Buckle Up

Medicaid is changing. New rural health money is arriving on a clock. The state already says the Big Island blew them away. Four things every clinician can do now, and why this island should lead.

HHTF Staff · 2026-09-23

Buckle Up

What is coming, and why the Big Island should lead the state into it.

David Isei, MPH, MAOL, PMP · Executive Director, Hawaiʻi Healthcare Task Force

Here is what is coming, in plain terms.

The federal budget law passed last year changes Medicaid. In Hawaiʻi, Med-QUEST covers about 463,000 people. That is about one in three of us, including 152,000 children. Last October, a state official told our group that Med-QUEST had been moving to pay 150 percent of Medicare for all services in 2026 under its waiver, and that the federal law forced it to pull that back.

The same law created the Rural Health Transformation Program. Hawaiʻi's award, announced December 29, is $188,892,440. The first awards from it were announced on September 1.

Hawaiʻi's RHTP award $188.9M Announced Sept. 1: workforce $45M Announced Sept. 1: EMS $13M DIRECT Hawaiʻi's Rural Health Transformation Program award and the first announced awards: $45 million for workforce through the University's medical school and $13 million to the Department of Health for ambulances and emergency communications. Governor's office and engage.hawaii.gov/rhtp, re-verified September 2026. The national program runs from fiscal 2026 through fiscal 2030. So we are being asked to do two things at once. Absorb a cut, and spend new money well, on a clock.

The state already knows about the Big Island

At a public panel this month, the director of the Governor's rural health transformation office talked about Hawaiʻi Island. He traced its habit of taking charge of its own health planning back to a mayor's healthcare emergency declaration years ago, and to an organization built by, in his words, "people who just gave a damn, retirees who thought they could help their neighbor."

"When this opportunity dropped, the Big Island put together a bunch of ideas that blew us away."

That is our reputation. Now we have to earn it again.

The trap in the baseline

My co-author, a family physician in Kona, has been warning me about something that deserves its own report. She put it this way:

"Claims show care that happened. They do not show the stress echo that could not be obtained in West Hawaiʻi, the developmental evaluation that never occurred, the specialist referral that went nowhere, the child who never reached pediatric endocrinology, the patient who did not fly to Oʻahu, or the woman whose cancer workup stalled because a needed part of the pathway was unavailable."

Here is why that matters right now. New money and new payment models get built on what was spent before. When scarcity keeps care from happening, it keeps spending down too. If a budget is built on that history, it budgets the island for its own scarcity.

We will not let that happen quietly. The Big Island knows what it lacks. The job now is to write it down before the baselines are set.

What buckling up looks like

Four things. The Big Island is already doing every one of them.

Check the count. When we ask who is still practicing, answer.

Tell us about the care that did not happen. The referral that went nowhere. The flight the patient could not take. That is data too.

Show up for each other. For the storm, for the hearing, for the colleague whose clinic is on the line.

Bring someone who does not usually stand with you. The hospital. The foundation. The dentist. The nurse practitioner. The tax foundation. It has worked every time.

Why the Big Island

I work from Honolulu, and I will say it again. I give the credit to the Big Island.

It is fragmented. It is short on almost everything. People there disagree loudly and stay in the room anyway. And when it counts, it pulls together.

We have members of the Task Force who have already lost their clinics. They are still in the Task Force, because they believe in the fight.

That is the example for the rest of Hawaiʻi. Buckle up. Let's get to work.

Truth in the data. Care in the community.

Sources and data modes. MEASURED means computed by us from record-level data. DIRECT means published by a named authority. FIELD-VERIFIED means reported by the people doing the work, corroboration pending. Med-QUEST enrollment, about 463,000 including 152,000 children: Department of Human Services, Med-QUEST Section 103F-107 Report to the Legislature, April 2025. DIRECT.

Planned move to 150 percent of Medicare and its reversal: statement of a state health official to the Task Force, October 2025. Reported, not independently verified.

Rural Health Transformation Program award to Hawaiʻi, $188,892,440, December 29, 2025; first awards September 1, 2026: engage.hawaii.gov/rhtp and the Governor's release; The Garden Island, September 3, 2026. DIRECT, re-verified September 2026. National authorization FY2026 to FY2030 under Public Law 119-21.

Remarks of the director of the Governor's rural health transformation office: public panel, September 2026.

Baseline passage: my co-author's working draft of a Hawaiʻi Island scarcity baseline report, September 2026, quoted with permission.