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September 15, 2014

As an academic surgeon living in Hawaii, it’s appropriate for me to write a blog about the status of medical care in my state.

            Hawaii has been progressive in terms of providing care to every person in the state. Many years before Massachusetts enacted “Romneycare,” Hawaii mandated that all employees must be covered by insurance. As a result, the number of uncovered individuals within Hawaii was  - and probably still is - the lowest in the nation. The care of those without care then could be easily assimilated into state budgets and everyone within Hawaii had almost the same standard of care, with very few being treated in charity clinics.

            When the Affordable Care Act came about, then, the direct effect upon individual care in Hawaii was negligible. Very few additional patients were covered.

            So what has happened since? What is the current status of medicine in Hawaii?

  1. Hawaii has been rated by Forbes Magazine for many years as the worst state in America in which to begin a small business. In fact, one issue referred to Hawaii as the “Peoples Republic of Hawaii.” While this isn’t entirely due to the health care mandate, the mandate is a definite factor in discouraging small businesses in Hawaii. As a result, the economy is more dependent upon tourism and the military than it should be, and the economic boom times during the 90’s never occurred in Hawaii.
  2. The “Hawaii Health Connector” (HHC) was Hawaii’s attempt to form an Affordable Care Act health insurance connector. After $200,000,000 of expenditures, the HHC is a dismal failure. Predictably, those who were advocates asked for a few more millions of dollars to get it right. In the meantime, HMSA, Hawaii’s Blue Cross provider and the largest insurer in Hawaii, pulled out of HHC, citing the greatly expanded costs of dealing with the HHC and the poor returns, since very few patients have benefitted from HHC. With only about 20,000 uncovered individuals in the entire state and a population of about two million, you can see that the numbers never did really add up.
  3. Our local paper, the Honolulu Star Advertiser ran an article this Sunday, indicating that physicians within Hawaii are disgusted with the additional paperwork, poor reimbursement, ever-rising costs of practice, and gross interference with their relationships with patients and are quitting in droves. One physician states that she now spends all day staring at her computer instead of interacting with patients. The article notes that Hawaii now has a deficit of 700 physicians, with a projected deficit of 1400 physicians by 2020. Primary practice has been particularly hit, but many subspecialists are also seeking greener pastures.
  4. Poor reimbursement for fractures about five years ago prompted a statewide refusal of orthopedic surgeons to take night call. The Queens Medical Center, our academic hospital and the largest trauma facility in the state, could find only two orthopedic surgeons willing to take call. They could cover about half the nights. Most hospitals on islands other than Oahu could find none.
  5. Last year, the only transplant hospital in the state went bankrupt. A series of quick fixes followed, but the end result is that if you need a transplant, you’re probably going to have to go 2500 miles to California to get it. The same is true for open-heart surgery and a variety of other subspecialty services. Many of these (brachytherapy for prostate cancer and collagenase treatment for hand contractures, for example) are common on the mainland, but Hawaii patients never know of their existence.
  6. Many physicians in Hawaii and elsewhere now limit the number of patients with Medicare, Medicaid, or Chip that they see, because they lose money on these patients. The best total joint surgeon in Hawaii does not accept Medicare any longer. Patients with government insurance are finding it impossible to find physicians willing to grant them care. Ironically, access to care for the poor in Hawaii is diminishing, not increasing.
  7. Most patients and physicians in Hawaii are happy with their care. Hawaii has fine physicians, with a very large percentage being Ivy League trained. People aren’t aware of the limitations of their care. I, myself, thought Hawaii’s medical care was excellent until I joined the faculty of a medical school in Texas and saw the astounding variety of care available there. You could take all the hospitals in the state of Hawaii and they would not fill our campus in Texas. When I spent a week in Cuba, and toured their medical facilities, I saw a similar phenomenon. Patients and physicians thought the medical care was wonderful, because they had no basis of comparison. Those of us who came from elsewhere knew, however, that their care, like their cars, was forty years out of data
  8. I am one of those who have dropped out as a care provider, so I’m now just another concerned consumer. I hasten to say that I wasn’t in it for the money and have never been in private practice. I worked for the Federal Government for twenty years, a charitable organization for a decade, and for the State of Texas for another decade. During this time, I saw magnificent technical advances in medicine (most of these now stem from research in Asia or Europe, since research in America has been throttled by bureaucracy). I loved the patient interactions, helping people get through the tough times and guiding them to a less painful and more functional future. I loved designing surgeries for them that solved problems they’d had for decades. But I think that when we started treating medicine as a business, when we started referring to those we served as “clients” rather than “patients,” when we allowed bureaucrats in Washington to step into the examination room and interfere with our communications, we ripped the soul out of medical practice and we are all the worse for it.