Hawaii health policy and prospects for the 2018 legislature

2018 started off with a panic-inducing nuclear false alarm and, while imminent death isn’t now on the horizon, the forecast doesn’t include a lot of effective health policy action.  Governor Ige, facing a serious primary challenge and little confidence from his erstwhile legislative colleagues, provided a State of the State speech that most panned as insubstantial.  It certainly lacked attention to health care, although, arguably, the emphasis on issues that would make Hawaii a more livable place – schools, jobs, and the environment – would support better health status.  Not incidentally, Hawaii lost some 13,500 residents in fiscal year 2017 who moved to more affordable states with better economic prospects.  30,000 have left since 2014-15.

The leadership of the state House, which re-organized at the end of 2017, continues to be challenged by factions and may have a hard time moving a disciplined agenda.  The shortage of Republicans in office (5 in the House, 0 in the Senate) doesn’t mean that Democrats have an evident common purpose.  It is also a truism that controversies are avoided in an election year.  One likely area of agreement is thwarting any policies coming from Washington.  The Governor’s biggest State of the State applause line came from drawing a distinction between the values of Hawaii and those of the Trump administration.

Health care and coverage issues always get a lot of legislative attention but will the legislature be able to address the priorities of the health care industry?  As confirmed at the recent State of Reform conference in Honolulu, Hawaii’s health care leaders have the following interests:

Health care cost growth

The Insurance Commissioner is increasingly strident with his prediction that insurance premiums will top $14,000 per person within 8 years. Since Hawaii’s Prepaid Health Care Act requires employers to cover the great majority of the premium, escalating health care costs result in wage trade-offs in a state where worker pay already falls short of the high cost of living.  This is a tough one for health policy makers in a small state with little control over big cost-drivers.

Workforce and access to care

Hawaii’s rural areas have doctor shortages, particularly for those covered by Medicaid and Medicare.  The model of care featuring a team of providers practicing at the top of their licenses is (mostly) well-accepted but there is a chasm between the concept and the reality, especially in transforming the small practices that dominate Hawaii’s primary care delivery system.  Access to dental care is challenging to people covered by Medicaid, whether children with good benefits but few willing providers, or adults who have no meaningful benefits.  Legislators will continue the push for telehealth, which promises quicker access to specialty, behavioral health, and dental care, but may not be able to restore funding for Medicaid dental benefits or progress with usually contentious licensing or scope changes.

Maintaining coverage

Thankfully, CHIP has been addressed by Congress but Hawaii’s virtually universal coverage could be eroded by the lack of an individual mandate.  Bills will be considered to shore up ACA provisions that are or could be threatened.

Payment reform that supports population health with special concerns for homeless individuals

Med-QUEST is trying to address this issue but it isn’t clear how the current conservative CMS will treat Hawaii’s waiver application or proposed amendments.  Addressing population health issues through the health care system is tough since standard clinical interventions don’t influence the socio-economic factors that affect health status.  Expect legislative attention in this area to focus on homelessness.