Category: SCII State Profiles Tags: Hawaii, Disability Policy, Community Integration, Olmstead, HCBS, Disability Rights, SCII 2026, State Profile, Independent Living, Policy Analysis, Chronic Homelessness, Subminimum Wage Elimination, Forensic Psychiatric Care
Introduction
Hawaii presents a distinctive inversion of the typical institutional-burden story: its Medicaid HCBS system is genuinely strong by national standards — a zero-waitlist I/DD waiver, a consumer-directed option, and full elimination of subminimum wage — yet the state carries one of the nation’s highest per-capita chronic homelessness burdens and a state psychiatric hospital system that has effectively become an extension of the criminal justice system, admitting only forensic patients. The result is a state that scores well on the infrastructure it has built for people already connected to Medicaid HCBS, but shows real gaps in the safety net for those who fall outside it.
2026 SCII Score Card
| Composite Score | 67 / 100 |
| National Rank | Part of the 2026 rolling expansion — see the full ranking on the SCII Data Analysis page |
| Tier | 🟡 Tier 2 — Progressing |
| Active DOJ Olmstead Action | None identified |
| Olmstead Plan Status | No current, comprehensive, binding Olmstead Plan identified |
| Judicial Posture | Neutral/Protected — Ninth Circuit, no narrowing precedent |
| Data Current As Of | 2026 (source data dated 2015–2025) |
Domain Scores
| Domain | Score | Notes |
|---|---|---|
| Institutional Population Burden | 11 / 20 | State hospital population entirely forensic (one of two states nationally); 2,720 chronically homeless individuals (2024), 62% reporting a disabling condition |
| HCBS Infrastructure | 16 / 20 | Zero waitlist for the DD/ID Medicaid waiver, confirmed independently by state DDD and KFF’s 2025 national survey; Consumer-Directed option available |
| Olmstead Compliance | 8 / 15 | No current comprehensive Olmstead Plan identified; no active DOJ enforcement found; Ninth Circuit posture neutral-to-protective |
| Criminal Justice Diversion | 11 / 15 | Hawai’i CARES 988 answers 94% of calls (~9 second wait); statewide Crisis Mobile Outreach; pre- and post-booking jail diversion; Mental Health Court since 2005 |
| Housing & Economic Self-Determination | 12 / 15 | Eliminated subminimum wage via SB793, effective June 2021; "Going Home Plus" supportive housing initiative; 2017 CIE rate (43%) is dated |
| Voice, Oversight & Civil Rights | 9 / 15 | Hawaii Disability Rights Center (P&A) facing a projected 44% FY2026 federal funding cut; Long-Term Care Ombudsman historically reduced to one staff person |
Critical Population Counts
| Setting | Count | Source |
|---|---|---|
| Nursing facility residents under 65 | Not separately reported by age (statewide NF population estimated at 3,000+ overall) | Hawaii Medicaid Long-Term Care Programs [via medicaidlongtermcare.org] |
| State psychiatric hospital census | Entirely forensic population; exact current census not separately confirmed | Hawaii DOH Adult Mental Health Division, FY2024-25 Block Grant Plan [1] |
| ICF/IID residents | Not separately reported (17 licensed ICF/IID facilities statewide) | Hawaii DOH Office of Health Care Assurance [3] |
| Estimated incarcerated adults with serious mental illness | Not separately reported for Hawaii | — |
| Chronically homeless adults with disabilities | 2,720 individuals statewide (2024 PIT count, down from 3,355 in 2023); 62% of surveyed homeless individuals reported a disabling condition | Hawai’i statewide Point-in-Time Count via Spectrum News Hawaii [4]; Hawai’i Health Data Warehouse [5] |
| HCBS waiver waitlist (I/DD Medicaid Waiver) | 0 individuals waiting (2025) | Hawaii DOH Developmental Disabilities Division [6]; confirmed by KFF’s 2025 national survey [7] |
Three Strengths
1. Zero-waitlist HCBS infrastructure with self-direction. Hawaii’s DD/ID Medicaid waiver carries no waiting list, a claim independently confirmed by both the state DDD [6] and KFF’s 2025 national survey of HCBS waiting lists [7], and the state offers a Consumer-Directed option letting participants manage their own care workforce [8]. This puts Hawaii in a small tier of states where formal HCBS access is not gated by years-long queues.
2. Full statutory elimination of subminimum wage. SB793 (2021) repealed Hawaii’s Section 14(c) exemption outright, requiring full minimum wage for workers with disabilities [10][11] — a legislative commitment that predates the now-withdrawn federal DOL rule to phase out 14(c) nationally, and one that only a small number of states nationally have made.
3. A responsive, high-performing crisis line paired with real diversion infrastructure. Hawai’i CARES 988 answers 94% of calls with roughly a nine-second average wait and guarantees rerouting rather than drop-offs [13], backed by Crisis Mobile Outreach and both pre- and post-booking jail diversion programs that a 2023 news investigation credited with diverting "scores" of people with mental illness from incarceration [14][16].
Three Critical Gaps
1. A state hospital system that has effectively exited civil commitment. With the Hawaii State Hospital population entirely forensic [1][2], Hawaii appears to lack a functioning civil psychiatric hospital safety valve — meaning acute psychiatric crises that in other states might route to a civil bed instead pass through police contact, the ER, or incarceration before reaching treatment.
2. Among the nation’s highest chronic homelessness burdens for people with disabilities. 2,720 people were chronically homeless in Hawaii’s 2024 count, with the majority of the state’s broader homeless population reporting a disabling condition [4][5] — a housing and disability crisis operating at a scale most mainland states of comparable population do not face.
3. A long-term care ombudsman program that has been critically understaffed. A 2015 state reorganization reduced Hawaii’s LTCOP to a single staff member statewide, reportedly the only program of its kind nationally staffed that thinly, undermining the independent oversight function this domain weighs directly [Hawaii State Legislature HB610 HD1, 2018].
Key Insight
Hawaii illustrates a pattern this Index is specifically built to catch: strong formal Medicaid HCBS infrastructure and progressive labor policy (zero waitlist, self-direction, full 14(c) elimination) can coexist with severe, unaddressed institutional burden that simply doesn’t run through the traditional nursing-home/ICF pipeline the disability-policy field usually measures. In Hawaii’s case, that burden has migrated into chronic homelessness and a forensic-only psychiatric hospital system — both of which represent people with disabilities effectively institutionalized or left without any non-institutional safety net, just not in the settings most state scorecards are built to count. A state can score well on "HCBS access for people already in the system" while performing poorly on "keeping people out of institutional and quasi-institutional settings in the first place," and Hawaii’s composite score reflects exactly that split.
References
[1] Hawaii Department of Health, Adult Mental Health Division. (2023). FY 2024-2025 Mental Health Block Grant Plan (Draft for Public Comment). https://health.hawaii.gov/amhd/files/2023/08/HI-MHBGApp_DRAFTforPublicComment.pdf
[2] Becker’s Behavioral Health. States with the highest ratio of state psychiatric beds by population, citing Treatment Advocacy Center data. https://www.beckersbehavioralhealth.com/behavioral-health-news/states-with-the-highest-ratio-of-state-psychiatric-beds-by-population/
[3] Hawaii Department of Health, Office of Health Care Assurance. Intermediate Care Facilities for Individuals with Intellectual Disabilities. https://health.hawaii.gov/ohca/medicare-facilities/intermediate-care-facilites-for-individuals-with-intellectual-disabilities/
[4] Spectrum News Hawaii. (2024, May 16). Point-in-time count shows rise in homelessness. https://spectrumlocalnews.com/hi/hawaii/politics/2024/05/16/point-in-time-count-shows-rise-in-homelessness
[5] Hawai’i Health Data Warehouse. (2023). 2023 Point in Time Counts. https://hhdw.org/na-2023-point-in-time-counts/
[6] Hawaii Department of Health, Developmental Disabilities Division. Medicaid I/DD Waiver. https://health.hawaii.gov/ddd/participants-families/waiver/
[7] KFF. (2025). A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2024. https://www.kff.org/medicaid/a-look-at-waiting-lists-for-medicaid-home-and-community-based-services-from-2016-to-2024/
[8] Hawaii Department of Health, DDD. Consumer-Directed (CD) Option. https://health.hawaii.gov/ddd/participants-families/consumer-directed-option/
[9] Medicaid.gov / Mathematica. (2023). Trends in Users and Expenditures for HCBS as a Share of Medicaid LTSS Spending (LTSS Rebalancing Brief). https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltss-rebalancing-brief-2023.pdf
[10] Hawaii State Legislature. SB793 CD1 (2021). https://www.capitol.hawaii.gov/session2021/bills/SB793_CD1_.HTM
[11] Epstein Becker Green, Wage & Hour Blog. (2021). Hawaii Repeals "Disability Subminimum Wage." https://www.wagehourblog.com/hawaii-repeals-disability-subminimum-wage
[12] The RespectAbility Report. (2019). 810 Hawaiians with Disabilities Leave the Workforce. https://therespectabilityreport.org/2019/03/23/hawaii-disability-employment-2019/
[13] Hawai’i CARES 988. https://hicares.hawaii.gov/
[14] Hawaii Department of Health, Adult Mental Health Division. Jail Diversion. https://health.hawaii.gov/amhd/jail-diversion/
[15] Hawaii State Judiciary. Mental Health Court (Circuit Court – First Circuit, Honolulu). https://www.courts.state.hi.us/special_projects/mental_health_court_oahu
[16] Hawaii News Now. (2023, January 25). This program has diverted scores of mentally ill people from jail to treatment. It’s also saved millions. https://www.hawaiinewsnow.com/2023/01/25/program-diverting-mentally-ill-defendants-treatment-instead-jail-wins-support/
[17] Hawaii Disability Rights Center. About HDRC. https://hawaiidisabilityrights.org/about-hdrc/
[18] Office of the Governor, State of Hawaii. Hawaii Disability Rights Center [funding request]. https://governor.hawaii.gov/wp-content/uploads/2025/10/Hawaii-Disability-Rights-Center_250000_OP.pdf
[19] Independent Living Research Utilization (ILRU). Directory of Centers for Independent Living — Hawaii. https://www.ilru.org/projects/cil-net/cil-center-and-association-directory-results/HI
[20] Hawaii State Legislature. HB610 HD1 (2018) [Long-Term Care Ombudsman staffing]. https://www.capitol.hawaii.gov/session2018/bills/HB610_HD1_.HTM
[21] Hawaii Long-Term Care Ombudsman. https://www.hi-ltc-ombudsman.org/
[22] Justia. 2025 Hawaii Revised Statutes, Title 26, Chapter 489, Discrimination in Public Accommodations. https://law.justia.com/codes/hawaii/title-26/chapter-489/section-489-5/
[23] Hawaii Civil Rights Commission. Discrimination in Public Accommodations. https://labor.hawaii.gov/hcrc/files/2013/01/DIS_pc_2016.pdf
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