Thousands of Native Hawaiians could lose Medicaid eligibility and access to affordable, lifesaving care once the Trump administration’s new Medicaid qualifications take effect on January 1– all because the federal government, for over a century, has refused to federally recognize them as a group.
Under the “One Big Beautiful Bill Act,” people will need to prove they work, are in school, or volunteer at least 80 hours a month. Many Native American and Native Alaskan tribes have federal recognition, which establishes a clear government-to-government relationship and rights to self-govern. Federal recognition has meant access to such services as Medicaid and exemptions from these new eligibility requirements.
Native Hawaiians lack federal recognition and, therefore, are ineligible for those exemptions. There are roughly 160,000 Native Hawaiians on Medicaid.
“Excluding Native Hawaiians from Medicaid work requirement exemptions ignores more than 150 Federal laws affirming their unique political and special trust relationship with the United States,” Rep. Jill Tokuda, D-Hawaii, told The Emancipator in a statement. “Narrow tribal definitions should not determine who gets health care.”
More than 680,000 Native Hawaiians live in the U.S. according to the 2020 Census, with most Native Hawaiians living in Hawaii, California, Washington, Nevada, Texas, and Oregon. Although most Native Hawaiians live on the mainland, the majority of Native Hawaiians and Pacific Islanders in the U.S. who are on Medicaid live in Hawaii, according to a KFF analysis of 2024 population data. Not all Pacific Islanders are Native Hawaiians; however, most analyses on Medicaid usage do not distinguish between Pacific Islanders and Native Hawaiians.
The Roots of a Modern Double Standard
This political double standard is rooted in the long and complicated history with the U.S. government, which colonized Hawaii and the Native Hawaiian people.
In 1820, American missionaries sought to convert Native Hawaiians to Christianity. They soon realized Hawaiian land was good for growing sugar cane, and investors arrived quickly after and started snatching up land.
By 1875, the settlers successfully pushed for Hawaiian trade to be tied to the U.S. economy through the Treaty of Reciprocity. This treaty established free trade and boosted sugar sales for the Hawaiian Kingdom; however, American businessmen exploited their economic influence to gain political control over the islands and eventually coerced the Native Hawaiians into joining the union against their will.
In 1887, a group of White businessmen called the Hawaiian League partnered with the militia, the Honolulu Rifles, to force King Kalākaua at gunpoint to sign a new constitution that stripped him of his power and revoked the rights of Native Hawaiians. It also replaced the Native Hawaiian cabinet with White politicians and businessmen. The constitution came to be known as the Bayonet Constitution since King Kalākaua signed it under duress.
Robert Kalanihiapo Wilcox of Maui was one of many Native Hawaiians to organize protests and acts of resistance against the American colonizers. In response to the Bayonet Constitution, Wilcox launched an armed insurrection to overthrow the agreement and the White politicians who wielded political power over the islands.
The insurrection failed, and the “Committee of Safety” – a group of U.S. Businessmen and politicians who wanted to take advantage of the sugar industry in Hawaii – seized the Hawaiian Kingdom in 1893. They staged a coup and kept the queen hostage until the Native Hawaiians gave up their land.
In 1897, Queen Lili’oukalani organized a massive petition against the annexation of Hawaii, and 21,269 Native Hawaiians signed it. Although unsuccessful, when Hawaii was later annexed in 1898, as an act of protest, Queen Lili’oukalani refused to attend the annexation ceremony where the Hawaiian flag was lowered and the Stars and Stripes was raised. Hawaii officially became the 50th state in the Union on August 21, 1959.
Since then, many Native Hawaiians have continued to call for federal recognition and a reclamation of the lush island lands which are culturally significant to Native Hawaiian practices and traditions.
According to Ka’opua, a Kanaka Maoli (Native Hawaiian) scholar and expert in Native Hawaiian social movements, the definition of sovereignty looks different to many Native Hawaiians.
“From that point, there were really two parallel streams of the movement,” Ka’opua previously told Voice of America. “One is seeking more of a nation within a nation, that is, federal recognition status. The other is asserting the claim for a country independent from the United States.”
From Colonization to Current Health Crisis
As the debate on Native Hawaiian sovereignty continues, Native Hawaiians still experience significant health disparities similar to other indigenous groups in the U.S., like Native Americans and Native Alaskans.
Native Hawaiians face some of the highest rates of obesity, diabetes, cardiovascular disease, and depression, according to research conducted by public health professor Lorinda Riley at the University of Hawaii.
The research examines the link between Native Hawaiian health disparities and historical trauma, stemming from the colonization and overthrow of the Hawaiian Kingdom. Riley defines historical trauma as the “cumulative emotional and psychological wounding over the lifespan and across generations, emanating from a massive group trauma event.”
To properly address this historical trauma, Native Hawaiians need appropriate health care and resources to conduct further research and make systemic changes, according to Riley.
The new Medicaid eligibility work requirements and a lack of exemptions for Native Hawaiians could further health disparities.
Geographic locations of hospitals in Hawaii make it difficult for Native Hawaiians to receive proper care. Many Native Hawaiians have to take planes from smaller islands like Kauai to Oahu since there is less infrastructure, fewer doctors, and fewer hospitals on the less populated islands.
Local health providers worry about barriers such as funding transportation costs between the islands or from rural areas to urban centers for care.
Typically, Medicaid helps support those costs.
According to a 2024 analysis by Forbes, Hawaii has one of the highest costs of living in the nation. This, coupled with a high rate of homelessness due to a lack of affordable housing, will make complying with the new Medicaid rules especially challenging, experts fear.
“Generations of dispossession and forced assimilation have left Native Hawaiians facing severe health and economic disparities,” Tokuda said in a statement.
“Instead of closing those gaps, Republicans are dismantling decades of Federal progress and widening them. I will keep fighting to reverse these barriers, close the safety-net gap, and ensure the Federal Government fulfills its trust responsibility to Native Hawaiians.”
