Myra Williams, a breast cancer survivor, displayed a yoga posture behind her house in Kailua, Hawaii. Williams, 64, has lived in Hawaii for 35 years.

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The state’s system and also widespread insurance allowance coverage typical its residents are some of the nation’s healthiest.

Unequal Treatment

Hawaii’s trailblazing health care underscores disparity


Myra Williams, a breast cancer survivor, displayed a yoga pose behind her home in Kailua, Hawaii. Williams, 64, has lived in Hawaii because that 35 years. Much more photos

fourty years ago, the state ended up being the very first to call for employers to carry out health benefits.

By Noam Levey

Photography by Christina House

Reporting indigenous Honolulu


April 5, 2014

as soon as the large kapok and nawa trees the tower end the Queen’s Medical facility in downtown Honolulu were planted much more than a century ago, Hawaii faced a health crisis.

Many top top the islands, consisting of the queen who started the hospital in 1859, fear that indigenous Hawaiians, ruined by smallpox, measles and also other illnesses lugged by foreigners, were in risk of dying off completely.

Today, the people who go under this trees are some of the healthiest in America.


Hawaiians live longer than your counterparts on the mainland. They dice less commonly from common diseases, such as breast and colon cancers, also though these cancers occur an ext often below than in many other states. They likewise pay much less for their care; the state’s healthcare expenses are among the shortest in the country.

Hawaii’s success owes much to the state’s trailblazing wellness system and also its long history of near-universal health and wellness insurance.

Forty years ago, the state came to be the an initial to need employers to carry out health benefits, codifying a legacy that flourished out of Hawaii’s agrarian past, when sugar and pineapple plantations employed doctors to care for your workers.

That system has actually led to several of the greatest rates the coverage and best access to medical treatment in the country.

“There has constantly been a mentality below that if you room sick, you walk to the doctor. The just part of the culture,” claimed Myra Williams, 64, who has lived in Hawaii because that 35 years and was newly treated efficiently for early-stage chest cancer.

Nearly 99% of the patients at the cancer center at Queen’s have health coverage, a level unheard the at many urban medical centers ~ above the mainland.

Hawaii Healthcare

Obamacare is affecting the Hawaii healthcare system.

health care in America is a tale of two countries.

Residents that the healthiest areas live as lot as 14 years longer on typical than those in unhealthy places. They space a third less likely to die from treatable illnesses such as chest cancer, childhood measles and diabetes, according to data indigenous the commonwealth Fund, a foundation devoted to improving the healthcare system.

Big variations in poverty, education and also diet might explain part of this divide. In Hawaii, the huge share of residents of East oriental descent, who have actually lower mortality prices for many diseases, may additionally have an impact.

But distinctions in local wellness systems nationwide — consisting of disparities in insurance money coverage — likewise likely play an essential role, according to an evaluation of local and also national medical care data, a testimonial of scholastic studies, interviews v scores that experts, and visits come communities throughout the country.

Nearly anyone is extended in the country healthiest places, consisting of Hawaii, Massachusetts and also parts that the top Midwest. By contrast, fewer 보다 7 in 10 working-age adults have health insurance in components of Texas, Florida and the Deep southern — locations with some of the highest possible rates of death from preventable illnesses.

In Texas, which has the lowest price of insurance coverage in the nation, inhabitants are 40% an ext likely to die from chest cancer 보다 they are in Hawaii, according to commonwealth cancer data.

These disparities might grow also larger in coming years together the Affordable treatment Act is imposed unevenly around the country. Although the regulation offers claims the chance to insurance their occupants insurance, only about fifty percent the states have elected to execute so.


Ramona Engoring, left, sees Dr. Randall Suzuka for a checkup in ~ Haleiwa household Clinic in Haleiwa, Hawaii, in a landscape area the Oahu when covered with sugar cane plantations. Suzuka took end a former plantation doctor’s practice. an ext photos

In Hawaii, health and wellness insurance has actually reshaped healthcare, native the the smallest clinics to significant urban hospitals, affecting when patients room treated and also even exactly how they recover.

On Oahu’s phibìc Shore, a landscape stretch the Hawaii’s many populous island as soon as covered v sugar cane plantations, Dr. Randall Suzuka sees many of the regimen complaints typical to a ar physician’s office.

One morning at Haleiwa family Health Center, Suzuka, who has operated there since 1986, had tendency to an elderly woman having actually trouble sleeping, a municipal worker with a strained neck and a 10-month-old who had reduced her finger on broken glass.

But his office, originally opened up by a former plantation doctor, differs from plenty of medical methods in one crucial way: the rarely needs to discuss skipping treatment with a patience just because the human doesn’t have adequate insurance.

“It’s just not something we speak about,” said Suzuka, a fifth-generation Japanese American who family concerned work ~ above the plantations.

Nationwide in 2012, more than 4 in 10 working-age adult did not look for needed clinical care, skipped a recommended check or didn’t fill a prescription since of concerns around cost, follow to a inspection by the commonwealth Fund. Delayed treatment is even more common among uninsured adults, with two-thirds report they had put off a doctor’s visit or a prescription.

Insurance status can make a large difference in how soon cancers are found.

Uninsured women, because that example, space two and a fifty percent times as likely to it is in diagnosed v late-stage chest cancer as women who have actually private wellness coverage, follow to an American Cancer culture study.

In numerous parts the Hawaii, cancer screenings are easily available.

Kaiser Permanente, one of the state’s leading insurers, screens more than 80% the its standard members for chest cancer, amongst the highest rates in the nation. Kaiser is additionally stepping up initiatives to reach patients, v a mobile mammography van that travels around the mostly rural big Island the Hawaii.


Jul Lynn Parsons of Punalu’u, Hawaii, is examined by Dr. Clayton Chong during a consultation because that her ongoing chemotherapy treatment at the Queen’s Medical facility cancer center in Honolulu. much more photos

early detection and also early therapy — rarer in other parts that the nation — do cancer much easier to treat in Hawaii, claimed Dr. Clayton Chong, a senior oncologist in ~ Queen’s that trained in ~ the famous M.D. Anderson Cancer center in Houston.

Queen’s Cancer facility gets almost half of all new cancer patient in the state.

Many are favor Eric Martinson. The father of two young sons, Martinson, 51, to be diagnosed through lymphoma last summer after ~ his dentist uncovered an abnormal expansion in his jaw during a regimen cleaning.

The cancer was uncovered early, as is often the situation in Hawaii. Martinson was provided chemotherapy, and follow-up tests proved the cancer hadn’t spread out to any kind of organs.

To ensure Martinson was the end of danger, Chong brought him earlier in for a bone marrow biopsy.

“This might hurt a little,” Chong warned gently, as he rolled Martinson ~ above his stomach and also felt because that the ago of his pelvic bone. After clean the skin and injecting a neighborhood anesthetic, Chong hurry an awl-like tool right into Martinson’s back. Rocking the probe back and forth, he propelled it v the bone. Martinson groaned into a pillow.

“Do girlfriend know exactly how to count in Hawaiian?” Chong request to distract his patient. “How around backward?”

Chong closely pulled a nub the bloody marrow indigenous the pelvic bone and also smeared it on a glass slide. Subsequent experimentation showed no sign of cancer.

“I take into consideration myself really blessed,” Martinson said. The has since returned to work, his cancer in remission.

Hawaii’s extensive insurance coverage also allows Queen’s to inspect up an ext easily on patient after they end up treatment, i m sorry is crucial to avoiding a recurrence.

Queen’s is amongst a group of centers nationally that run so-called survivorship programs, which name: coordinates follow-up care for patients together they readjust to life ~ treatment.

The survivorship services at Queen’s are readily available at no price to patients. That would be daunting if the cancer facility had to serve an ext patients without coverage, said Darlena Chadwick, the clinical center’s evil president because that patient care.

“Insurance makes a difference,” she said.

The 40-year-old structure of the state’s system is the Hawaii Prepaid Health care Act. It requires carriers with an ext than 10 employees functioning at the very least 20 hrs a week to provide an easy health benefits.

But the law, i beg your pardon places more requirements on employers 보다 the federal legislation that president Obama signed in 2010, has actually not resolved all the state’s health problems.

Native Hawaiians and other Pacific Islanders, that are usually poorer, have far worse health outcomes despite efforts to address the disparity.

The state’s safety-net providers, consisting of clinics that offer low-income Hawaiians, still confront strains indigenous patients that can’t afford health coverage.

But even as the remainder of the country continues to fight over Obama’s law, there has actually been practically no talk in Hawaii about repealing the Prepaid Health treatment Act, even amongst business leaders.

“Like everywhere, employers have concerns around costs,” stated Sherry Menor-McNamara, president of the state room of Commerce. “But end the years, businesses have pertained to see the important affect of the law in boosting health.”

Widespread insurance coverage has had another, more intangible benefit, says Jennifer Diesman, an executive with Hawaii clinical Services Assn., the state’s dominant insurer.

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Unlike in countless states, wherein separate and also unequal medical systems care for the insured and also uninsured, “everyone right here uses the same doctors and the very same hospitals,” Diesman said. “It create a more egalitarian spirit.”

A similar consensus coagulation behind wellness reforms in Massachusetts, i beg your pardon in 2006 became the second state to create a mechanism for guaranteeing coverage. Massachusetts’ law was the version for the Affordable care Act.