Access to healthcare plays a vital role in the health of individuals and of populations. Healthy People 2010 and 2020 identify access to care as a leading indicator of health.
Access to healthcare is influenced by: whether or not people have health insurance, whether there is an adequate health provider workforce, how long the travel distances are to reach providers, and whether there are language and cultural barriers, and cost. Barriers in any of these areas can result in lack of access, delays in care, higher costs and worst outcomes.
According to the Institute of Medicine (1993) “access to healthcare is the timely use of personal health services to achieve the best possible health outcomes.” This definition, underscores the importance of timeliness as a feature of good access to care. However, timeliness is more difficult to measure than simple ratios of physicians to the population. Additional data on timeliness is needed.
Impact of Inadequate Access to Healthcare in Hawaii County
People without health insurance or without a primary care provider are less likely to get timely treatment, screening and preventive services, and are more likely to use costly emergency services resulting in higher emergency room and higher hospitalization rates per 1,000 population for Hawaii County (Chart).
Higher Uninsured Population in Hawaii County
Hawaii County and Kauai County are essentially tied for the highest average percent of the population who were uninsured for the years 2002-2009. The proportion of uninsured on all islands has risen as unemployment has risen. Those who lack insurance often defer or delay healthcare (chart).
Children without health insurance are five times more likely to use emergency rooms for regular care and four times more likely to delay seeking care.
Resource: To find information or to help enroll children in health insurance, see www.coveringkids.com/news. Kids’ Health Insurance hotline – dial 211. A free call from all islands.
Hawaii State Actual Ratios of Physicians to Population are Half of Apparent Ratios
Because Hawaii Sate has many licensed physicians who are visitors with a mainland or foreign primary address and do not have a primary Hawaii address, the actual ratio, based on licensed physicians with a primary Hawaii address, is substantially lower than the apparent ratio, which is based on all physicians with a Hawaii license including those with a mainland or foreign primary address (Chart).
Hawaii County has the Lowest Ratio of Physicians
Hawaii County has the lowest ratio of licensed physicians per 1,000 population compared to the other counties. Because many of the licensed physicians with a primary Hawaii address are not actively practicing, the actual practicing ratios are even lower (Chart).
Hawaii County has 14% of the State’s population but only 10% of State’s Docs with a Hawaii Primary Address
Hawaii County has 14% of the state’s population based on the U.S. Census as of March 2009, however, Hawaii County has only 10% of the states licensed physicians with a primary Hawaii address, as of April 13, 2011 (Chart).
Declining Number of Physician Offices in Hawaii County
The number of physicians’ offices in Hawaii County declined substantially from 151 to 136 between 2006 – 2007 according to the U.S. Economic Census data at www.census.gov (chart).
Hawaii County Currently has a Shortage of 179 Doctors
According to the Hawaii County Physician Workforce study 2010 by John A. Burns School of Medicine, Hawaii County currently faces a shortage of 179 physicians based on the actual supply of actively practicing physicians compared to the calculated demand (chart).
Impact of Provider Shortage
The provider shortage most likely contributes to Hawaii 
County’s relatively high rate of hospitalizations and of “potentially avoidable hospitalizations” for uncontrolled diabetes per 100,000 population (chart).
More Hawaii County Residents Report Being Without a Personal Doctor
For 2009, Hawaii County and Maui County residents reported similar high rates, 17% vs 18% of not having a personal doctor, according to the Behavioral Risk Factor Surveillance Survey, 2009 (chart).
More Hawaii County and Maui County Residents with no Doctor Visit within Past Two Years
In 2008, more than one quarter of Hawaii County residents surveyed by the Behavioral Risk Factor Surveillance Survey reported no doctor visit in the past two years. The percent in Hawaii County reporting no visit increased by nearly 4% from 2007-2008 and is higher for Hawaii County than the State (chart).
Lower Rates of Preventive Screening
“Preventive screening is a cost-effective way to identify and treat potential health problems before they develop or worsen” (Center for Disease and Control).
Preventive screening such as pap tests, mammograms and sigmoidoscopy and/or colonoscopy can help to detect diseases at an earlier more treatable stage. According to the Center for Disease and Control (2009), “the pap test—the main test for cervical cancer is one of the most reliable and effective cancer screening tests available for women.”
Fewer Hawaii County Women had a Mammogram
On average from 2008-2009, only 75.7% of Hawaii County women 40+ years surveyed had a mammogram, within the past two years compared to 78.3% for the state (chart).
Only 81% of Hawaii County Women get Pap Test
Hawaii County women had pap smears at about the same rate as the City and County of Honolulu, though approximately 20% did not receive the recommended screening (chart).
Fewer Hawaii County Residents Screened for Colon Cancer
In 2009, slightly fewer Hawaii County residents, 58% vs. 60%, for the state were screened for colon cancer with a sigmoidscopy or colonoscopy. Though there has been increased screening at both the County and the State levels, Hawaii County screening is consistently lower that the State (chart).
Resource: The Guide to Clinical Preventive Services (2009) Recommendations of the U.S. Preventive Services Task Force provides useful recommended screenings ( http://www.ahrq.gov/clinic/USpstfix.htm).
Hawaii County Federal Designation of Provider Shortage
Hawaii County as a whole has a federal designation as a medically underserved area and population (Chart). However, the federal designation as a Health Professional Shortage Area (HPSA) sets policies for receiving federal dollars to improve access and only a few parts of Hawaii County are designated as a HPSA despite the clear data documenting the severe island wide shortage (chart). For the full report, visit State of Hawaii Primary Care Needs Assessment Data Book 2009.
The Department of Health and the Primary Care Association are working on updating Hawaii HPSA designations to be more consistent with the severity of the workforce shortages.
Improving Access
Attracting and retaining high quality health professionals is a challenge in North Hawaii and Hawaii County, because the cost of living is high, cost of private education is high and reimbursement from Medicare, Medicaid and private insurers is relatively low. At the same time, the demands for night and weekend call are high. Improving access and health status for North Hawaii and Hawaii County will require effectively addressing the complex issues behind physician and health professional shortages. Partnerships between providers, employers, payers, insurers and government to improve access to primary care in Hawaii County are essential to improve health status. The Hawaii Island Healthcare Alliance is a broad group of stakeholders working to improved access to healthcare in Hawaii County.
