Insurance Is Not Access: Hawaiʻi Needs to Stop Counting Healthcare It Cannot Deliver

You have insurance. Your doctor refers you to a specialist. The specialist is not on your island. The appointment is on Oʻahu. The airfare is yours. The missed work is yours.

HHTF Staff · 2026-06-10

You have insurance. Your doctor refers you to a specialist. The specialist is not on your island. The appointment is on Oʻahu. The airfare is yours. The missed work is yours. The hotel, if you need one, is yours. If the flight cancels, the wait starts over. The system will record you as covered. It will not record what access actually cost you.

That is the difference between insurance and access. Hawaiʻi has spent years measuring the first while too many families struggle with the second.

I hear it from members of our coalition every week. A kupuna in Kaʻū postponed a primary care visit because the nearest clinic was hours away and the next appointment was weeks out. A physician in Waimea told us she does not know whether her practice will still be open this time next year. Dr. Esther Smith, Vice President of the Hawaiʻi Healthcare Task Force, described a patient who waited eighteen months to see a rheumatologist on Oʻahu, and there is still no rheumatologist on her island who takes insurance.

These are not edge cases. They are the daily experience of too many families on every island.

The numbers confirm it. Of more than 12,000 licensed physicians in Hawaiʻi, fewer than one-third actively provide patient care, and the documented shortfall is 644 full-time physicians, rising to 833 when geography is taken into account. Dr. Kelley Withy of the John A. Burns School of Medicine, who has tracked Hawaiʻi's physician workforce for years, put it plainly: "If we don't have enough providers, it doesn't matter if we all have insurance. We can't get care."

That sentence should be the starting point for every healthcare reform discussion in Hawaiʻi.

On June 8, the Hawaiʻi Medical Service Association announced a six-month extension of its new primary care payment model. That extension matters. Physicians and nurse practitioners organized, patients spoke up, Governor Josh Green engaged directly, and more than 200 community members submitted public comments. The result was a reprieve. A reprieve is not a reform.

The six-month window is not extra time to wait. It is the period in which Hawaiʻi builds the foundation for a primary care system that can survive beyond January 1, 2027. On that date, HMSA's payment model becomes mandatory for primary care practices that have not already opted in, and Performance Year 1 of Hawaiʻi's federal AHEAD Model begins. These are the same transition arriving on the same day. Before either of them, on June 30, the state must sign its cooperative agreement with the Center for Medicare and Medicaid Innovation, the document that locks in the framework shaping primary care financing in Hawaiʻi through 2035. That deadline is approximately three weeks away.

If Hawaiʻi enters that transition without verified access standards, a transparent primary care investment benchmark, real provider engagement, and durable support for rural and Neighbor Island practices, we will have changed the payment language without fixing the access problem.

The Task Force has named four obligations of the six-month window. Equity of assistance, so that every primary care practice affected by the transition can access support, not only those that meet an early opt-in date. A permanent and transparent Neighbor Island differential, because the cost of delivering care in Kaʻū, Puna, Waimea, Hilo, Kona, and Molokaʻi is not the same as in urban Oʻahu, and a flat payment model will erase access where access is already thinnest. Provider engagement before AHEAD rules are written, because a payment system that will govern primary care through 2035 should not be designed without the people who deliver care. And a primary care investment standard anchored to the All-Payer Claims Database, so that progress is measurable and publicly reported.

Other states have made this choice. Rhode Island set a 10.7 percent primary care investment target in 2011. Oregon adopted 12 percent in 2021. Delaware followed in 2022. California is ramping toward 15 percent over the next decade. These are policy targets, not measured current shares, and the evidence band most often associated with stronger primary care systems sits between 12 and 15 percent of total healthcare spending. Hawaiʻi should set a measurable benchmark, anchor it to the data, and report against it publicly. A benchmark without measurement is a goal without accountability.

Hawaiʻi should stop asking only whether people are insured and start asking whether they can actually get care. Can they reach a provider? Can they obtain an appointment? Can they receive care on their island? If they must travel, is that travel covered? If a plan lists a provider, did that provider actually see enrollees in the measurement period? If a payment reform promises transformation, does it keep clinics open in the communities that need them?

Those are not technical questions. They are the public-interest questions that determine whether reform means anything to the people who live here.

The Task Force helped make the case for this six-month delay. Now we owe Hawaiʻi the harder work of making sure the delay leads somewhere.

The clock is running. So are we.

David Isei is Executive Director of the Hawaiʻi Healthcare Task Force, a coalition of physicians, advanced practice clinicians, rural health advocates, and community partners working to ensure that every person in Hawaiʻi can access the primary care they need. Reach the coalition at info@hawaiihealthcaretaskforce.org .