Our average insurance costs put us 44th of the 50 states in what we pay for health insurance. That is because virtually all full time employees in Hawaii receive employer provided group insurance plans. Employers get a federal tax credit for providing this insurance offsetting the premiums the employers paid. And employees get the benefit not being taxed by the Feds on the benefit they receive from the employer's payments. Note: Republicans are considering eliminating the employer tax credit, and eliminating the employee exclusion for the benefit of employer paying share of medical insurance. Plans from other states do provide individual coverage, but the only competitors with HMSA for group plans are UHA, Kaiser, and United Healthcare. We are a small market so there is less competition. But most importantly is employers and physicians like HMSA because administration of payments and treatment approvals is relative to mainland plans, very efficient.