The three years of COVID-19 were difficult for everyone, the health-care sector among those facing the harshest stress test. But even within that sector, the pain was not felt uniformly. The disconnect was jarring in some cases — such as at the Hawaii Medical Service Association, the state’s largest health insurer that at least officially is a nonprofit.

HMSA hasn’t behaved like a nonprofit in recent years — aside from reaping the benefits of its savings from state tax exemptions. And it’s time for state authorities to take another look at that nonprofit status.

HMSA’s top executives received generous raises and bonuses during the pandemic, upgrades unveiled Sunday in a comprehensive report by Honolulu Star-Advertiser writer Sophie Cocke. President and CEO Mark Mugiishi’s total compensation, including salary and bonus, increased from $2.5 million to $3 million, to cite just one example.

Additionally, the company’s board of directors voted to begin compensating themselves annually, for the first time in the nonprofit’s history. The highest-paid directors, prominent and well-paid Hawaii execs, got around $100,000 in 2022. According to the National Council of Nonprofits, the vast majority of board members of charitable nonprofits are unpaid volunteers.

On the austere side of this split-screen view, a total of 107 HMSA employees lost their jobs during a company restructuring last year, with 89 additional workers transferred to another company, or “rebadged,” to firms based in India and Maryland.

The topper in all this may be that, owing to HMSA’s particular nonprofit status, it pays no state taxes on revenue from its insurance premiums and is also exempt from certain financial transparency rules regarding board compensation.

In Hawaii, HMSA is organized as a nonprofit mutual benefit society, an entity that is subject to federal taxes, but gets tax relief at the state level. Like other independent companies in the Blue Cross Blue Shield federation, it lost its federal tax-exempt status when Congress passed the Tax Reform Act of 1986.

According to an Internal Revenue Service published analysis, Congress had decided that “the Blues” historically once operated in a way to further community benefit and social welfare. But “these plans had evolved to the point where many of the characteristics that distinguished them from the commercial insurance carriers were no longer apparent … there was no longer any justification for the continuing exemption.”

Arguably, that same case could be made at the state level here: How is HMSA any different? That case has been made in other states, such as California, where Blue Cross’ state exemption was revoked in 2014.

State Insurance Commissioner Gordon Ito told the Star-Advertiser that his office regulates insurance companies, including HMSA, but addresses more specifically their financial solvency, not tax status. It weighs proposals for premium rate hikes as well, he said, generally evaluating whether increases would be justified based on financial losses the company experiences and anticipates, going forward.

That said, though the frankly excessive payouts at the top of HMSA are not in current calculations by the Insurance Commission, someone at the state level ought to consider whether they fit a nonprofit — especially one as impactful as HMSA, which provides health insurance to at least half of the people of this state. Even more urgently, filings on compensations ought to be opened to the public, many of them ratepayers who deserve to know how or whether any “mutual benefit” justifies these salaries and bonuses.

This is not a new concern. In 2008, for instance, state House Concurrent Resolution 146, which was not adopted, called on the insurance commissioner’s office to initiate an investigation and corporate audit of HMSA.

Among its introducers: then-Rep. Josh Green, the House health chairman, now the governor.

And now, as then, consumer interest would be served by taking a closer look.