Healthcare For All Hawaii

Our first letter to Governor Ige:


January 23, 2017


Dear Governor Ige:


Hawaii is approaching a healthcare crisis.  Large numbers of Hawaii’s physicians are leaving private practice and leaving Hawaii.  Many of them are refusing to take new Medicare or Medicaid patients because of inadequate compensation.  Hawaii’s hospitals are in financial jeopardy.  And a hostile administration and Congress in Washington are likely to make this difficult situation much worse very soon.  Hawaii urgently needs to prepare for this crisis.


As you know, the Hawaii Health Authority (HHA) was established by the Legislature in 2009, over Governor Lingle’s veto, to prepare Hawaii for eventual adoption of universal healthcare, sometimes called “single payer.”


Because the ACA was adopted shortly afterward, the work of HHA has gotten sidetracked, although HHA has issued three reports that analyze and recommend solutions to the problems facing healthcare delivery in Hawaii.  


For medical providers, most of those problems are caused by radically increased administrative burdens due to extensive documentation and reporting requirements of new payment models being imposed by HMSA and Medicare, plus marked escalation in formulary restrictions and prior authorizations being imposed by HMSA, Medicare Advantage and D plans, and Medicaid plans.  This is creating a steadily worsening crisis – more and more Hawaii physicians are leaving independent practice to work in hospitals or other facilities, or are leaving the state altogether.  Private practice medicine costs less than medicine provided in a hospital, so when more medical services are provided in hospitals, the overall cost of healthcare increases.


Medical consumers are also facing a crisis as more and more primary care physicians, 47% of physicians in Hawaii, are refusing to take new Medicare and Medicaid patients, primarily because of the excessive administrative burdens and costs combined with low compensation rates.


And, as you well know, our hospitals are facing major financial losses, especially on the Neighbor Islands, where a disproportionately large number of patients are under Medicaid.


On top of these crises locally, we are all facing a hostile new US Congress that is attempting to repeal the ACA without any replacement, an act that will have catastrophic consequences for both the physical and financial health of our nation, our State, and our people.


At one time, not long ago, Hawaii’s medical care system led the nation in comprehensiveness, fairness, and efficiency.  Whether it currently does is now open to question. We do not want it to erode further.

We cannot remain unprepared for these eventualities.  We cannot rely on either Washington or the insurance industry to decide what’s best for us.   


We must at least have a planning process “up and running,” and working in the public interest under State leadership during this very dangerous period.   We need a State agency whose primary task is to engage in this critical planning that will be alert and responsive to changes that are coming from multiple directions.  We already have that agency – the HHA – but it is inactive.


For these reasons, we – a group of volunteer concerned citizens – are asking for your support in revitalizing the HHA.  We are led by Dr. Stephen Kemble, who is one of the three holdover members of HHA as well as a past president of the Hawaii Medical Association.  We have received formal support for our efforts from the Democratic Party of Hawaii’s State Central Committee at its meeting on January 18, 2017, as a legislative priority of the Party.

We are asking Legislators to consider a bill that would ask the HHA to develop the “comprehensive plan” for state-level healthcare that HRS §322H-2(e) directed it to prepare by December 2011, but HHA never had the funding or even the membership to write it. We are looking at a new deadline of December of this year, or possibly next year. We are seeking a small sum for staff and other administrative funding.  We believe $250,000 is reasonable.


Such a new bill restarts the planning process, but would NOT prescribe the terms and provisions of such a healthcare system, nor would it actually change anything in our current healthcare laws.  


Vice Speaker John Mizuno has already introduced a version of this bill as HB 129.


We recognize that there are many obstacles to the adoption of universal healthcare by the State, including frankly not only multiple federal legal requirements that would require important waivers, but also disagreements from our local leaders, such as Dr. Pressler of the state Department of Health.  


We frankly acknowledge a concern among some people that Hawaii government has a “reverse Midas touch” in administering complex and expensive projects and systems.  But we cannot allow this reluctance to prevent us from starting the planning that is needed now.


We believe that, especially with the onset of the Trump administration, it is critical for all of us to at least meet and confer about these serious issues in the near future.


Accordingly, we request such a meeting with you, to see what we can do to help ensure that Hawaii will not be caught unprepared if and when the Congress inflicts major damage on our healthcare system and other aspects of our social safety net.  


Such damage may come very soon.  Thank you very much in advance for considering this request.


                    Very truly yours,


Alan B. Burdick        Stephen Kemble, MD

    Leslie Hartley Gise, MD    Bart Dame

    Dennis B. Miller        Erynn Fernandez

    Daria Fand


Please reply c/o Alan B. Burdick,





Second Letter to Governor Ige:


January 25, 2017

Dear Governor Ige:

This is our second letter to you regarding the Hawaii Health Authority (HHA) and the need to commence serious detailed planning to protect comprehensive healthcare for Hawaii’s entire population.  We send you this letter shortly after your administration has introduced companion bills in the Legislature, HB 1111 and SB 977, to abolish the HHA.

Those bills would abolish the HHA on the purported ground that all necessary healthcare planning can be accomplished by two other existing State agencies, the State Health Planning and Development Agency (SHPDA), and the Hawaii and the Health Care Innovation Office" (HCIO), which is located in the Governor's office.

However, as we detail below, neither of these agencies is designed to perform the comprehensive healthcare planning that HHA was designed to do and that is now urgently needed.

SHPDA is responsible for certifying when and where new facilities such as hospitals, MRI facilities, dialysis centers, etc. are needed according to public health needs. The director of SHPDA was (and hopefully still is) Romala Sue Radcliffe, who attended many of HHA’s meetings and was most supportive of what the HHA was doing. Conversely, HHA was very supportive of what her agency does.


Any well-designed health care system should have a SHPDA as part of its governance. However, SHPDA is not an overall planning agency for health care policy as a whole. It is specifically for determining the need for new facilities and approving or denying applications to build them. We need the HHA for overall planning and policy, and the maintenance of a number of agencies, including SHPDA, that serve necessary administrative functions within the governance of health care. 


The HCIO is the residual of former Governor Abercrombie’s “Health Transformation Initiative," later renamed "The Hawaii Health Project."  It was originally funded by the health insurance companies and was focused on implementing the Affordable Care Act (ACA), which is now being dismantled by the Trump administration.  


Regrettably, the ACA, combined with the Medicare Access and CHIP Reauthorization Act (MACRA), are the primary source of the very onerous documentation, reporting, and prior approval requirements that are having destructive and costly effects on healthcare delivery in Hawaii today. The HCIO has been entirely focused on implementing these very policies. As a result, doctors’ overhead costs have increased by over $40,000 per doctor per year, and they must now spend twice as much time paying attention to their computers as to their patients.  We are 20% short of doctors and losing more every year; a majority of our doctors are “burned out” and want to leave practice; and already 47% of primary care doctors in Hawaii are refusing new Medicare patients, with even more refusing new Medicaid.  This is a CRISIS!


These payment structures, policies, and procedures are what desperately need to be reformed, with the goals of improving quality of care and population health, and reducing cost.  However, the policies that have come out of the HCIO are having the opposite effects of these intended goals.  


We emphatically need the HHA and a new model for healthcare reform focused on administrative simplification, reduced healthcare overhead, and lowering healthcare prices, not misguided attempts to incentivize reduced utilization of health services via imposing more and more administrative burdens – which is what is happening now.


The bottom line is that the "federal policy changes, new business models, and new technologies,” which the administration bills refer to, are having increasingly destructive effects on doctors, hospitals, and patient access to care and are driving costs up, not down, perhaps more so in Hawaii due to the relative cost-effectiveness of our previous model compared to the rest of the country. These current policies and business models urgently need to be reassessed.  Failure to do so will leave the administration and legislature with an escalating crisis due to the unraveling of our health care delivery system. Proper planning will take time, and we need to get in front of these problems to minimize avoidable damage. Otherwise we will be attempting to repair a broken system in the absence of any effective solutions.

Thus, with great respect for you and the Department of Health, we believe that the HHA has a very important role to play that neither SHPDA nor HCIO can fill. Hence, there is a renewed and increasingly urgent need for the HHA to be revitalized and allowed to fulfill its mandate to comprehensively plan for state-level universal health care.

We are a core group representing literally thousands of very politically active and aware Hawaii residents, mostly active Democrats, who are very anxiously expecting major progress in health care legislation this year.

As we mentioned in our prior letter, our proposal to revitalize the HHA has been endorsed by the leadership of the Democratic Party of Hawaii as a priority for this year’s session of the State Legislature, and this initiative enjoys the strong support of the Democratic party’s Kupuna Caucus and other progressive organizations in Hawaii.

We respectfully renew our request for a meeting with your appropriate high-level staff to discuss this very serious and urgent matter.  Thank you very much again for your kind attention to this situation.


                    Very truly yours,


Alan B. Burdick            Stephen Kemble, MD

    Leslie Hartley Gise, MD        Bart Dame

    Dennis B. Miller            Erynn Fernandez

    Daria Fand                Karen Cobeen


Please reply c/o Alan B. Burdick,


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