After years of effort by Health Care for All Hawaii, spearheaded by the late Ah Quon McElrath and Jory Watland, the Hawaii Legislature passed a bill in 2009 (Act 11 2009) to create the Hawaii Health Authority (HHA), a 9-member board appointed by the Governor, charged with designing a “universal health care system covering everyone in the state.” The HHA includes 3 members appointed directly by the Governor, 3 from a list submitted by the President of the Hawaii Senate, and 3 from a list submitted by the Speaker of the House. The HHA was to report to the Legislature with actionable legislation by January 2011, but our then Republican Governor Linda Lingle vetoed the bill. The Democratically controlled legislature overrode her veto, but she refused to appoint the HHA Board and the law languished.

This session, the Hawaii Legislature passed a bill to extend the reporting date for HHA to January 2012. Our current Democratic Governor Neil Abercrombie was a co-sponsor or HR 676 (House single-payer bill) when he was our Congressman. On September 1, 2011 he hired Beth Giesting as his Health Transformation Coordinator, and he appointed the Hawaii Health Authority.

The HHA “shall be responsible for overall health planning for the state and shall be responsible for determining future capacity needs for health providers, facilities, equipment, and support services.”

“The authority shall develop a comprehensive health plan that includes:

1) Establishment of eligibility for inclusion in a health plan for all individuals;

2) Determination of all reimbursable services to be paid by the authority;

3) Determination of all approved providers of services in a health plan for all individuals;

4) Evaluation of health care and cost effectiveness of all aspects of a health plan for all individuals; and

5) Establishment of a budget for a health plan for all individuals in the state.

The authority shall determine the waivers that are necessary and available by federal law, rule, or regulation that are necessary to implement and maintain this chapter.”

The members are:

Nathan Chang, MSW (UH School of Social Work)

*Ritabelle Fernandes, MD (internist and geriatrician at KKV and KPHC, two community health centers serving the Medicaid population)

*Reynaldo Graulty (former state senator, insurance commissioner, and judge)

*Stephen Kemble, MD (internist and psychiatrist, working in both private practice and at Queen Emma Clinic, serving a Medicaid population)

S. Peter Kim, MD (child psychiatrist)

*Lawrence Miike, MD, JD (former Director of Health)

Marion Poirier, RN (Director of National Alliance for the Mentally Ill – Hawaii)

*Wendy Schwab, DDS (Dentist and single-payer advocate from Maui)

*Jory Watland (Former director of Kokua Kalihi Valley, community health center, and Director of Health Care for All Hawaii)

Of these, 6 are active members of Health Care for All Hawaii (*), and the others are likely to be supportive of the same goals.

The 2011 legislature also passed a bill to create a separate 9-member Hawaii Health Insurance Exchange Board, also appointed by the Governor. This Board is dominated by representatives of the health insurance industry. I had a meeting with the Governor in March 2011 during which we discussed the importance of giving the HHA primary authority over health care reform and ensuring that the work of the Health Insurance Exchange Board would be subordinate to the HHA, following Vermont’s bill. The first choice would be to implement a single-payer plan in lieu of the exchanges if we can get the necessary waivers, or if we can’t then we need to make sure the exchange is implemented in a way that would be a stepping stone to single-payer when we do get the necessary waivers.

Hawaii may have an advantage because we already have a partial ERISA exemption, enabling us to keep our Prepaid Health Care Act from the 1970’s. The Hawaii Prepaid Health Care Act has allowed us to be the only State with an employer mandate prior to the PPACA. It requires employers to pay for health insurance with comprehensive benefits and a minimum 80% actuarial value to all employees working 20 hours a week or more. Hawaii’s commercial health insurance market is dominated by HMSA, a local non-profit BC-BS plan with around 70% market share, and Kaiser, a staff-model full-service HMO, with around 25% market share, plus a couple of smaller companies specializing in the small business market.

In the meantime, we have a shortfall in our Medicaid budget. Hawaii Medicaid was turned over to for-profit managed care companies during the last administration, and private-sector physician participation has dropped drastically. Hawaii’s DHS has reduced eligibility from 200% FPL to 133% FPL and capped benefits for GA and AFDC recipients (but not for ABD/QExA patients) at 20 doctor visits and 10 in-patient days per year. This will mean more uninsured and the sickest Medicaid recipients will be selectively targeted by the benefit limits. The damage will have to be undone as we move to a universal system.

Also, in 2009 the Hawaii Medical Association adopted my resolution supporting single-payer health care reform, although it was shot down at the Regional meeting of the AMA. I was subsequently elected Treasurer of HMA, I will be President-Elect in 2012, and President in 2013. From my position on the Executive Committee, I have been stirring up support for single-payer from within HMA.


Stephen Kemble, MD

Member, Hawaii Health Authority

Member, Health Care for All Hawaii and PNHP

Executive Committee, Hawaii Medical Association