Q&A: Hawaii Sen. Stanley Chang on health care, housing, and bills this session

Sen. Stanley Chang represents Hawaii’s 9th Senatorial District, which includes the Honolulu neighborhoods of Hawai’i Kai, Kuli’ou’ou, Niu, ‘Aina Haina, Wai’alae-Kahala, and Diamond Head. Chang is chair of the Senate Committee on Housing and Vice Chair of the Senate Committee on Commerce, Consumer Protection, and Health.

For this interview, we talked to Chang about the ways health and housing intersect in Hawaii, how that’s reflected in legislation, and the biggest issues in health care this session.

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Sara Gentzler: You have a leadership positions on two committees that are integral to legislative action in health care. What bills or issues do you view as having substantial momentum this year? 

Stanley Chang: I think that there has been a long-term push to recognize the aging population of Hawaii. Kupuna Care has been an initiative a few years now, and there are efforts to expand the program to help address the needs of caregivers and elderly folks who need the care.

The real issue here is funding. You have these elderly folks who are unable to care for themselves. We’re finding that a lot of people are leaving the workforce to care for their elderly parents or other relatives. The purpose of Kupuna Care is to help people stay in the workforce by paying for care for these elderly folks.

The problem is, of course, the care is extremely expensive. At the end of the day, it’s just a calculation: Without over-burdening the taxpayers of Hawaii, how can we help these caregivers stay in the workforce or even just give respite for their elderly loved ones?

The answer, in terms of how much funding goes into this program and how much people can help, comes down to the budget process and all the other priorities out there. I think and I hope that the funding amount will be increased from last year, but we’re so far away from adequately filling the entire demand that any help will be a benefit.

There’s also a push, this year, to address a public health issue that I think is affecting Hawaii in a more severe way than the rest of the country, which is vaping. One of the really hot topics this year is the ban on flavored tobacco, a ban on those flavored vape liquids. I think, in Hawaii, the percentage of young people who are vaping is much higher than that of the rest of the country. This is a huge issue that we’re only just starting to tackle in a real way. The flavored liquid ban is a big part of that.

Finally, one of my big issues — and there’s quite a lot of movement this year — is mental health. We have a substantially higher suicide rate than the rest of the country. There’s a suicide prevention curriculum bill that’s still moving. And there’s a bill that allows adolescents, I think, to have anonymous mental health services, so their parents don’t know that it’s mental health that they’re being treated for.

Another aspect of mental health is the folks who are homeless on the streets. That’s the attention-grabber, but what I think is a huge crisis is just how pervasive mental health issues are across our community.

We all know people who have diseases. But, when I think of my circle of friends and people I know very well, almost everyone has some sort of mental health-related issues. Whether it’s depression, anxiety, eating disorders, substance issues — it’s just shocking to me how many people have some sort of mental health issue. And, I don’t know that the system, as a whole, has gotten around to that point. I think tides are turning, but I don’t know that they’re there yet.

SG: I’d love to hear more about mental health bills, in general. And, specifically, about efforts to improve the Assisted Community Treatment Law, so that it’s more helpful for people facing serious mental health issues — can you tell me a bit about that work and how that sort of change can be accomplished?

SC: Right now, let’s say you see somebody who has an extreme mental illness on the street, and you think they need to get care. It’s very hard to have someone receive care involuntarily.

The bill would make it easier to get somebody mental health care, even if they’re not consenting. I think it’s really necessary.

There have been various periods in our history with how our country deals with mental health. There have been periods when people are basically locked up. We’re kind of in the backlash of that stage, right now, where people have individual liberty and freedom.

If an adult chooses not to be committed or receive treatment, it’s a very, very, very high bar. One case that I always tell people about: In California, there was a woman who was so sick that she was eating her own feces. There was an effort to force her to receive care, and she did not want that. It went to court, and the judge found that, because the standard is ‘imminent harm to self and others,’ that it had to be dangerous to her life. Because she would not die from eating her own feces, treatment was rejected.

So, it’s a very, very high bar. There are good reasons for that — we don’t want to lock people up indiscriminately. But there has to be a balance.

SG: So that’s more to do with the Assisted Community Treatment Law. Are there other mental health bills you would highlight that seem to have momentum? Or maybe some long-term efforts at the beginning of this biennium?

SC: This is not necessarily a specific bill, but one of the things I find troubling is that one of the standards for mental health care, whatever condition it is, is that it has to affect your daily life.

What does that mean? It means being late to work, missing commitments with family, losing your job. Basically, the standard is: Your life has to be ruined by mental illness before we want to treat it.

I understand that people want to draw a distinction between being sad over getting dumped by a significant other versus other types of depression, but I actually think those lines are much less black-and-white than a lot of people believe.

I see a lot of friends struggle with a condition, and it doesn’t necessarily cause them to lose their job, but it still produces a lot of pain and misery to that person and to their families. I don’t know that we should just be O.K. with that as a society, where we just don’t think that’s a problem.

SG: I see mental health and housing overlapping in Hawaii, in particular. Do you see that overlap as a manifestation of a shifting focus on mental health?

SC: Yes, 100 percent. Housing and health care and public health are really, inextricably, intertwined.

I was in Vienna, where they have an excellent public housing program, elements of which we borrowed for our housing bill.

You have to understand where Vienna’s baseline was. After World War I, the empire collapsed. Conditions were extremely, extremely bad. We talk about a housing shortage today in Hawaii, or in D.C. for that matter — the housing shortage in Vienna was so acute that they weren’t just renting rooms, they were renting beds in rooms. And they weren’t renting a bed, they were renting one bed in eight-hour shifts. Space was so short, they did not have separate kitchens and bathrooms.

There was tons of contamination. All these epidemics — they were calling Tuberculosis ‘The Viennese Disease.’

All these issues, they’re not just medical issues. When the new government came in, they had to solve them by providing housing. You get your own bedroom, you can separate the toilet from the kitchen. You’re going to establish a much higher level of hygiene, which, in turn, is going to greatly improve mental and physical health of the entire population.

SG: Do you see that as how your ALOHA homes plan could ripple out and impact health care in Hawaii?

SC: I do. We no longer have the situation of Tuberculosis. We no longer have the situation of kitchens and bathrooms in the same place — for the most part. But, we do have new problems today.

Some fun facts about Hawaii: We have the highest percentage of people working two or more jobs in the country. We have the highest percentage of both parents working in the country. We, as a state, are waking up the earliest in the country. And we also spend some of the longest commute times, in traffic, in the country.

Do all of these factors contribute to public health issues, to mental health issues? Of course they do. If both parents are never home, does that impact the well-being of the kids who have no parental guidance for most of the year? Of course it does. It’s very common in Hawaii for people to wake up at 4 in the morning, then the kids fall asleep in the car, they get to school super early and then they sleep there before the school day starts.

Does that impact public health? Does that impact mental health? Of course it does. And all of these are extensions of the housing crisis that has produced the highest home prices in the country. That is the principal factor, I believe, in all of these trends that I just named.

The purpose of the ALOHA homes bill is to alleviate the housing shortage, so commutes can be greatly mitigated. You’re no longer going to have the commute times because people are going to be able to jump right onto public transit. They can get to school at a predictable hour. You’re going to have walkability, so people are no longer driving everywhere, which, of course, contributes to a lack of physical activity — which contributes to major public health consequences. You’re going to have families being able to spend much more time together, because they’re not going to have to commute. A preschool, a school, a senior center — all of these things will be in walking distance.

It’s going to have profound impacts on mental health, on public health. And, I don’t even know that people will be aware that that’s happening. It will be happening under this new proposal.

SG:  I saw that it passed the Senate. Do you think it has a shot at going all the way this session?

SC: I think there’s a very good shot.

I’ve spoken with my counterparts in the House. They’ve raised a number of excellent questions that we’ve been ironing out. It’s gone through the committee process here in the Senate.

Are there still outstanding issues, questions? Of course there are. But, our House counterparts are really talented, capable people. They have a lot of experience working with stakeholders, interest groups, and we’ve been working hand-in-hand for a month now to ensure that we’re all on the same page.

I’m really optimistic that they’re going to work hard and make the bill a better bill once it comes out of the House.

SG: Shifting back to health care. Is any of this action in housing and intersection between housing and health strengthened by the new availability of Medicaid dollars in Hawaii to fund efforts transitioning chronically homeless people into housing?

SC: That is a real game-changer.

I have to give a lot of credit to Lieutenant Governor, former Senator Josh Green. He’s been the real champion of the idea for years now. You probably know all about his story: He was an ER doctor. These frequent flyers would come in, literally consuming over $1 million dollars of health care services a year, and what they really needed was a home.

You can patch them up today and send them back to the street tomorrow. But if you’re homeless, your life expectancy goes way down — your alcohol and substance issues are greatly exacerbated. I read that the life expectancy of someone who’s homeless is in their fifties, or something.

The Medicaid waiver does not allow for funds to be used directly to pay for housing, rent, that sort of thing. But, it takes care of a lot of services that lead right up to the door of the actual rent itself.

It takes a lot of work to get somebody in the right mental frame to look for an apartment — to have placement services, counseling services. Once they do have all those services, they become a much more attractive candidate or recipient for these programs.

Another fun fact: You first have to wait, in many cases, up to 10 years to get a Section 8 rent-supplement voucher. But, even after you wait the 10 years, half of all those who’ve been awarded a voucher have to return the voucher because they can’t find a landlord who’s willing to rent to them.

All of these services are really important to get that formerly homeless person, that person who’s receiving treatment, to the point where they will be a good tenant and have a much higher likelihood of using a rent supplement like a Section 8 voucher or another program that can place them into a home.

All of it works hand-in-hand. If that 50-percent statistic gap is closed even a little bit, we’re talking about a lot of people. We’re talking about a huge impact.

Because it’s so new, we haven’t seen the effects of it yet, but I think this will be a very, very impact venture.

This interview was edited for length and clarity.