Illustration by Camilla Watson
By Alison Lu
By 2025, it is estimated that across the United States, there will be a shortage of between 124,000-159,000 physicians, and Hawaii is no exception.1 In Hawaii, it is estimated that there was a shortage of 732 physicians in 2021, and that number is expected to continue to grow.2 While the entire United States faces many challenges when it comes to the worsening physician shortage, Hawaii, which is the only state comprised solely of islands, has additional, unique problems that exacerbate the physician shortage. These problems–Hawaii’s growing aging population, doctors going into retirement, the high cost of living, and geographical diversities within the state–need to be addressed. All of these conditions have led to a growing physician shortage in Hawaii, and the Johns A. Burns School of Medicine Area Health Education Center (AHEC) is attempting to address them.3
Age plays a huge role in the future number of physicians in Hawaii. According to the Association of American Medical Colleges, Hawaii had the second-highest percentage of active physicians who are age 60 or older, with 37.3% of physicians age 60 or over.4 The average age of physicians in Hawaii is 54.6 years old, with 48% of Hawaii’s physicians aged 55 or over and 22% of Hawaii’s physicians aged 65 or older, over the retirement age. Notably, there are five physicians who are 90 or older and still practicing.3 These numbers underscore the aging physician population, with many of them still practicing as they near or are already past retirement age. However, the number of young physicians coming in to replace these retiring physicians is not nearly as high, one of the main reasons being wages.
To make matters worse, it is financially unfeasible for many physicians to practice in Hawaii. Many young doctors graduating from medical school have large medical school debts. At the same time, in 2018, physician income in Hawaii was ranked as the third-lowest in the nation.5 Not only does Hawaii have one of the lowest physician incomes, but the costs of living in Hawaii are also incredibly high. For example, transportation costs are 149% higher than the national average, while grocery bills are 169% and housing costs are 319% higher than the national average respectively.5 These financial factors are important when young physicians are considering where they plan to live and practice medicine.
Even for physicians that have been practicing for years in Hawaii, low Medicare reimbursement rates and Hawaii’s General Excise Tax means that Hawaii’s doctors earn less than their counterparts in different states, such as Alaska, making it difficult to continue practicing in Hawaii.3 Low Geographic Price Cost Indices (GCPI) quantify lower reimbursement rates for providers, and Hawaii’s GCPI of 1.06 is on the lower end of the spectrum, especially when considering the healthcare delivery challenges that Hawaii’s physicians also endure. When compared to Alaska, both Alaska and Hawaii face similar difficulties in providing healthcare in diverse and rural communities. Yet, Alaska’s GCPI is 1.5 while Hawaii’s is 1.06. This significantly lower GCPI is indicative of lower reimbursement rates for physicians in Hawaii.5 Hawaii is also the only state to tax gross receipt private practice revenue with Hawaii’s General Excise Tax, meaning that every Medicare, Medicaid, Tricare, and insurance dollar is taxed.5 The General Excise Tax is 4.5% on gross income, but with Medicare and Medicaid patients, the 4.5% tax grows closer to 15%-20% tax on average family practices.3 These factors lead to a large financial barrier preventing physicians from wanting to or continuing to practice in Hawaii, and they consequently lead to some Hawaiian communities facing shortages to care.
The severity of the physician shortage in Hawaii also varies significantly depending on the geographical location. Even though the entire state is facing a physician shortage, counties like Maui, Hawaii, and Kauai, which are much more rural, bear the brunt of the physician shortage. Statewide, the physician shortage in 2021 was 22%; however, that number is an average of the physician shortage for Honolulu County, Maui County, Hawaii County, and Kauai County, which have a physician shortage of 15%, 40%, 40%, and 26%, respectively.2 Therefore, even though Hawaii as a state faces a significant physician shortage, certain counties in Hawaii are in even more dire situations. Hawaii County, Maui County, and Kauai County are among the top 15 counties in the US with the highest primary healthcare worker shortage. Hawaii County has the third-largest shortage in the nation, Maui County follows with the fifth-largest shortage in the nation, and Kauai County the thirteenth-largest.6
To many Oahu residents, the physician shortage has not historically been a noticeable issue. Honolulu County is the most populated county, and in 2004, about 80% of Hawaii’s physicians were practicing in Honolulu.7 The relatively large number of physicians in Honolulu County compared to neighboring island counties leads many Oahu residents to be unaware of the plight that neighboring island residents endure. As the physician shortage in the neighboring islands increases and patients are forced to fly from neighboring islands to Oahu to receive specialty care, Oahu residents are now beginning to feel the effects of the physician shortage. One example of this would be when an Oahu resident calls their doctor and is told that they need to wait weeks for an appointment due to appointments from community members on neighboring islands.6 Because of this effect on their healthcare access, Oahu residents have become more cognizant of Hawaii’s physician shortage and how it may affect everyone in the state.
The Johns A. Burns School of Medicine Area Health Education Center (AHEC) has been working on possible solutions to grow, keep, and support the physician workforce. AHEC publishes annual healthcare workforce assessments to present to state legislatures, updating and informing the public on statistics of the physician shortage as well as solutions they are implementing.2 Multiple solutions have since been implemented: expanding pathways to health careers, expanding rural training opportunities, and expanding loan repayment.
In 2018, the Physician Workforce Assessment team interacted with over 3,000 health profession students and developed the Hawaii Health Careers Navigator, a 140-page health career resource book with information on health professions in Hawaii that was distributed to 3,500 students, counselors, and parents. Another program started with federal grant funding is the Hawaii Pre-Health Career Corps for students interested in health careers to receive shadowing, research, and mentoring experiences, and over 1,300 students are enrolled.8 These opportunities not only allow students from Hawaii to gain exposure regarding the healthcare field, but they also more directly support and encourage students to pursue health professions.
To expand rural training opportunities, AHEC hired a rural coordinator to work with neighboring island communities to recruit and support students interested in health careers, work with community members to host and teach health profession students, and document the impact of rural activities on rural health professions training.2 The Aloha Welcome Wagon Program and the University of Hawaii Homestay Aloha Program were created by AHEC to coordinate travel and host lodging for University of Hawaii health sciences students on clinical rotations across the state and especially in neighboring islands. These efforts remove many of the barriers that physicians experience to working in rural locations such as finding affordable short-term housing, and they also incentivize physicians to work in rural areas, where there is a large physician shortage.
Both federal and state funding have been obtained to support a doubling of the number of loan repayments given out to physicians, an effort to incentivize physicians to practice in Hawaii. Since 2012, the Hawaii State Loan Repayment Program has supported 60 providers in rural and underserved areas across the state. Physicians ranging from allopathic and osteopathic physicians to nurse practitioners to physician assistants and psychologists are also eligible for loan repayment via the Hawaii State Loan Repayment Program, and federal funding is expected to help other specialties such as pharmacists, dentists, dental hygienists, certified substance abuse counselors, and more.8 On top of that, AHEC is working with banks in Hawaii to allow physicians financial incentives such as low-interest or low-down payment loan packages to purchase homes or practice resources.2 By implementing several strategies to reduce the financial barriers that prevent physicians from choosing to practice in Hawaii, AHEC aims to recruit more physicians to stay and practice in Hawaii.
Although Hawaii continues to face a significant physician shortage, the state has been actively taking steps to control and improve the physician shortage. The solutions listed in this article are only some of the solutions that Hawaii has been implementing to help stem this shortage. Because of the severity and extent of the issue, many of these solutions may take a while to administer and even longer to observe their positive outcomes. The ultimate goal is that AHEC’s diverse efforts to recruit physicians will be able to improve the situation in Hawaii before it gets any worse.
- Akina K. Healthcare bottom line: ‘We have a shortage of all those things’. Grassroots Institute of Hawaii. Published December 9, 2021. Accessed March 6, 2022. https://www.grassrootinstitute.org/2021/12/healthcare-bottom-line-we-have-a-shortage-of-all-those-things/
- Association of American Medical Colleges. Hawaii Physician Workforce Profile. https://www.aamc.org/media/37891/download. Published 2019. Accessed March 5, 2022.
- Hawaii State Health Planning and Development Agency. State of Hawaii Health Services and Facilities https://health.hawaii.gov/shpda/files/2013/04/shhsfp09.pdf. 2009. Accessed March 5, 2022.
- Jacobson PD, Jazowski SA. Physicians, the Affordable Care Act, and primary care: disruptive change or business as usual?. J Gen Intern Med. 2011;26(8):934-937. doi:10.1007/s11606-011-1695-8
- Junger S. The Perfect Storm 2021: The Hawaii Physician Shortage Crisis 2nd Edition. https://www.scribd.com/document/490581230/The-Perfect-Storm-2021-Hawaiʻi-s-Physician-Shortage-Crisis#from_embed. Published 2021. Accessed March 8, 2022.
- Pasia N. Hawaii is the ‘most hostile health environment to practice in,’ physician says. State of Reform. Published December 7, 2021. Accessed March 8, 2022. https://stateofreform.com/news/hawaii/2021/11/hawaii-is-the-most-hostile-health-environment-to-practice-in-physician-says/
- Withy K. Report to the 2022 Legislature Annual Report on Findings from the Hawai’i Physician Workforce Assessment Project. https://www.hawaii.edu/govrel/docs/reports/2022/act18-sslh2009_2022_physician-workforce_annual-report_508.pdf. Published November 2021. Accessed March 6, 2022.
- Withy K. Report to the 2019 Legislature Annual Report on Findings from the Hawai‘i Physician Workforce Assessment Project. https://www.hawaii.edu/govrel/docs/reports/2019/act18-sslh2009_2019_physician-workforce_annual-report.pdf. Published December 2018. Accessed March 5, 2022.