WAIANAE, Hawai\u2018i \u2014 Native Hawaiians will need to comply with new work requirements to qualify for Medicaid after being excluded from exemptions carved out for other Indigenous groups, an omission that clinicians fear will exacerbate the challenges the marginalized population already faces in getting healthcare.<\/p>\n
In 43 states and the District of Columbia<\/a>, President Donald Trump\u2019s signature One Big Beautiful Bill Act will require most adults to work, go to school or enter a training program, or volunteer for at least 80 hours a month. Native Americans and Alaska Natives are exempt from the mandates, which take effect in January.<\/p>\n Of the nearly 700,000 Native Hawaiians<\/a> in the U.S., around 47% live in Hawai\u2018i. Within the contiguous United States, California, Washington, Nevada, Texas, and Oregon have the largest populations of Native Hawaiians.<\/p>\n Hawai\u02bbi\u2019s Medicaid administrator, Meredith Nichols, said the Centers for Medicare & Medicaid Services didn\u2019t respond to the state\u2019s request to include an exemption for Native Hawaiians but said she believes the decision came down to the population\u2019s lack of recognition as a tribal nation. Hawai\u2018i has about 390,000 Medicaid enrollees<\/a>, 15% of whom identify as Native Hawaiian, Nichols said.<\/p>\n \u201cWe know that when we\u2019ve asked similar questions in the past, it all comes down to federal recognition,\u201d she said.<\/p>\n Hawai\u02bbi health administrators met with Trump administration officials in June. Some unsuccessfully pushed to add an exemption to the new law, which would need congressional approval.<\/p>\n White House spokesperson Kush Desai did not respond to requests for comment. In a statement, CMS spokesperson Timothy Foster confirmed that the agency met with 16 health centers in Hawai\u2018i about Medicaid changes but didn\u2019t respond to other questions.<\/p>\n Barriers to Care<\/strong><\/p>\n Native Hawaiians face many of the same health disparities<\/a> as Native Americans and Alaska Natives<\/a>, including higher risks during pregnancy, higher infant mortality rates, and higher rates of being uninsured than the white population. And in Hawai\u02bbi, Native Hawaiians have the second-lowest life expectancy<\/a> among ethnic groups after other Pacific Islanders.<\/p>\n Kapono Chong-Hanssen is the medical director of Ho\u2018\u014dla L\u0101hui, the Native Hawaiian healthcare system on Kaua\u2018i that also serves the privately owned island of Ni\u2018ihau, whose 170 full-time residents are predominantly Native Hawaiian. Chong-Hanssen said he anticipates many of his patients will no longer receive the care they need once the new work requirements take effect.<\/p>\n \t\t\t\t\t<\/p>\n \t\t\t\t\t\t\tChong-Hanssen says new Medicaid work requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients.\t\t\t\t\t\t (Ashley Mizuo\/KFF Health News)<\/p>\n \t\t\t\t\t<\/p>\n \t\t\t\t\t\t\tHo\u2018\u014dla L\u0101hui, the Native Hawaiian healthcare system on Kaua\u2018i, operates out of multiple locations, including its clinic in Waimea on the west side of the island. Kaua\u2018i and Ni\u2018ihau were impacted by Hurricane Lowell this week, forcing Ho\u2018\u014dla L\u0101hui to temporarily close facilities.\t\t\t\t\t\t (Ashley Mizuo\/KFF Health News)<\/p><\/div>\n<\/div>\n The new requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients, who, in response to historical disenfranchisement<\/a>, are more likely to disengage and \u201cthrow the whole system out\u201d when they run into barriers, Chong-Hanssen said. \u201cIt just flies in the face of everything that we\u2019re trying to do.\u201d<\/p>\n Beyond medical services, Medicaid covers transportation expenses when patients travel between islands for care. A round-trip ticket between Kaua\u2018i and O\u2018ahu, for example, can cost hundreds of dollars.<\/p>\n Congress placed over 200,000 acres of land in a trust for Hawaiian homesteads in 1921 to bring Hawaiians back to their native lands after the U.S. backed the 1893 illegal overthrow of the Hawaiian kingdom<\/a>. Nearly 30,000 Native Hawaiians are still waiting for land<\/a>, while, as of the 2020 census<\/a>, more than 34,000 people lived on Hawaiian homelands. The homesteads are often far from Honolulu, where most health services are located.<\/p>\n Waianae Coast Comprehensive Health Center primarily serves the west side of O\u2018ahu, which is home to the island\u2019s largest Native Hawaiian population, near four Hawaiian homesteads.<\/p>\n Waianae Coast Comprehensive Health Center CEO Rich Bettini (right) and Vice President Leinaala Kanana demonstrate how to use pods throughout the campus that connect patients via phone to an employee who will help them submit needed information and applications to the state\u2019s Medicaid program. (Ashley Mizuo\/KFF Health News)<\/p>\n The center\u2019s vice president, Leinaala Kanana, said that many of its patients are geographically isolated and that few jobs are available in the area. Patients also have trouble securing transportation to get to work or finding affordable childcare.<\/p>\n The center\u2019s CEO, Rich Bettini, said Hawai\u2018i\u2019s high living costs and depressed wages have pushed many people into homelessness, creating another barrier to complying with the new Medicaid requirements. Native Hawaiian and Pacific Islanders make up about 60% of O\u2018ahu\u2019s homeless population<\/a>. The center estimated about 2,800 of its patients may be affected by the requirements, half of whom are Native Hawaiian.<\/p>\n The annual \u201ccost of living for a family of four in Hawai\u02bbi on O\u2018ahu is $100,000-plus. The average income of our patients is under $30,000 a year,\u201d he said. \u201cThat is an enormous gap.\u201d<\/p>\n \u2018Bigger Fish To Fry\u2019<\/strong><\/p>\n Native Hawaiians face obstacles to being granted the same exemptions as other Indigenous groups. While several federal laws refer to Native Hawaiians as an Indigenous group, they are not among the 575 tribes recognized by the federal government. Federal recognition can be granted either by Congress or administratively through a process established by the Department of the Interior<\/a>. Native Hawaiians remain divided<\/a> about whether they would even want federal recognition<\/a>, with some fearing it would jeopardize their ability to restore Hawaiian independence.<\/p>\n Laws governing Medicaid also don\u2019t acknowledge Native Hawaiians, aside from the 2021 American Rescue Plan Act<\/a>, signed by former President Joe Biden. In the covid-era law, the federal government fully reimbursed Native Hawaiian health centers for Medicaid services for two years. However, all the qualifying Native Hawaiian health centers were in Hawai\u2018i, where fewer than half of Native Hawaiians<\/a> in the country now live.<\/p>\n The federal government fully reimburses Indian Health Service and tribal facilities for healthcare services provided to Native Americans and Alaska Natives. Native Hawaiian healthcare systems<\/a> instead receive the same reimbursement rate as in the rest of Hawai\u02bbi.<\/p>\n Waianae Coast Comprehensive Health Center CEO Rich Bettini said Hawai\u2018i\u2019s high cost of living and depressed wages have pushed many people into homelessness, creating another barrier for Native Hawaiians to comply with new Medicaid requirements. (Ashley Mizuo\/KFF Health News)<\/p>\n Keolamaikalani Dean, the CEO of the King Lunalilo Trust, which provides services for Native Hawaiian elders, pointed to the new Medicaid requirements as just one of many federal policies limiting Native Hawaiians\u2019 healthcare.<\/p>\n \u201cIt\u2019s horrible as a policy, but there are bigger fish to fry,\u201d he said.<\/p>\n Dean said he\u2019d rather advocate for giving Native Hawaiian healthcare systems the same full Medicaid reimbursement that the Indian Health Service receives. The change would have greater impact on patients seeking care, he said.<\/p>\n Native Hawaiian advocates said they have been overextended as they work to guard against an onslaught of threats to revoke other federal funding by the Trump administration.<\/p>\n In Trump\u2019s proposed 2027 budget, cuts to Native Hawaiian programs cited the group\u2019s lack of federal recognition as a \u201ctribal nation.\u201d The proposed cuts coincide with lawsuits from conservative groups<\/a> challenging Native Hawaiian<\/a> education programs and long-standing legislation<\/a> that provides homestead land to some Native Hawaiians at almost no cost, alleging the programs racially discriminate against other groups.<\/p>\n Papa Ola L\u014dkahi<\/a>, a nonprofit that oversees the Native Hawaiian healthcare systems in the state, declined to comment for this article. The group is involved in a lawsuit filed by a conservative group aiming to stop a university scholarship for Native Hawaiians pursuing healthcare careers.<\/p>\n U.S. Rep. Jill Tokuda (D-Hawai\u02bbi) viewed the exclusion of Native Hawaiians from the exemptions to Medicaid work requirements as an attempt to further erode Native Hawaiians\u2019 Indigenous status, pointing to recent challenges by the Trump administration and lawsuits.<\/p>\n \u201cThese are not one-offs,\u201d Tokuda said. \u201cThis is a targeted, coordinated attack to undercut the Indigenous status of Native Hawaiians.\u201d<\/p>\n<\/div>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/em><\/p>\n This article<\/a> first appeared on KFF Health News<\/a> and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License<\/a>.<\/p>","protected":false},"excerpt":{"rendered":" WAIANAE, Hawai\u2018i \u2014 Native Hawaiians will need to comply with new work requirements to qualify for Medicaid after being excluded from exemptions carved out for other Indigenous groups, an omission that clinicians fear will exacerbate the challenges the marginalized population already faces in getting healthcare. In 43 states and the District of Columbia, President Donald…<\/p>\n","protected":false},"author":0,"featured_media":15473,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-15472","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/15472"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=15472"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/15472\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/15473"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=15472"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=15472"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=15472"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}