Trust Is Not Evidence | One Health Hawaiʻi, HMSA, HPH, and the Burden of Proof

Trust is not evidence. One Health Hawaiʻi’s backers should prove, with independent evidence, that consolidation will help patients instead of raising costs.

HHTF Staff · 2026-06-30

Trust Is Not Evidence

The people who benefit from One Health Hawaiʻi should bear the burden of proof.

The proposed One Health Hawaiʻi structure asks the public to accept a familiar promise. HMSA and Hawaiʻi Pacific Health say closer alignment will make care more coordinated, more efficient, and better for patients. That is the standard language of healthcare consolidation now. Nobody announces that a merger will make the powerful more powerful, the contracts harder to understand, the referral patterns harder to challenge, and the independent doctor’s life a little more ridiculous.

The problem is not that HMSA and HPH are making the promise. The problem is that Hawaiʻi has become too comfortable treating promises from interested parties as if they were evidence. The organizations seeking approval may sincerely believe this structure will help patients. They may also benefit from the structure being approved. Both can be true at the same time, which is why the burden of proof belongs on them.

Every lawyer knows how to treat an interested witness. Their testimony is not thrown out, but it is examined with the financial interest in view. A developer does not get to declare its own environmental impact harmless. A bank does not get to decide whether its own merger threatens competition. A drug company does not get approval because it describes the future patients who might benefit. The people asking for permission to gain power are expected to produce evidence strong enough to overcome the obvious reason they might see their own proposal generously.

Healthcare should not get a special exemption from ordinary skepticism. The weight of the research on vertical integration in healthcare is already unfavorable. These arrangements are usually sold with the same vocabulary we are hearing now: coordination, efficiency, data, value, quality, access. The published evidence has been stubbornly unfriendly to that story: higher costs or prices are common, while improvements in quality are inconsistent, weak, or absent. That history does not prove this specific proposal will fail, but it should make reassurance almost worthless unless it comes attached to independent proof.

The insurer side of the transaction deserves its own scrutiny because insurers do not have a simple financial incentive to make healthcare cheaper. Medical loss ratio rules are often described as a limit on insurer profit, and in one sense they are. They also work as a percentage of premium revenue. When premiums rise, the dollars available for administration, reserves, executive compensation, vendor contracts, data systems, affiliated arrangements, and margin can rise too. A smaller slice of a growing pie may still buy a very nice office building.

The instinct not to make waves runs deep in Hawaiʻi politics, especially when the organizations involved are familiar, powerful, and good at sounding reasonable. An insurer can spend years talking about lowering healthcare costs while benefiting from a healthcare economy in which total costs continue to rise. It can present itself as the adult in the room, the one managing waste and disciplining everyone else, while its own financial position improves through premium growth, greater market share, broader administrative reach, and increasing control over more pieces of the healthcare system. This does not require a conspiracy. It only requires a business model.

Once an insurer becomes more closely tied to hospitals, physician groups, data platforms, care management systems, or artificial intelligence tools, the public needs to know what is actually being built. Integrated care is the slogan. Control is the mechanism. The public deserves to know who controls the claims data, who controls the payment rules, who controls the referral incentives, who can steer patients without calling it steering, who can define quality in a way that rewards its own structure, and who has enough market power to make everyone else adapt or disappear.

Independent physicians already know what this feels like in smaller form. A payer changes a rule, a portal changes a requirement, a prior authorization vendor asks for documentation already sent, a quality program counts something that has little relationship to the patient sitting in front of us, and the cost lands in the clinic. The patient experiences it as delay. The physician experiences it as unpaid work. The insurer experiences it as process.

That is why physician skepticism should not be dismissed as ordinary turf protection. Physicians have financial incentives too, and I will not pretend otherwise. We argue about reimbursement because we are trying to keep practices open in one of the most expensive places in the country. Yet many physicians practicing in Hawaiʻi have already chosen against the easiest money. Radiologists can live here and read scans for mainland hospitals. Telemedicine has made similar arrangements possible in other specialties. I could do work like that now. I could stay in my home, avoid much of the local administrative fight, and make more money taking care of patients somewhere else.

Many of us stay because our patients are here, our families are here, and our obligations are here. That does not make us pure, and it does not make us automatically right. It does mean our incentives are not the same as an insurer seeking approval for a structure that places more financing, delivery, data, and bargaining power under one roof. A local physician asking for enough payment to keep seeing local patients is not standing in the same place as a dominant insurer asking the state to trust it with more control over the machinery.

The public cannot see most of what will determine how this structure behaves after approval. Patients cannot see the internal contracts. Independent physicians cannot see the future referral logic, data use agreements, risk arrangements, quality formulas, or payment incentives. Smaller hospitals and clinics cannot know how their bargaining position will change until the new structure is already part of the terrain. By then, the harm will be described as the market adjusting, as if gravity had done it.

That is why the burden cannot be placed on the public to prove every future injury in advance. The people asking for approval can see more than the public can. They know the contracts they plan to write, the data they plan to use, the incentives they plan to create, and the financial assumptions beneath the public language. If the benefits are real, durable, measurable, and large enough to overcome the documented risks of vertical integration, they should be able to show that with evidence produced and tested outside their own walls.

Hawaiʻi cannot afford to presume familiarity means safety. HMSA is familiar. HPH is familiar. Their leaders are familiar. Familiar institutions can still accumulate too much power, especially in a small state where patients have few alternatives, physicians have limited bargaining room, and policymakers often hear from the largest organizations first because the largest organizations can afford to keep showing up.

Community donations and sponsorships may make an institution familiar and well-liked, but they do not answer the regulatory question. A company can fund useful programs and still seek approval for a structure that increases its market power, weakens competition, or raises costs. Charity is not evidence.

The proposed One Health Hawaiʻi structure should be reviewed with the burden of proof in the right place. The question is not whether HMSA and HPH can imagine a better future. The question is whether they have produced enough independent evidence to justify moving Hawaiʻi further into a model that research already tells us often raises costs without reliably improving care. The people who benefit from the transaction should have to prove that this time will be different. If they cannot, the missing evidence should not be replaced with trust.