Geography Is Not a Billing Code

While the system attributes this to geography, it is fundamentally a pricing issue. This scenario occurs frequently in Hawaiʻi: a patient on Kauaʻi is referred to an endocrinologist, but none are avai

HHTF Staff · 2026-05-27

While the system attributes this to geography, it is fundamentally a pricing issue.

This scenario occurs frequently in Hawaiʻi: a patient on Kauaʻi is referred to an endocrinologist, but none are available on the island. In fact, 12 specialties are entirely absent from Kauaʻi, including allergy/immunology, neonatology, pediatric cardiology, endocrinology, pulmonology, rheumatology, pediatric gastroenterology, and pediatric hematology/oncology. The patient must travel to Oʻahu, incurring flight costs of $120 to $320 each way, in addition to appointment cost-sharing, lost wages, and parking expenses. Insurance typically does not cover travel costs, except for Medicaid patients who successfully complete the prior authorization process.

As a result, the patient pays more for the same care than an Oʻahu resident with identical insurance and diagnosis. Insurers do not recognize or reimburse these geographic expenses; they are treated as a consequence of the patient’s residence.

The Travel Cost Is Not Incidental

According to the UH Rural Health Research and Policy Center Transportation Report (June 2025), an inter-island flight in Hawaiʻi costs $120 to $320 one way . A round-trip for a specialty appointment ranges from $240 to $640 before any clinical care is received. For patients on Molokaʻi or Lānaʻi, where flight schedules are highly unreliable, cancellations or delays can lead to missed appointments and longer wait times for rescheduling in a specialty-limited environment.

Missing a specialty appointment for oncology, cardiology, or high-risk pregnancy is not a minor inconvenience; it is a clinical event with significant consequences. However, the system does not account for this as a cost; instead, it categorizes it as a missed appointment.

The Insurance Asymmetry Is the Design

According to the UH RHRPC Transportation Report, Medicaid is the only insurer that fully covers non-emergency medical transportation, including inter-island travel for appointments. Patients with commercial insurance are responsible for all out-of-pocket travel costs.

HMSA, Hawaiʻi’s largest commercial insurer with approximately 760,000 members, offers a benefit for inter-island travel for non-emergency care under specific conditions: the care must be unavailable on the home island, the service must be covered, the referring provider must initiate the referral, and prior authorization must be obtained before travel. This process does not ensure access; it applies prior authorization requirements to geographic barriers.

The prior authorization gate means a patient who has already established that their needed specialty does not exist on their island must still wait for a plan administrator to confirm that fact before the travel benefit activates. The AMA’s 2025 Prior Authorization survey found that 93% of physicians say prior authorization delays patient care, and 94% say it negatively impacts clinical outcomes. Applying that mechanism to travel for care that is structurally absent on the home island is not a coverage guardrail. It is a delay mechanism atop a gap.

Pregnant Patients Are Relocating

The clearest illustration of where this system breaks down is the experience of pregnant patients on neighbor islands. Some neighbor islands lack obstetric delivery capability or the neonatal support required for anything other than uncomplicated low-risk births. Pregnant patients facing higher-risk pregnancies are sometimes advised to relocate to Oʻahu weeks before their due date to be within range of the delivery and neonatal infrastructure they need.

According to Civil Beat’s January 2026 coverage of neighbor island healthcare access, most commercial insurers do not cover the cost of relocation, including extended housing on Oʻahu before delivery. In these cases, patients incur significant out-of-pocket expenses that Oʻahu residents with the same diagnosis and insurance do not face, despite following all required procedures.

This disparity is not an inherent feature of being an island state; it results from deliberate choices in insurance product design and coverage policies.

The Molokaʻi and Lānaʻi Problem Is Compounded

According to the UH RHRPC Transportation Report, Molokaʻi and Lānaʻi have the most unreliable air service among Hawaiʻi’s inhabited islands. There is no inter-island ferry from either island to Oʻahu, and the limited Maui-Lānaʻi ferry does not provide access to the specialist care needed. When flights are canceled, patients must re-enter the specialty appointment queue rather than simply rescheduling for the next day.

Molokaʻi’s population of approximately 7,500 is predominantly Native Hawaiian and experiences the highest rates of chronic disease, diabetes, and cancer in the state. The intersection of high disease burden and unreliable access to specialist care is a foreseeable outcome of a healthcare system that fails to account for geographic realities.

Patients requiring emergency transport from neighbor islands are taken to Oʻahu’s Level 1 Trauma Center by Hawaiʻi Life Flight, a private for-profit air medical service. While emergency transport addresses immediate scheduling issues, it does not eliminate financial risk or resolve the underlying gaps in access to preventive and chronic care.

The Math of What It Actually Costs

A Big Island resident referred to a specialist on Oʻahu, who typically spends $240 to $640 on round-trip airfare. They lose at least one day from work, childcare, or other responsibilities. If an overnight stay is required, hotel accommodations in Honolulu cost $150 to $300 or more. Additional expenses include ground transportation. For patients with chronic conditions needing quarterly visits, annual out-of-pocket costs can reach several thousand dollars, beyond standard cost-sharing.

An Oʻahu patient with the same diagnosis, the same insurance, and the same specialist pays none of those costs. The geography is the only variable.

The system treats these expenses as a cost of living on a neighbor island. In reality, it imposes an additional financial burden on patients who expect their insurance coverage to function the same way as that of Oʻahu residents.

This Is a Design Problem, Not a Geography Problem

According to UH RHRPC data, 30% of Hawaiʻi’s population lives in rural areas across six islands, which together represent 95.1% of the state’s land area. Insurance products are priced uniformly across the state, yet coverage varies by location. A product that costs the same but delivers different levels of access depending on the island is not truly uniform; it is a geographic pricing structure with a flat premium.

Addressing this issue requires clear policy decisions. Non-emergency inter-island travel for care unavailable on the home island should be covered without prior authorization. Insurers offering statewide products should ensure their networks provide equivalent access across all islands, not just comparable directory listings. The state should also include travel costs when assessing whether coverage meets adequacy standards.

Geography will remain constant. The key question is whether the system will be redesigned to address these realities or continue to overlook their impact on the value of insurance coverage.

David Isei is the Executive Director of the Hawaiʻi Healthcare Task Force and Architect of the Hawaiʻi Healthcare Intelligence Platform (HHIP).