What’s Working, What’s Failed and What Needs to be Done to Fix The Decades-Old Problem of Job Shortages?

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hirty-six years ago, new family physician Randall Suzuka set up shop at a small clinic on O‘ahu’s North Shore.

The young doctor got to do a little bit of everything, from treating kids’ ear infections to managing parents and grandparents with high blood pressure. Back then, it was common to strike out alone or in small group practices, where you could serve your neighborhood as your own boss. “Now 70% of medical residents want to be employed by a large group,” he says. “The mom-and-pop practices have become an endangered species.”

Recently, Suzuka has been barely hanging on at the Hale‘iwa Family Health Center. The problem isn’t finding patients. The North Shore, like most rural parts of the state, has only a handful of doctors to treat its sprawling population. Instead, a tangle of financial issues, many unique to Hawai‘i and all compounded by the high cost of living, is making it increasingly difficult for doctors in private practice to stay solvent. It’s also helping to drive a severe physician shortage in the Islands.

The 2019 Hawai‘i Physician Workforce Report, prepared by Dr. Kelley Withy, a professor of family medicine and community health at the John A. Burns School of Medicine, found that the state is short 820 full-time physicians, with primary care shortages the most dire. Across the Islands, 300 more primary care physicians are needed in general and family practice, general internal medicine, pediatrics and geriatrics—and that was before COVID-19 delivered a devastating blow to the financials of many small practices. More than 40% of the 989 physicians surveyed in August said they had been negatively impacted by the pandemic. With nearly a quarter of the state’s physicians over 65, some are now opting for retirement, while others have reduced their hours.

Along with a lack of doctors, essential positions including teachers, licensed practical nurses and police officers have been short-staffed for years. As the state reckons with a pandemic-fueled economic meltdown, provider burnout and potentially risky workplaces, what will it take to stop the shortages?

1) Primary Care Physicians:

“Death by a Thousand Cuts”

When adjusted for cost of living, Hawai‘i ranks near the bottom in the U.S. for physician income, according to a recent Medscape physician compensation report. In a state known for low wages, that comes as no surprise. Primary care physicians, for instance, earn about a third less than specialists and Mainland peers. While Withy estimates that primary care salaries fall in the $150,000–$200,000 range, far higher than the median income, they are offset by heavy costs, particularly in private practices.

Suzuka’s practice has three full-time and three part-time doctors, and has always shouldered the overhead, support staff, insurance and other costs associated with running a clinic. But in the past decade, the growth of information technology expenses, ballooning administrative costs and time spent getting preauthorization from insurers for even routine procedures were becoming overwhelming. When the new coronavirus hit in spring, most appointments were canceled or moved online or on the phone, which are reimbursed at lower rates—particularly the phone calls that Suzuka’s older and less affluent clients prefer. “We took a 20% cut in payments,” he says.

Another major hit comes from Medicare’s lopsided fee structure for services, which reimburses Hawai‘i doctors at the same rate as those in Ohio, where the cost of living is less than half of Hawai‘i’s. “Something is way off with Hawai‘i Medicare. Why are we paid the same as rural Ohio?” asks Dr. John Lauris Wade, a radiologist in Hilo and core member of the Hawai‘i Physician Shortage Crisis Task Force. The group says that Medicare’s payment formula doesn’t properly weigh Hawai‘i’s cost of living and unique tax burdens. Private insurers then base their reimbursements off of Medicare’s, compounding the problem.

The task force recently enlisted the state’s federal delegation to advocate for higher reimbursements, pointing out that isolated, high-cost states such as Alaska have negotiated increases: For every $100 Hawai‘i doctors receive for services, Alaska doctors get $150. In September 2019, all four members of the state’s congressional delegation in Washington, D.C., petitioned Medicare’s administrative agency for a change. It didn’t happen and another review of reimbursements won’t happen until 2023. That leaves Hawai‘i doctors stuck with the same federal payments. The physician group is hoping a bill will be proposed in Congress, similar to the one introduced in July to increase Medicare payments to Hawai‘i’s nursing facilities.

More disappointment came in March when Senate Bill 2542, which would have exempted private practices from paying the state’s general excise tax, stalled in the House as the pandemic hit. It was the first time such a measure ever made it out of committee—similar efforts have been made regularly over the past decade—and Wade says it’s critical to pass the bill next session. Nonprofit hospital systems don’t pay the tax, but private practices in Hawai‘i, like other businesses, are taxed on gross revenue, including paltry Medicare reimbursements. However, unlike other businesses, it’s illegal for doctors to pass the tax along to their Medicare patients. While a 4.5% general excise tax (4% on Maui) may seem innocuous to an outsider, for many private practice physicians operating on razor-thin margins, the tax puts their practices squarely in the red. As Wade explains it: “Two entrenched systems, the general excise tax and the Medicare safety net, have intertwined to severely damage our community and its health care. It is a true manifestation of the law of unintended consequences.”

This year also delivered an unexpected blow to new physicians. The state’s loan repayment program was not funded by the Legislature for the coming year, Withy says. The program had already awarded debt-relief grants of $40,000-$50,000 a year to 52 students who committed to practicing primary care and behavioral health care in underserved areas. The grants make lesser-paid primary care positions more attractive as doctors can leave medical school with debts averaging more than $200,000, which can translate into monthly payments of well over $2,000. “I will be begging for money from anyone who will listen,” says Withy.

Source: University of Hawai‘i System, Annual Report on Findings from the Hawai‘i Physician Workforce Assessment Project, December 2019

Add it all up, and the cumulative financial pressures on physicians create what Wade describes as “death by a thousand cuts—you don’t realize what’s happening until you’re about to go extinct.”

In the immediate term, Dr. Nicole Apoliona, medical director of the Kula Hospital, worries about the pandemic’s wide-ranging impacts on both patients and physicians. One concern is that as people are pushed into unemployment, they will lose their private health insurance and turn to Medicaid, the low-income health insurance program that, nationally, only 68% of primary care doctors accept. Suzuka, who stopped seeing new Medicaid patients in 2012, explains that if HMSA pays $80, Medicaid pays $20, further eroding physicians’ ability to keep their doors open.

For his own practice, Suzuka recently grabbed a lifeline and began partnering with The Queen’s Health Systems, which is buying his physical assets and hiring his team of physicians as employees. He still faces a large debt but hopes to pay it off in two years and join Queen’s on salary himself. At this point, he says, it’s about survival and staying in the game. At 61, Suzuka is planning to practice medicine for 20 more years. “I hope to retire at the mortuary,” he jokes.

Photo illustration: Janelle Kalawe-Ching

2) Public School Teachers:

Mass Exodus

Just as people sometimes grumble about physicians being overpaid, teachers are often thought to have cushy jobs that end in the early afternoon, with summers off. Honolulu teacher Phillippe Galicinao describes a far different reality. He switched from a career in civil and environmental engineering to education about seven years ago. Student teaching took him to Wai‘anae High School and then to a permanent position at Hālau Kū Māna, a Hawaiian-focused public charter school in upper Makiki Valley.

“Education has been a huge transition in my personal and professional life,” Galicinao says of the career move. Now, as a math and science teacher, he gives kids a grounding in their culture, which helps them see themselves as capable scientists and makes STEM subjects—science, technology, engineering and math—more relevant. “I feel a sense of kuleana to the work, and I try to make an impact on my students’ lives and on their families and the community,” he says.

The job is deeply rewarding but can be taxing, especially as teachers grapple with new distance learning technology, engaging students via computer and answering questions throughout the day and night. As an engineer, Galicinao left work behind at the end of the day. He now puts in longer hours for less pay, while also studying for a doctoral degree on the side. Getting additional credits and degrees, he explains, is the surest way to earn small pay raises. Driven and enthusiastic, Galicinao faces a common dilemma among his cohort: doing challenging, meaningful work in a system riddled with burnout and an ever-revolving door.

“The teaching itself is amazing, but all the extras—the red tape, fighting for pay—that gets us down.”

—Phillippe Galicinao

And in early August, with COVID-19 numbers rapidly rising, some feared more teachers would leave. While the Department of Education doesn’t release official employment figures until November, Corey Rosenlee, president of the Hawai‘i State Teachers Association, says the union is hearing troubling stories. News had just arrived from Waikoloa Elementary and Middle School on Hawai‘i Island that eight of 44 classroom teachers were taking leave or retiring because of health conditions or child care concerns. “That’s about 18% of the teachers at that school,” says Rosenlee. “I’m worried about our long-term ability to have a teacher force in Hawai‘i.”

Since 2012, Hawai‘i’s public schools have experienced an annual exodus of more than a thousand teachers. Long-term substitutes and emergency hires now fill the gap; many of them are underprepared for the job or are recent transplants who struggle with housing costs. According to Lois Yamauchi, a professor in the Department of Educational Psychology at UH Mānoa, the pay versus cost-of-living imbalance has triggered the crisis-level teacher shortage. “Since furlough Fridays in 2009-2010, there’s been little movement in compensation, especially among veteran teachers,” she says. “It creates a situation where morale is low.”

Yamauchi is a member of Hawai‘i Scholars for Education and Social Justice, a group made up of educators who hope to attract and nurture more highly qualified, homegrown teachers. The notion that people don’t want to be teachers is a myth, she says. The group’s research shows that hundreds of high school and community college students are doing teaching- focused coursework, and about 1,200 students are enrolled in university-based teacher education programs in Hawai‘i. Even among substitute and emergency hires, she notes, many would like to stay in the field and are working toward becoming licensed teachers.

Pay Bumps Help

Interest is one thing. But the number of new graduates is still far outpaced by the number of teachers who leave. To combat the shortage, the Hawai‘i State Teachers Association and the Department of Education launched an ambitious five-year plan to fill every classroom with a qualified teacher. The linchpin of the plan is better compensation. The first step happened at the start of the winter/spring 2020 term, when the Hawai‘i Board of Education approved $14.7 million for nearly 4,000 special education teachers, teachers in Hawaiian-language immersion schools, and hard-to-fill positions in remote areas such as the Wai‘anae Coast, Hāna and rural Hawai‘i Island.

The compensation plan was a resounding success, says Rosenlee. “It helped us recruit and retain 250 teachers, or a quarter of the teacher shortage. And more people than ever are going into special education,” which earns the highest bonus pay.

Yamauchi recognizes that the $3,000 to $10,000 increases are difficult given recent state and DOE budget shortfalls—the entire program was almost suspended, but the BOE voted to move ahead with $30 million for the full 2020-21 school year. “We need to consider that this is a policy that has long-term implications for many children’s lives,” she says. “Research indicates that the quality of children’s teachers is the most important school-based variable related to student learning and engagement.”

The next step in the five-year plan is to lift the salaries of experienced teachers—which are far below similarly high-cost states, often $20,000 less per year, according to a January 2020 compensation report commissioned by the DOE—with the long-term goal of giving across-the-board increases. The state’s economic woes, however, could delay increases indefinitely. As of now, the entry-level salary for a teacher with a bachelor’s degree is $49,100; a teacher with a master’s degree and six years of experience earns $54,169. “It’s a strain for teachers to stay in the profession,” says Galicinao. Many have second jobs to cover rent and student loans, or depend on summer jobs, he notes. “The teaching itself is amazing,” he says, “but all the extras—the red tape, fighting for pay—that gets us down.”

Galicinao is committed to staying. Like many of his peers, he hopes that long-sought pay increases will stabilize Hawai‘i’s 13,000-strong teaching force and incentivize educators to build lasting careers in the country’s most expensive state.

Interested in teaching?
Investigate Hawai‘i’s four-year colleges for undergraduate education degrees or post-baccalaureate certification or degrees. Scholarship information and student loan forgiveness programs can be found at hsta.org.

3) Licensed Practical Nurses:

Bottlenecks in Training

Just 15 years ago, Hawai‘i was in the throes of a nursing crisis, with the shortage of registered nurses reaching 858 and more dire projections for the future.

Today, the need has shifted, says Carrie Oliveira, a specialist for workforce research with the Hawai‘i State Center for Nursing, which was established in 2003 to help deal with the crisis. While staffing for better-paid generalist registered nurses, or RNs, is stable—thanks to heightened interest in the field since the Great Recession, more admissions into college programs and delayed retirements, explains Oliveira—the weakness now is among licensed practical nurses, or LPNs, who work under RNs to administer medicines, dress wounds, monitor patients and more. Unlike RNs who often earn bachelor’s degrees, LPNs complete, at minimum, a 12-month practical nursing program and a variety of prerequisites.

“We don’t have the faculty to run more classes or let more students in.”

— Carrie Oliveira

The shortage has been building since 2015. Since then, nearly 400 LPNs left the field, with most retiring, moving away or training to become higher-paid RNs. By the end of 2019, the statewide vacancy rate was 20%, or about 144 unfilled LPN positions, mostly in community-based settings such as doctor’s offices, outpatient clinics and nursing homes.

The biggest problem is the pipeline. Practical nursing programs in Hawai‘i are competitive, says Oliveira. In the 2018-19 academic year, only about 1 in 3 students were admitted into training programs at Kapi‘olani Community College, Honolulu Community College, UH Hilo and UH Maui. Despite demand, “we don’t have the faculty to run more classes or let more students in,” she explains. And it’s a national dilemma. As colleges compete with hospitals for talent, many potential faculty members choose much higher paying clinical jobs, leaving schools scrambling for professors.

Source: Hawai‘i State Center for Nursing, Hawai‘i’s Nursing Workforce Supply 2019.

Currently, only about 50 new LPNs graduate each year in Hawai‘i. While the shortage is projected to worsen as demand for LPNs grows and more LPNs exit than enter, fixing the problem would require significant funding for more faculty positions. But with UH instituting a hiring freeze and eliminating more than 600 mostly vacant positions in the fall semester, increasing faculty does not appear to be an option right now.

By the end of August, the surge in COVID-19 cases had also spurred a demand for specialty nurses, who are in short supply in the Islands—just 6% of positions are unfilled, but that represents 463 openings—particularly in areas such as emergency/trauma and critical care. The Healthcare Association of Hawai‘i requested that the Federal Emergency Management Agency deploy Mainland nurses to O‘ahu and Maui. At the same time, traveling nurses were already arriving to help overwhelmed hospital staff. According to Oliveira, Hawai‘i’s nursing programs don’t have enough faculty to add specialty training, leaving hospitals to fill the gap with their own training.

Beyond nursing, Healthcare Association of Hawai‘i data points to a need for medical assistants and certified nurse aides, both of which were impacted when the for-profit Argosy University closed in 2019, ending a popular entry route. People in these positions are paid less than LPNs, whose salaries range from $39,890-$62,050. The positions also require less training. Many community colleges in the Islands offer certification, and new partnerships have started between health care organizations and O‘ahu public schools to help students get certified.

Interested in a career in health care? Check out the online Hawai‘i health career navigator, prepared by the Hawai‘i/Pacific Basin Area Health Education Center. It details 92 specific jobs, including salary ranges and required degrees/certifications.

Photo illustration: Janelle Kalawe-Ching

4) Police Officers:

Bucking National Trends

After the police killing of George Floyd and others spurred a summer of protest, images of militarized officers firing tear gas and rubber bullets at unarmed crowds in Minneapolis, New York, Washington and other cities are turning national recruitment efforts into a tough sell. And low morale is driving many to retire.

But in Hawai‘i, where racial dynamics are less fraught, police have largely been spared public anger. Honolulu’s largest Black Lives Matter protest in early June drew record, but peaceful crowds, estimated at 10,000. While the national BLM movement has amplified calls to shift some funding, and functions, from police departments to social services, a recent informal Honolulu Star-Advertiser poll found most respondents wanted to maintain current police responsibilities and funding levels.

Recruitment hasn’t suffered either. “We haven’t seen a drop in the number of applications,” says Maj. Aaron Takasaki- Young, commander of HPD’s Human Resources Division. In fact, the department, which had recently struggled to find recruits, is experiencing a dramatic increase in interest. In March 2020, Takasaki-Young reported that vacancy numbers had climbed to 323, up from 270 the year before. But by June 15, less than three months later, there were just 206 vacancies, with 154 recruits in training—almost double the usual number—who will eventually be added to the 1,842 sworn personnel. The 95 new positions that Honolulu’s mayor added in his pre-pandemic budget remain unfunded, Takasaki-Young notes, and interest in civilian positions continues to languish, with about a third of positions still unfilled.

Source: University of Hawai‘i Community Colleges, Hawai‘i Career Explorer

What is working is a new, faster hiring process. The department now accepts applicants on a rolling basis instead of once or twice a year, which has reduced the processing and hiring time from seven or eight months to just three or four. Through COVID-19 lockdowns, HPD continued recruiting with phone and video interviews, limited testing groups, and temperature checks, facial masks and social distancing.

Applicants must be at least 20 years old, have a high school or GED diploma and pass a background check. They undergo an aptitude test; take physical readiness, psychological and medical exams; and should demonstrate “integrity, maturity and professionalism,” says Takasaki-Young.

Recruits are paid once they begin training at the academy, with wages better than many jobs that don’t require a college degree. They earn $65,652 a year, which jumps to $73,556 after meeting behavioral expectations. Infractions run the gamut from mistreating prisoners to drinking on the job to unapproved absences. After completing the training and probationary period, the base starting salary for a police officer rises to $68,244 annually, or $76,148 with the differential. But Hawai‘i’s high cost of living eats into that figure, notes Takasaki-Young. “We’re also competing with other police departments that offer higher starting salaries,” he says.

But in challenging economic times, says Takasaki-Young, being a police officer means stable work, an important factor in an uncertain employment landscape.

Interested in being a police officer or dispatcher? See joinhonolulupd.org for information and to apply online.

5.) Emergency Medical Services:

Relentless Demands

Emergency medical technicians and paramedics work at an intense pace: 12-hour shifts, with 12–16 calls a shift—responding to an accident victim on the highway, a heart attack in a hotel lobby, an overdose in a bathroom. Between March and July, teams on Oʻahu treated and transported 97 COVID-19 patients and stepped up labor-intensive safety protocols, such as sanitizing ambulances and stations.

The city government department runs 21 units with 260 employees to cover nearly a million residents and, until a quarantine was enacted, millions more tourists. While some thrive in the whirlwind, the demands of the job can take a toll. Over the years, it’s resulted in a huge recruitment and retention problem, says Shayne Enright, Honolulu Emergency Services Department’s public information officer.

“People resign to find work that isn’t as stressful, doesn’t require so many hours and so many calls during a shift,” says Enright. And working in a pandemic is inherently stressful. Five months into the pandemic, the EMS reported its first positive case. “The unknown is always difficult but this unknown could kill you,” she says. “Does this patient have COVID-19? Will I get it? How will I know if I have it? Will I give it to my family?”

Fresh recruits face their own challenges. After completing an intensive one-semester EMT certification class at Kapi‘olani Community College, as well as prerequisite classes, newly hired EMTs undergo a series of evaluations. Many drop out, unprepared for how hard the job is, says Enright. Those who make it are expected to head back to school for paramedic certification; again, many don’t complete the training and shortfalls persist.

Despite the difficulties, Enright says staffing has stabilized since March and the outpouring of appreciation from the public has been gratifying. On the training end, enrollment has soared at KCC, says Jeffrey Zuckernick, chair of the college’s emergency medical services program. Ninety-three students enrolled in spring and fall 2020 EMS classes, up from 61 in 2019. He attributes the rise to outreach to high schools and anticipates another round of increased applicants in response to a stalled economy. “People want a career field that is rewarding and somewhat recession-proof,” he says.

Enright, who is married to a paramedic, thinks the emergency medical services field is great for people who don’t like desk jobs. “Every day is different, every hour is different,” she says. “It’s an adrenaline-fueled career where every move you make could lead to someone having more time with their loved ones.” With starting salaries for an entry-level EMT II at $47,628 and paramedics at $60,888, the pay is better than many other jobs, though still below the “low income” threshold set by the U.S. Department of Housing and Urban Development for a single person in Honolulu: $67,500 per year.

The Emergency Services Department also oversees the 212 ocean safety officers who watch over Oʻahu’s beaches. Starting pay for ocean safety recruits is about $20 an hour. While retention is exceptionally strong, Enright says the department hopes to recruit more officers once the COVID-19 crisis has passed. Additionally, plans are in the works to steadily increase staffing after July 1, 2021, when extended dawn-to-dusk hours are slated to begin.

Interested in serving as an EMT or paramedic? Visit Kapi‘olani Community College’s website for complete information on classes, training and required certifications.

This story originally appeared as “Help Still Wanted” in the November 2020 issue of HONOLULU Magazine. Get your copy at shop.honolulumagazine.com and subscribe to the print and digital editions now.