More than a decade ago, when I was practicing medicine on the Big Island, a young woman in her 30s walked into my clinic. I was startled by her appearance. She was emaciated, weighing less than 90 pounds, and her skin was an unnatural yellow-orange color.
She was also very weak, on the verge of collapse, and I knew immediately that she was gravely ill. We brought her into a private room, and when I examined her wasted body, I could feel multiple tumors in her abdomen and pelvis.
She confided in me that she hadn’t seen a doctor in years because she couldn’t afford insurance, and had lost faith in a system that made it so difficult to get care. She had turned to people with no training for medical advice, who recommended unproven treatments that did nothing to treat her illness.
Through years of missing routine women’s health exams like Pap smears and pelvic exams, she had failed to catch an aggressive cervical cancer early. The tumors had spread throughout her body, blocking her kidneys and sending her into renal failure.
That day I got her basic emergency coverage. The next day, tests confirmed she had cancer that had spread to her vital organs and bones, and I admitted her into hospice care. Her platelet count had fallen so low that her blood couldn’t clot properly, and three weeks later she died from blood loss during her menstrual cycle.
I have never forgotten her. As a physician who spent more than two decades in emergency rooms, I have seen too many tragedies that began with one simple fact: someone could not afford basic health insurance, so they went without primary medical care and skipped the checkups that could have saved their lives.
Today, as governor of Hawaii, I carry those patients with me. That is why I have included $16.5 million in my proposed 2026 state budget to protect Hawaii families from a looming national health care disaster that threatens to strip insurance coverage from thousands of our people: expiration of the Affordable Care Act’s enhanced premium tax credits at the end of 2025.
These enhanced tax credits, in place since 2021, are the reason millions of Americans can finally afford decent coverage through the ACA marketplaces. If Congress allows them to expire, more than 4 million people nationwide are projected to lose their health insurance. Average premiums on the exchanges will jump by more than 75%, with some states seeing premiums more than double. Hospitals and clinics will lose more than $30 billion in revenue per year, uncompensated care will soar, and state economies will shrink by over $40 billion while more than 300,000 jobs disappear nationwide.
Those aren’t just numbers. When people lose insurance, they delay care. They skip cancer screenings and diabetes checkups. They stretch medications or stop taking them altogether. They wait until a stroke, a heart attack, an asthma crisis or a complicated infection forces them into the emergency room, where the care is more expensive, the outcomes are worse, and the financial fallout can last a lifetime. That is the real human cost of letting these subsidies end.
Right now, more than 24,000 Hawaii residents get their health coverage through the ACA marketplace, with 83% of them relying on federal subsidies to make that coverage affordable. If the enhanced tax credits expire, the average premiums for plans on our exchange are projected to jump by 32%. For many families, costs could more than double.
In Hawaii, as many as 8,000 people could lose coverage or drop their plans altogether because of the cost increase. As many as 1,500 jobs could be lost, primarily in health care and related sectors, because of reduced spending and higher uncompensated care. Our state economy is projected to shrink by approximately $150 million as federal dollars disappear, health spending falls, and local businesses feel the downstream effects.
Faced with this cliff, we have a choice. We can wait and hope for Congress to do the right thing, or we can act to protect our people.
In our state, we are choosing to act. The $16.5 million in our budget will cover the cost of these enhanced ACA tax credits for everyone here currently using them to buy insurance — to keep coverage affordable for our families, seniors and children.
Economically, this is a smart investment. For a fraction of the $150 million loss we expect if the subsidies lapse, we can keep thousands of our residents insured, stabilize our hospitals and clinics, and prevent job losses in one of our most important sectors. We can avoid a spike in uncompensated care that would otherwise be shifted onto hospitals, insurers, and ultimately every premium-paying household and business in the state.
Socially, it supports hard-working people who do not have employer coverage and do not qualify for Medicaid. Many are self-employed, work in tourism, agriculture, or small businesses, or juggle multiple part-time jobs. They are exactly the people we say we want to help stay healthy and productive.
I know what it looks like when families are forced to make impossible, heartbreaking choices.
A mother once confided in me as her doctor that she only gave her daughter asthma medicine half as often as recommended, because she couldn’t afford to use the full dose and needed to make it last twice as long.
When I asked what they would do if their daughter got much sicker and couldn’t breathe, she told me that they would then decide as a family whether to go to the emergency room and pay that inevitable terrible cost, and be forced to skip paying the next months rent and ask for mercy from their landlord.
No family in America should be forced to make those intolerable choices. Yet if the enhanced ACA tax credits are allowed to expire, stories like this will become common. Not just in Hawaii, but in every state.
Congress should extend these subsidies nationwide. The data are clear, and public support crosses party lines. But until Washington acts, states will decide whether to stand by and watch their residents lose coverage, jobs disappear and their economies shrink — or to take action and live up to their values.
In Hawaii, we are choosing to protect our people. Our proposal to sustain the enhanced ACA tax credits is not just a line item in our budget. It is a statement of who we are: a community that refuses to push our neighbors off a health care cliff when we have the power to pull them back to safety.
If we succeed, I hope our example can help lead the way.