Hawaii’s good health still leaves room for improvement

THE ISSUE An annual examination of the nation's health ranks Hawaii the fourth-healthiest state.

HAWAII earned a high score in recent ratings of health, ranked fifth among the nation's healthiest states. That could improve in the years ahead if, as projected, increased tobacco taxes result in a reduction of smoking. However, the report by the United Health Foundation raises questions about whether health care in the islands is worth its high cost.

Smoking is a category that received the most weight in the rankings, accounting for 10 percent of the score, and Hawaii's performance has been impressive. In 1990, 27.6 percent of the state's population were smokers, and that has improved to 17 percent, fourth-lowest in the country and significantly below the national average of 20.6 percent.

Hawaii's death rate from cardiovascular deaths is 230.9 per 100,000 population, lowest in the nation, which averages 326 heart-related deaths per 100,000. Cancer deaths per 100,000 in Hawaii are 159.8, nearly tied with Utah for the lowest rate.

The islands received high marks for having the second-lowest prevalence of obesity and being among the top five states for lowest frequency of residents feeling too mentally or physically ill to perform work or household tasks.

The report also credited Hawaii for its low rate of children in poverty -- 10 percent, compared with the national average of 17.6 percent -- and public health spending of $499 per person, leading the nation. However, those rankings may be skewed by the state's high cost of living.

While the poverty rankings are based on national poverty thresholds, the health risks of the homeless remain a problem. "I know we need to do something," Dr. Chiyome Fukino, the state health director, told the Star-Bulletin's Helen Altonn. "We can't keep up with spiraling valuations on homes."

Most troubling is an addendum to the report by Dr. Elliott S. Fisher, a professor at the Dartmouth Medical School. Fisher notes that the cost of $33,518 for inpatient and Medicare expenses during the two years preceding a person's death from chronic illness in Hawaii is among the nation's highest, but the quality of that care is next to lowest.

Research has found that greater use of discretionary "supply-sensitive" services such as hospital stays, visits and specialist referrals, he writes, "is, if anything, associated with slightly worse outcomes, poorer quality and lower satisfaction with care."

Fisher cites reports of "a weak negative association between spending and state-level average performance on Medicare's current measures of hospital quality." The reasons are unclear, he writes, "although a likely possibility is that the higher spending regions have more complex delivery systems (e.g. more physicians involved in a given patient's care), and greater complexity increases the chances of errors."