Twenty-Five Years, Then Laser-Focused

People tried for 25 years to stop Hawaiʻi from taxing doctors for Medicare and Medicaid care. It passed when we got narrow, got together, and stayed visible. Here is the method.

HHTF Staff · 2026-09-23

How a fragmented island actually wins.

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

On January 1, Hawaiʻi stopped charging its general excise tax on what doctors, nurse practitioners, and physician assistants are paid to care for Medicare, Medicaid, and TRICARE patients.

By the estimate of the senator who carried it, as reported in the press, that is about $74 million a year that stays with the people delivering care.

People had been trying for a long time. One of our officers put it this way:

"Everybody's been trying to get the GET bill through for 25 years."

So what changed?

Get narrow, then get together

Three things, as best I can tell from being in the room.

We got narrow. We sat down with a senator and tried, in our officer's words, "to be laser like at what could possibly pass." Not everything we wanted. What could pass.

We brought people you would not expect. The head of the state's tax foundation, whom the Legislature respects. Nurse practitioners. Dentists. "A multi disciplinary approach," as he said.

We stayed visible. In the final week or two, the issue was in the press almost every other day.

None of that is a secret. It is just hard to do when everyone wants to be the captain. There are a lot of captains on the boat in Hawaiʻi healthcare, and every one of them is right. When everyone is right, everyone is wrong. The GET win happened when enough captains agreed to row.

Then widen the circle

The final bill left dentists out. The week the dust settled, our officer wrote the senator to ask that they be added, and offered to bring dental leaders to the table.

He told her a story. A colleague's wife cracked a crown. They called every dentist in Hilo. Every one was booked out more than a month. They were making plans to fly to California. Then a dentist in Kona got her in.

That is the island in one story. A gap in Hilo, a neighbor in Kona.

Say thank you, then say what is next

In May, the state's largest health plan put a 15 percent fee differential in place for primary care on the neighbor islands, Hawaiʻi Island included. We wrote to thank them. We called it "a meaningful first step, not a complete solution," and we asked to meet. Their chief medical officer answered within a day.

Then we decided who would sit at that table. Not me. Two independent physicians who run practices and a volunteer who reads claims data for fun. They are "where the rubber meets the road," I wrote. A nurse practitioner offered to come too, to show that the Task Force is not just a group of physicians.

The honest part

A win is not a cure. One of our officers wrote something to the state last year that I have never forgotten. At the current pace of reform, he said, most private practices will be out of business before the reforms take effect.

"It is kind of like treating a patient with a malignant tumor with a fraction of the radiation dose they need to effect a cure."

He is a radiologist. He knows the dose.

So the lesson of the GET fight is not that we can relax. It is that we know how to win, and we need to do it faster.

The method

Get narrow. Ask for what can pass.

Bring people who do not usually stand together.

Stay visible until it is done.

Thank people when they move.

Then ask for the next thing, and bring the people who were left out.

The Big Island did not invent that method. It just keeps using it.

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. General excise tax exemption on Medicare, Medicaid, and TRICARE payments, effective January 1, 2026; about $74 million a year: estimate of the sponsoring senator as reported by Spectrum News. DIRECT, a legislator's estimate reported in press.

Neighbor island primary care fee differential of 15 percent: acknowledged in writing by the health plan and the Task Force, May 2026. FIELD-VERIFIED.

Officer remarks: Task Force correspondence and a recorded working call, used with permission and without names.