Hawaiʻi’s health care system is straining under rising costs, administrative complexity, and worsening physician shortages. The situation has been exacerbated with the effects of the ACA premium credit expiration and the federal passage of the One Big Beautiful Bill which has caused significant cutbacks on Medicaid. Health care affordability is a pressing and urgent issue for Hawaii residents as many will have no choice but to go uninsured because of rising costs.
Against that backdrop, the proposed arrangement between the Hawaii Medical Service Association (HMSA) and Hawaiʻi Pacific Health —packaged as a partnership under a new entity, One Health Hawaiʻi — presents itself as a needed redesign, not a traditional merger. The proposed One Health Hawaiʻi aims to reduce costs in healthcare delivery, which is admirable and potentially proactive, to shake up the status quo that’s simply not working for the average income-earner.
But when a single structure is positioned to have immense – almost monopolistic influence– the bar for public trust must be far higher than reassuring language and ambitious projections. This is where regulators overlooking the proposed consolidation must carefully assess and project with precise modeling what would be the realistic outcomes under this new system.
Supporters argue integration could cut duplicative billing and paperwork, coordinate care more seamlessly, and save up to $2 billion over the next decade—resources they say would be reinvested in urgent needs.
Those goals are certainly worth pursuing. Yet in health care, efficiency gains do not automatically translate into lower premiums, copays, or faster access (as data shows) unless savings-sharing is explicit, measurable, and enforceable. This is where the hand of government – not overly intrusive but looking after the best interests of the public – must be a robust enforcer.
Otherwise, “system reform” as proposed in this case, can become a one-way ratchet: greater consolidation with uncertain benefits for families already struggling to afford care.
Regulators should pay special attention to how Medicaid/Medicare and the uninsured would be affected by the proposed new “open” system, “open” network.
The central worry to the general public is that the design of affordability and cost-savings will not trickle down to patients. These corporations and regulators must understand the intense struggle Hawaii residents are facing to pay for healthcare. And they should be ensuring that cost-savings actually do trickle down to patients-consumers.
Even with “open access” plans, integrated systems tend to make referrals, scheduling, records-sharing, and approvals easiest inside their own walls, as some critics of the integration are saying. Independent physicians warn that patients will follow “the path of least resistance,” and over time that drift can structurally disadvantage community practices—especially in a state where access is already fragile on neighbor islands and in rural areas. If convenience becomes de facto steering, choice shrinks even without a formal rule change.
That risk extends beyond private practices. Queen’s Health Systems has warned that if commercially insured patients are nudged toward a preferred HMSA–HPH network, Queen’s could be left carrying a heavier share of Medicaid, Medicare, uninsured, and high-acuity “safety net” services—trauma and behavioral health among them—without the commercial revenue that helps keep those programs viable.
Integration without accountability is just market power in a new wrapper—and market power reroutes patients and revenue.
If regulators approve One Health Hawaiʻi, they should do so only with binding guardrails that protect patients and the broader provider ecosystem. That means clear, audited commitments against steering and discrimination; network adequacy requirements that keep independent and rural clinicians viable; parity in prior-authorization rules so “insiders” and “outsiders” are not subjected to two standards; transparency on administrative savings; and an independent oversight mechanism with real enforcement and penalties.
Hawaiʻi does need change. Ask local residents and they will tell you how dissatisfied, even enraged, about the high cost of healthcare. But the state cannot trade existing challenges for monopoly logic, unless it makes sense and benefits the public and not just corporations.
One Health Hawaiʻi may be capable of real transformation—if it is built to lift the whole system. Until the public can see enforceable protection, transparency, and accountability that matches the scale of this massive consolidation, skepticism is not obstructionism. It is being smart and cautious.
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