Independent workers in Hawaii brace for skyrocketing health premiums

For Shelley Oats-Wilding, a former Olympian who now runs a Honolulu-based nonprofit teaching ocean sports and safety to youth, health care in the U.S. is a complicated mess.

Oats-Wilding, 60, runs the Ikaika Hawaii Watermans Academy and has for 14 years been on her own in securing health care coverage. She went through the Affordable Care Act marketplace to get it but has found it to be expensive.

At the start of this year, her rates went up to $1,200 a month from $900 a month and are set to rise again next year.

"The last two months, I've had to not pay myself," she said. "So I got out of the insurance because it was so expensive."

Through her church, she discovered Medi-Share, a health savings account pool funded by members who contribute monthly. The monthly contribution is much less, at just under $300.

Oats-Wilding is one among thousands of Hawaii residents who have struggled with obtaining health insurance without employer-provided coverage or being able to qualify for federal programs such as Medicare and Medicaid.

Hawaii has a low uninsured rate overall due to the state's Prepaid Healthcare Act of 1974, which requires private employers to provide health insurance for employees who work at least 20 hours per week for four weeks in a row.

But some still fall through the cracks.

An estimated 24 million Americans nationwide are enrolled in the ACA marketplace, often referred to as Obamacare, with the majority relying on federal subsidies to keep prices down. That figure includes an estimated 23,000 to 24,000 Hawaii residents.

Many are self-employed or contract workers, according to KFF, a nonprofit health policy think tank, which estimated about half of U.S. adults under age 65 are affiliated with small businesses. They include real estate agents, freelancers, nonprofit contractors, gig workers such as Uber and Lyft drivers, farmers and artists, who are bracing for a spike in premiums.

The debate over whether to extend the enhanced tax credits — approved as part of the American Rescue Plan Act in 2021 — led to a standoff between Democrats and Republicans in Congress and a historical 43-day government shutdown.

While the shutdown ended Nov. 12, an extension of those tax credits was not part of the deal. Congress is expected to vote on the issue in December.

The quest for coverage

KFF says ACA premiums are rising an average of 30% in 2026, regardless, for states such as Hawaii that use the federal healthcare.gov platform. This is due to an increase in hospital costs, Trump administration tariff policies and the rising popularity of expensive drugs like Ozempic.

Without an extension of the tax credits that are set to expire Dec. 31, however, KFF said enrollees can expect to see their monthly premiums more than double, depending on age, income and type of plan.

Sarah Fairchild, who works for the Duke Kahanamoku Foundation as an independent contractor, said she has been covered through the ACA exchange for about six years. Before open enrollment began Nov. 1, she went online to run some numbers and saw premiums at double the rate next year.

"It's going to go up, for sure," she said.

With those costs increasing, Fairchild may have to ask for a contract increase because the ACA exchange is, so far, the best option she is aware of for health insurance.

For Ashiya Carter, a professional dancer and teaching artist, searching for health care has been an endless quest.

Carter, 47, teaches creative dance and storytelling to kids from kindergarten to ninth grade through grants and fellowships. She previously lived on Maui and moved to Kauai three years ago.

In the early 2000s, prior to the passage of the Affordable Care Act, she worked at a nonprofit that provided health care to its employees. But when the nonprofit underwent restructuring, she became an independent contractor, and that's when she discovered how expensive it was to get health care.

Carter was in her 20s and in good health at the time, and decided to risk going without coverage.

"It was out of our price range," she said. "I knew there were health issues within my family. There was hypertension, there were heart issues, and I wanted to make sure I got my checkups but I couldn't afford it. I was banking on the fact I was in good shape."

Then she got pregnant and decided she could no longer risk being uninsured. Carter was able to get coverage through Med-QUEST, Hawaii's Medicaid program.

Today, Med-QUEST helps cover her family, including two children, but being on Kauai, she still finds it a challenge to find health care providers that take the insurance.

Without knowing the specifics, Carter also is worried about changes to Medicaid in 2027 and new work requirements. She generally works during the school year and not during summer.

Independent contractors

An estimated 30,000 to 40,000 Hawaii residents are potentially impacted by the changes that resulted from the passage of H.R.1, also known as President Donald Trump's "One Big Beautiful Bill."

Lance Owens, president of Hawaii Realtors, says real estate agents typically work as independent contractors and are on their own for health insurance.

Owens has been paying for his own insurance via Kaiser Permanente, footing a monthly cost of $1,160. Being based on Hawaii island, he has found Kaiser helpful when travel to Oahu is required for certain procedures such as MRIs.

Next month, he turns 65 and will be able to get coverage through Medicare.

In his younger years, he, too, risked going without insurance after quitting the corporate world, and by luck made it then without a major health disaster. He recalls, however, that his rates went up when Obamacare was instituted, so is not a fan of the program.

Hunter Heaivilin, advocacy director at Hawaii Farmers Union, did not have specific data on health insurance among the state's farmers but said it is a concern among members.

"During our outreach events, it has been brought up as a concern," he said, "and interest in some type of health care subsidy or support has been voiced a few times."

For farmers, income is often seasonal, with variability, Heaivilin said, so a provision that looks at annual income would allow more to qualify for Med-QUEST.

Ripple effects of increases

Health officials are concerned the ACA premium increases will result in people opting to go uninsured, which in turn puts pressure on hospital emergency rooms and potentially pushes up future costs for all patients, including the insured.

Holly Kessler, executive director of the Small Business Chamber of Commerce Hawaii, said the expiration of ACA tax credits for individual coverage in the islands is deeply concerning.

"These credits have made health care coverage affordable for many local residents, especially entrepreneurs and self-employed individuals who often lack access to traditional employer-sponsored coverage," she said in an email.

From a small business perspective, providing health care has been a challenge in Hawaii's high-cost environment, especially for employers that cannot claim a federal ACA small business health care tax credit due to a waiver.

Because the state's Prepaid Health Care Act, Hawaii has its own fund to help small business provide affordable coverage.

The chamber has partnered with Hawaii Medical Assurance Association to provide cost-effective group plans for its members.

Oats-Wilding, a two-time Olympian who competed for Australia in the women's kayak canoe sprint, loves what she does and believes in her nonprofit's mission. She considers health a priority, and continues to race and run marathons to stay in shape.

In her native Australia there is universal health care covering all Australians and permanent residents through a 2% Medicare levy on taxable income.

Instead of extending tax credits for the ACA, she likes the idea of money going directly to people for health care instead of through an insurance provider.

"I'm looking forward to reform," Oats-Wilding said.

Carter said she often thinks about how independent artists could work together to get health care coverage, as is offered by some unions for artists in other states.

"For most teaching artists, our pay isn't necessarily the best," she said, "but we love what we do, so we put ourselves out there to continue doing it."

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Hawaii's ACA marketplace at a glance

There are 23,000 to 24,000 Affordable Care Act enrollees in Hawaii, less than 2% of the state's population.

With federal enhanced subsidies, the cost of ACA health insurance is capped at no more than 8.5% of a person's income (less for lower incomes). Subsidies are set to expire Dec. 31.

Without federal enhanced subsidies, premiums for ACA health insurance could more than double.

Families with household incomes over 400% of the federal poverty line would no longer be eligible, leaving them with the full cost of their health insurance premium. In Hawaii, 401% over the poverty line is $72,140 a year for individuals.

In Hawaii, the projected increase without enhanced tax credits for a 60-year-old making 401% of the poverty line for a benchmark silver plan is about 125%, or $638 a month.

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Sources: State Department of Health, KFF