The Mirage in the Data: Why Hawaiʻi’s “Best Healthcare System” Rankings Miss the Point

Although national scorecards consistently rank Hawaiʻi as having the best healthcare, citing long life expectancy, low uninsured rates, and efficient healthcare spending, these metrics obscure significant challenges. Many families lack access to primary care, mothers are often required to deliver on other islands, and hospitals frequently face staffing shortages.

This contradiction is longstanding and originates from the limitations inherent in the data collection methods.

The Gap Between Surveys and Measured Outcomes

National rankings are based heavily on self-reported surveys, including the Behavioral Risk Factor Surveillance System (BRFSS) and the Pregnancy Risk Assessment Monitoring System (PRAMS). These instruments rely on phone and mail responses, which systematically exclude individuals experiencing housing instability or working multiple jobs.

In 2022, PRAMS contacted more than 2,400 new mothers in Hawaiʻi and received approximately 1,300 responses. The responses of non-participants were statistically weighted into the results as if they had participated. However, algorithmic adjustments cannot replace perspectives that were never captured. The omitted individuals are predominantly low-income and rural families, who are also most likely to face barriers to care.

In contrast, objective data sources such as death certificates and hospital records reveal more troubling outcomes. Hawaiʻi’s maternal mortality rate is 26.3 deaths per 100,000 births, and infant mortality is 5.8 per 1,000 live births, both of which slightly exceed the U.S. average. Suicide rates are also higher than national norms. These outcome-based indicators directly challenge the narrative of Hawaiʻi as having 'The Best Healthcare.'

Poverty on Paper and Poverty in Practice

A significant portion of this distortion stems from the way poverty is defined.

The Federal Poverty Level (FPL)—the standard for all these surveys—is nearly uniform across the nation. In 2024, a family of four is considered “poor” if its income is $31,200 or less. Hawaiʻi gets a small 15 percent adjustment, raising that threshold to about $35,900.

However, a family of four in Honolulu typically requires $120,000 to meet basic expenses. National definitions classify such a family as 'middle class,' yet in practice, they remain at risk of eviction after a single missed paycheck.

This mismatch distorts every statistic related to poverty. Programs and datasets categorize Hawaiʻi as a prosperous state based solely on higher nominal incomes, despite the fact that these earnings have less purchasing power than anywhere else in the country.

Why Corrective Sampling Fails Here

National surveys attempt to address under-representation by oversampling high-poverty census tracts. However, Hawaiʻi’s distinctive geography and housing patterns undermine the reliability of this corrective approach.

Hawaiʻi does not have large, homogenous low-income areas; instead, it features mixed-income communities, such as apartment buildings for service workers located next to multimillion-dollar homes. When a tract is designated as 'poor,' surveys frequently reach stable, higher-income households within that area. Although the mathematical adjustments may appear valid, the experiences of the most vulnerable residents remain unrepresented.

Insurance Is Not Care

Hawaiʻi’s high ranking for insurance coverage conceals the state’s most significant challenge: limited healthcare capacity. Although coverage is nearly universal in theory, actual access to care remains inadequate.

Maui and the neighbor islands exemplify these challenges: insured mothers must travel to Oʻahu to deliver, patients wait months for specialty care, and hospitals operate with minimal staff. Possessing an insurance card does not guarantee access to a physician. Furthermore, Hawaiʻi’s long life expectancy does not necessarily reflect a superior healthcare system; it is influenced by demographic and migration patterns. The state’s Asian-majority population already has one of the longest life spans globally, independent of healthcare models. Additionally, the islands attract healthy retirees and send individuals with serious illnesses to mainland hospitals. Consequently, the data favor those who arrive in good health and overlook those who must leave to access necessary care.

From Illusion to Adequacy

Current scorecards emphasize stability over capacity and focus on insurance coverage rather than the actual ability to deliver care. To accurately assess system health, rankings should incorporate adequacy metrics that capture:

• Provider-to-population ratios by specialty and region.

• Wait times for appointments and inter-island transfers.

• Numbers of skilled-nursing-facility beds and maternity wards.

• Workforce retention, burnout, and turnover.

• Cost-of-living–adjusted reimbursement levels.

Conclusion: Measuring What Matters

Hawaiʻi’s designation as the 'healthiest state' is a statistical illusion, reflecting only those who respond to surveys, those with the means to remain, and those who survive long enough to be counted.

If future health rankings are to reflect reality, they must measure system adequacy rather than coverage illusions. A state is not healthy because of its paperwork; it is healthy when its residents can access care any day, on any island, without needing to leave home to survive.