower the number, the more competitive the market. The analysis was divided into individual, small group and large group insurance markets. The data also includes information on the market share of the largest insurer in each state, as well as the number of insurers with a market share of greater than five percent.[62][63][64][65]

Hawaii had the least competitive individual, small group and large group insurance markets when compared to other West Coast states. Within the state, the large group market was the least competitive, with the largest insurer holding a market share of 71 percent.[62][63][64]

Health insurance market competition, 2013

State  | Individual  | Small group  | Large group
HHI* | Market share of largest insurer  | Insurers with >5% market share  | HHI* | Market share of largest insurer  | Insurers with >5% market share  | HHI* | Market share of largest insurer  | Insurers with >5% market share
Hawaii | 4,929 | 50% | 2 | 3,262 | 48% | 4 | 5,559 | 71% | 2
California | 3,021 | 48% | 4 | 2,139 | 31% | 5 | 2,591 | 44% | 5
Oregon | 1,779 | 31% | 7 | 1,521 | 23% | 6 | 2,537 | 41% | 4
Washington | 3,200 | 39% | 3 | 2,415 | 37% | 5 | 2,617 | 31% | 3
United States | 3,888 | 55% | 3 | 3,841 | 57% | 4 | 4,038 | 57% | 4
* "The Herfindahl-Hirschman Index (HHI) is a measure of how evenly market share is distributed across insurers in the market. HHI values range from 0 to 10,000, with an HHI closer to zero indicating a more competitive market and closer to 10,000 indicating a less competitive market. An HHI index below 1,000 generally indicates a highly competitive market; an HHI between 1,000 and 1,500 indicates an unconcentrated market; a score between 1,500 and 2,500 indicates moderate concentration; and a value above 2,500 indicates a highly concentrated (uncompetitive) market."
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"
Back to top↑

## Other sectors[edit]

### Pharmaceuticals[edit]

See also: Prescription drug sales by state

In the United States, there are more than 10,000 FDA-approved medicines available for doctors to prescribe or individuals to purchase over-the-counter. A major target of state healthcare cost-containment efforts is the price of these medicines. Prescription drugs generated a total of $259 billion in sales at retail pharmacies nationwide in 2014. Since generic drugs tend to be significantly less expensive than their brand name equivalents, all states allow pharmacists to dispense generics in place of brand name drugs for prescriptions. This practice is required in 13 states, except when a brand name drug is specifically ordered by a physician; this group of states includes Hawaii.[66]

Additionally, state Medicaid programs typically take a number of steps to control spending on pharmaceuticals. Most common are establishing preferred drug lists, which are prescription drugs that are automatically covered by the program, and negotiating rebates with manufacturers for both brand name and generic drugs. Hawaii's Medicaid program utilizes both of these strategies, and is also part of a multi-state pool designed to further reduce costs.[67]

In 2014, retail sales of prescription drugs at pharmacies in Hawaii amounted to about $1 billion, with about 15.6 million drugs sold. On average, women and individuals over age 65 bought more prescription drugs than men and those under age 65. These totals do not include medications sold over-the-counter.[68][69][70][71]

Prescription drugs filled at retail pharmacies, 2014

State  | Total sales for retail Rx drugs  | Total number retail Rx drugs  | Number per capita by age  | Number per capita by gender
Ages 0-18  | Ages 19-64  | Ages 65+  | Male  | Female
Hawaii | $1,028,794,409 | 15,627,633 | 4 | 11.3 | 23.5 | 10.3 | 12.6
California | $29,716,410,437 | 445,835,829 | 3.2 | 11.1 | 31.4 | 9.6 | 13.7
Oregon | $2,943,013,659 | 56,329,817 | 4 | 14.9 | 27.3 | 11.3 | 17.3
Washington | $4,620,217,239 | 91,965,000 | 3.8 | 14.1 | 26.4 | 10.5 | 16
United States | $259,092,876,285 | 4,002,661,750 | 4.1 | 12.6 | 27.9 | 10.4 | 14.9
Note: "These totals include prescriptions filled at pharmacies only and a small portion of over-the-counter medications and repackagers and exclude those filled by mail order."
Source: The Henry J. Kaiser Family Foundation, "State Health Facts"

#### Monitoring programs[edit]

States are also focusing on curbing prescription drug abuse and fraud as a method to contain costs.[72]

“  |

According to the Coalition Against Insurance Fraud, prescription drug misuse, abuse and fraud cost private health insurers almost $25 billion a year.[29]

| ”

|
|

—National Conference of State Legislatures

Between 2004 and 2009, there was a documented increase of 98.4 percent in emergency room visits caused by such abuse and misuse of prescription drugs. As an effort to combat the rise in prescription drug abuse and fraud, all but two states have authorized the development of prescription drug databases that can monitor the dispensing of certain controlled substances. These programs have been bolstered by federal grants encouraging their implementation.[72]

Hawaii's prescription drug monitoring program monitors Schedule II, Schedule III, Schedule IV and Schedule V substances, as well as non-controlled and non-scheduled substances. Information must be reported weekly by all pharmacies. Unlike in many other states, there are no exemptions from these requirements. The law does not require patients to be notified of the monitoring program.[73]

#### Right to try[edit]

Under the current model, access to experimental drugs by terminally ill patients is controlled by the Food and Drug Administration (FDA), which must give its approval after it receives a form from a patient's physician. What are known as "right to try" laws aim to allow such patients to gain access to experimental drugs without the permission of the FDA. As of March 2016, 27 states in total had adopted right-to-try legislation. At that time, Hawaii's legislature had considered right-to-try legislation, but no such measure had been enacted.[74]

### Health information technology[edit]

The HHS on the HIPAA Privacy Rule

Health information technology (IT) refers to electronic systems that manage, store and transmit health information, such as patient records. The adoption of modernized health IT has been promoted by the federal government as a way to increase quality while decreasing costs. For instance, the American Recovery and Reinvestment Act of 2009 required most health providers to adopt electronic health records by 2015. However, the digitization of health data raises concerns about the privacy of such data, which could be vulnerable to a breach if not properly secured. Since 1996, health IT privacy and security has been governed by the Health Insurance Portability and Accountability Act (HIPAA), which required and set national standards for the confidentiality of patient information "when it is transferred, received, handled, or shared."[75][76][77]

All-payer claims databases are one form of health IT that a growing number of states are implementing to track healthcare costs. All-payer claims databases are state systems for collecting data from public and private health insurance claims on demographics, types of services and total charges. According to the National Conference of State Legislatures, "the U.S. Department of Health and Human Services plans to build a nationwide all-payer claims database consisting of a representative sample of the population." All-payer claims databases exist in 17 states, while another 17 have demonstrated a "strong interest" in creating one. To view the status of such a program in Hawaii, click here.[78][79][80][81]

Back to top↑

## Studies[edit]

### Citizen health[edit]

Each year, the United Health Foundation releases a report titled "America's Health Rankings," which measures the overall health of the citizens in each state. The United Health Foundation is a nonprofit organization that "provides helpful information to support decisions that lead to better health outcomes and healthier communities." Factors taken into account for the report include the percentage of the state population that smokes tobacco, incidents of infectious diseases such as Salmonella, percent of the population uninsured, the number of primary care physicians, and the rate of infant mortality, among others.[82][83]

In its 2014 report, Hawaii ranked first in the nation, up from second in 2012. According to the report, although Hawaii had low rates of immunization coverage among children and high incidence of infectious disease, the state had a low prevalence of obesity and a low rate of cancer deaths, as well as the lowest rate of preventable hospitalizations in the country.[82]

In the report, California was ranked 17th, Oregon was ranked 12th and Washington was ranked 13th. To read the full report, click here.[82]

## Recent legislation[edit]

The following is a list of recent healthcare policy bills that have been introduced in or passed by the Hawaii state legislature. To learn more about each of these bills, click the bill title. This information is provided by BillTrack50 and LegiScan.

Note: Due to the nature of the sorting process used to generate this list, some results may not be relevant to the topic. If no bills are displayed below, then no legislation pertaining to this topic has been introduced in the legislature recently.

## Ballot measures[edit]

See also: Healthcare on the ballot and List of Hawaii ballot measures

Ballotpedia has tracked no ballot measures relating to healthcare matters in Hawaii.

## Recent news[edit]

The link below is to the most recent stories in a Google news search for the terms Hawaii healthcare. These results are automatically generated from Google. Ballotpedia does not curate or endorse these articles.

Healthcare policy in Hawaii - Google News

## See also[edit]

* Medicaid spending in Hawaii

* Effect of the Affordable Care Act in Hawaii

* U.S. Department of Health and Human Services

## External links[edit]

* Hawaii State Department of Health
* Office of Health Care Assurance
* The Henry J. Kaiser Family Foundation
* National Conference of State Legislatures, Health
* Health Affairs

### Additional reading[edit]

* The Henry J. Kaiser Family Foundation, "Health Care Costs: A Primer"
* Deloitte Center for Health Solutions, "Dig deep: Impacts and implications of rising out-of-pocket health care costs"
* The Pew Charitable Trusts, "State Health Care Spending Project Reports"Back to top↑

## Footnotes[edit]

1. ↑ 1.0 1.1 National Conference of State Legislatures, "Health," accessed July 8, 2015
2. ↑ 2.0 2.1 2.2 2.3 Fillmore, R., Florida Science Communications, Inc., "The Evolution of the U.S. Healthcare System," accessed July 8, 2015
3. ↑ History, "George Waring," accessed July 27, 2015
4. ↑ University of Houston: Digital History, "The Growth of Cities," accessed July 27, 2015
5. ↑ NPR, "Accidents Of History Created U.S. Health System," October 22, 2009
6. ↑ The Economist, "The insured and the unsure," January 26, 2013
7. ↑ NPR, "Health Care In America: Follow The Money," March 19, 2012
8. ↑ National Center for Biotechnology Information, "Why Is Health Care Regulation So Complex?" October 2008
9. ↑ Center on Education and the Workforce, "Healthcare," June 2012
10. ↑ Ensocare, "How Demographics Impact Health-care Delivery," accessed July 10, 2015
11. ↑ The Henry J. Kaiser Family Foundation, "Total Number of Residents," accessed July 17, 2015
12. ↑ Henry J. Kaiser Family Foundation, "Population Distribution by Age," accessed July 17, 2015
13. ↑ Henry J. Kaiser Family Foundation, "Population Distribution by Gender," accessed July 17, 2015
14. ↑ Academy Health, "Impact of the Economy on Health Care," August 2009
15. ↑ The Conversation, "Budget explainer: What do key economic indicators tell us about the state of the economy?" May 6, 2015
16. ↑ Health Affairs, "Socioeconomic Disparities In Health: Pathways And Policies," accessed July 13, 2015
17. ↑ The Henry J. Kaiser Family Foundation, "Distribution of Total Population by Federal Poverty Level," accessed July 17, 2015
18. ↑ The Henry J. Kaiser Family Foundation, "Median Annual Household Income," accessed July 17, 2015
19. ↑ The Henry J. Kaiser Family Foundation, "Unemployment Rate (Seasonally Adjusted)," accessed July 17, 2015
20. ↑ The Henry J. Kaiser Family Foundation, "Total Gross State Product (GSP) (millions of current dollars)," accessed July 17, 2015
21. ↑ 21.0 21.1 Health Affairs, "Employment-Based Health Insurance: Past, Present, And Future," November 2006
22. ↑ The Henry J. Kaiser Family Foundation, "Health Insurance Coverage of the Total Population," accessed July 23, 2015
23. ↑ Robert Wood Johnson Foundation, "State-Level Trends in Employer-Sponsored Health Insurance," January 29, 2015
24. ↑ The Pew Charitable Trusts, "State Health Care Spending on Medicaid," July 2014
25. ↑ Centers for Medicare and Medicaid Services, "National Health Expenditures 2013 Highlights," accessed July 28, 2015
26. ↑ Health Affairs, "National Health Spending In 2013: Growth Slows, Remains In Step With The Overall Economy," December 2014
27. ↑ Health Affairs, "National Health Expenditure Projections, 2013–23: Faster Growth Expected With Expanded Coverage And Improving Economy," September 2014
28. ↑ Peterson-Kaiser Health System Tracker, "Health Spending Explorer," accessed July 28, 2015
29. ↑ 29.0 29.1 29.2 29.3 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributable to the original source.
30. ↑ Health Affairs, "The Rise In Health Care Spending And What To Do About It," November 2005
31. ↑ National Conference of State Legislatures, "Equalizing Health Provider Rates," June 2010
32. ↑ The Henry J. Kaiser Family Foundation, "Health Care Expenditures by State of Residence (in millions)," accessed July 17, 2015
33. ↑ The Henry J. Kaiser Family Foundation, "Health Care Expenditures per Capita by State of Residence," accessed July 17, 2015
34. ↑ The Henry J. Kaiser Family Foundation, "Average Annual Percent Growth in Health Care Expenditures by State of Residence," accessed July 17, 2015
35. ↑ The Henry J. Kaiser Family Foundation, "Distribution of Health Care Expenditures by Service by State of Residence (in millions)," accessed August 27, 2015
36. ↑ The Henry J. Kaiser Family Foundation, "Total Medicaid Spending," accessed July 17, 2015
37. ↑ Medicaid and CHIP Payment and Access Commission, "Medicaid Benefit Spending per Full-Year Equivalent Enrollee by State and Eligibility Group, FY 2012," accessed September 14, 2015
38. ↑ The Pew Charitable Trusts, "State Health Care Spending on Medicaid" Table B.1, accessed July 17, 2015
39. ↑ The Henry J. Kaiser Family Foundation, "Federal and State Share of Medicaid Spending," accessed July 17, 2015
40. ↑ National Association of State Budget Officers, "State Expenditure Report: Examining Fiscal 2011-2013 State Spending: Table 5," accessed July 17, 2015
41. ↑ The Henry J. Kaiser Family Foundation, "Distribution of Medicaid Spending by Service," accessed July 17, 2015
42. ↑ The Pew Charitable Trusts, "State Health Care Spending on Medicaid," July 2014
43. ↑ The Henry J. Kaiser Family Foundation, "Total Medicare Spending by State (in millions)," accessed July 17, 2015
44. ↑ The Henry J. Kaiser Family Foundation, "Average Annual Percent Growth in Medicare Spending, by State," accessed July 17, 2015
45. ↑ The Henry J. Kaiser Family Foundation, "Medicare Spending Per Enrollee, by State," accessed July 17, 2015
46. ↑ The Henry J. Kaiser Family Foundation, "Average Annual Percent Growth in Medicare Spending per Enrollee, by State," accessed July 17, 2015
47. ↑ The Henry J. Kaiser Family Foundation, "Total Number of Medicare Beneficiaries," accessed July 17, 2015
48. ↑ The Henry J. Kaiser Family Foundation, "Medicare Beneficiaries as a Percent of Total Population," accessed July 17, 2015
49. ↑ The Henry J. Kaiser Family Foundation, "Distribution of Medicare Beneficiaries by Eligibility Category," accessed July 17, 2015
50. ↑ Medicaid.gov, "Seniors & Medicare and Medicaid Enrollees," accessed July 16, 2015
51. ↑ The Henry J. Kaiser Family Foundation, "Distribution of Medicaid Spending for Dual Eligibles by Service (in Millions)," accessed July 17, 2015
52. ↑ 52.0 52.1 The Pew Charitable Trusts, "State Prison Health Care Spending," July 2014
53. ↑ 53.0 53.1 53.2 53.3 53.4 The Pew Charitable Trusts, "State Employee Health Plan Spending," August 2014
54. ↑ 54.0 54.1 National Conference of State Legislatures, "State Employee Health Benefits," accessed July 20, 2015
55. ↑ 55.0 55.1 The Henry J. Kaiser Family Foundation, "Employee Health Benefits: 2014 Annual Survey," accessed July 24, 2015
56. ↑ The Henry J. Kaiser Family Foundation, "FAQ: How Employer-Sponsored Health Insurance Is Changing," September 17, 2013
57. ↑ The Henry J. Kaiser Family Foundation, "Average Single Premium per Enrolled Employee For Employer-Based Health Insurance," accessed July 24, 2015
58. ↑ The Henry J. Kaiser Family Foundation, "Average Family Premium per Enrolled Employee For Employer-Based Health Insurance," accessed July 24, 2015
59. ↑ The Henry J. Kaiser Family Foundation, "Average Monthly Premiums Per Person in the Individual Market," accessed July 24, 2015
60. ↑ The Henry J. Kaiser Family Foundation, "Average Single Premium per Enrolled Employee For Employer-Based Health Insurance," accessed July 17, 2015
61. ↑ The Henry J. Kaiser Family Foundation, "Average Family Premium per Enrolled Employee For Employer-Based Health Insurance," accessed July 17, 2015
62. ↑ 62.0 62.1 The Henry J. Kaiser Family Foundation, "Individual Insurance Market Competition," accessed July 24, 2015
63. ↑ 63.0 63.1 The Henry J. Kaiser Family Foundation, "Small Group Insurance Market Competition," accessed July 24, 2015
64. ↑ 64.0 64.1 The Henry J. Kaiser Family Foundation, "Large Group Insurance Market Competition," accessed July 24, 2015
65. ↑ Investopedia, "Herfindahl-Hirschman Index - HHI," accessed August 6, 2015
66. ↑ National Conference of State Legislatures, "Use of Generic Prescription Drugs and Brand-Name Discounts," June 2010
67. ↑ National Conference of State Legislatures, "Prescription Drug Agreements and Volume Purchasing," June 2010
68. ↑ The Henry J. Kaiser Family Foundation, "Total Retail Sales for Prescription Drugs Filled at Pharmacies," accessed July 21, 2015
69. ↑ The Henry J. Kaiser Family Foundation, "Total Number of Retail Prescription Drugs Filled at Pharmacies," accessed July 21, 2015
70. ↑ The Henry J. Kaiser Family Foundation, "Retail Prescription Drugs Filled at Pharmacies (Annual per Capita by Age)," accessed July 21, 2015
71. ↑ The Henry J. Kaiser Family Foundation, "Retail Prescription Drugs Filled at Pharmacies (Annual per Capita by Gender)," accessed July 21, 2015
72. ↑ 72.0 72.1 National Conference of State Legislatures, "The Burden of Prescription Drug Overdoses on Medicaid," January 2012
73. ↑ National Alliance for Model State Drug Laws, "Prescription Monitoring Program State Profiles – Hawaii," accessed July 21, 2015
74. ↑ National Conference of State Legislatures, "'Right to Try' Experimental Prescription Drugs State Laws and Legislation for 2014 & 2015," March 31, 2015
75. ↑ California Department of Health Care Services, "Health Insurance Portability and Accountability Act," accessed August 4, 2015
76. ↑ U.S. Department of Health and Human Services, "Health Information Technology," accessed August 8, 2015
77. ↑ U.S. Department of Health and Human Services, "Health Information Technology," accessed August 4, 2015
78. ↑ The Commonwealth Fund, "All-Payer Claims Databases: State Initiatives to Improve Health Care Transparency," September 2010
79. ↑ Governing, "More States Create All-Payer Claims Databases," February 4, 2014
80. ↑ APCD Council, "Frequently Asked Questions," accessed August 4, 2015
81. ↑ National Conference of State Legislatures, "Collecting Health Data: All-Payer Claims Databases," May 2010
82. ↑ 82.0 82.1 82.2 United Health Foundation, "America's Health Rankings," December 2014
83. ↑ United Health Foundation, "About the United Health Foundation," accessed July 27, 2015

v • e

State of Hawaii
Honolulu (capital)

|

Elections |

What's on my ballot? | Elections in 2026 | How to vote | How to run for office | Ballot measures

Government |

Who represents me? | U.S. President | U.S. Congress | Federal courts | State executives | State legislature | State and local courts | Counties | Cities | School districts | Public policy

Ballotpedia

About

Overview • What people are saying • Support Ballotpedia • Contact • Contribute • Job opportunities

* * *

Executive: Leslie Graves, Founder and CEO • Gwen Beattie, Chief Operating Officer

Communications: Alison Graves, Director of Communications • Carley Allensworth • Abigail Campbell • Sarah Groat • Nathaniel Harwood • Dillon Redmond
External Relations:  Geoff Pallay, Director of External Relations • Ken Carbullido, Vice President of Election Product and Technology Strategy • Ashley Fleming • Thomas Mardik • Hannah Nelson
Operations: Meghann Olshefski, Director of Operations • Amanda Herbert • Mandy Morris • Caroline Presnell • Kelly Rindfleisch
Tech: Matt Latourelle, Director of Technology Operations • Ryan Burch • Kirsten Corrao • Beth Dellea • Travis Eden • Tate Kamish • Margaret Kearney • Eric Lotto • Joseph Sanchez • Mary Susmitha

Contributors: Scott Rasmussen

* * *

Editorial Content

Josh Altic, Director of Content • Daniel Anderson, Associate Director of Elections & Data • Cory Eucalitto, Associate Director of Features • Ryan Byrne, Managing Editor of Ballot Measures • Mandy McConnell, Managing Editor of News • Doug Kronaizl, Managing Editor of Local Expansion • Abbey Smith, Managing Editor of Elections • Janie Valentine, Managing Editor of Law • Joel Williams, Managing Editor of Events • Joseph Greaney, Managing Editor of Policy • Andrew Bahl • Jaclyn Beran • Marielle Bricker • Joseph Brusgard • Emma Burlingame • Kelly Coyle • Jon Dunn • Victoria Edwards • Thomas Ellis • Nicole Fisher • Thomas Grobben • Brianna Hosea • Molly Kehoe • Tyler King • Glorie Martinez • Norm Leahy, Senior Editor • Nathan Maxwell • Brandon McCauley • Andrew McNair • Ellie Mikus • Mackenzie Murphy • Kaley Platek • Samantha Post • Adam Powell • Annelise Reinwald • Spencer Richardson • Victoria Rose • Briana Ryan • Myj Saintyl • Maddy Salucka • Emma Soukup • Alexis Thacker • Mina Vogel • Samuel Wonacott • Trenton Woodcox • Heather Yates