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Living on Hawaii’s least populated islands means specialized medical care is not readily available. It’s always been part of the reality on Molokai and Lanai, but the challenge has become increasingly severe due to air travel options.

Long drives to reach big-city medical help are common in rural America, where populations are too small to support specialized doctors who diagnose and treat serious and chronic health issues. But on an isolated island, it’s more complicated. 

Residents of Molokai and Lanai rely on airline travel for emergency and even routine medical care. Boarding a plane is essential to see a dermatologist or cardiologist. Lanai residents must also fly for colonoscopies, mammograms, any kind of surgery — even an ankle fracture. 

Women can’t give birth on Lanai, a 140-square mile isle with roughly 3,000 residents. On Molokai, which has a population of about 7,000 residents, only low-risk patients who forgo an epidural can deliver a child. 

This has for generations been the norm, a widely accepted way of life on islands with more dirt roads than paved ones. But then the pandemic hit, slashing flights. 

Molokai and Lanai travelers now have one choice when traveling by air: Mokulele Airlines. Two other airlines that used to serve the islands — Makani Kai and — ceased operations in November 2020 and January 2021, respectively, as the Covid-19 pandemic decimated the travel sector, prompting airline bankruptcies, closures and downsizings worldwide.

The last surviving public airline servicing Molokai and Lanai has since become a target of a months-long barrage of customer complaints over lengthy travel delays and flight cancellations that began early this year. The ongoing disruption has caused many patients to miss pressing appointments with Honolulu doctors — in some cases repeatedly.

“We’ve got many more failure points now in terms of the ability to get patients to see doctors on a timely basis,” said Hilton Raethel, chief executive officer of the that represents the state’s hospitals and other health care facilities. “The access isn’t increasing, it’s decreasing, unfortunately, from what we had even just a couple of years ago. And it’s very, very concerning.”

Mokulele executives publicly acknowledged recent shortcomings primarily affecting Molokai and Lanai residents and promised in March to “step up” service. But the problem goes beyond the temporary air travel mess that is a result of factors ranging from pilot availability and to crowded runways and fickle weather.

An enduring issue is that Mokulele primarily operates nine-passenger Cessna Grand Caravans that can fill up quickly, making last-minute medical travel difficult even when flight schedules run smoothly. 

To better accommodate passengers, the airline announced that it would invest $10 million to order more planes and improve customer service. But, for now, diminished flight options and shrunken seat availability, coupled with a statewide doctor shortage, have widened the disparity in access to health care for Molokai and Lanai residents compared to the rest of the state.

As a result, some residents are flying to doctor appointments a day early and paying out of pocket for a hotel room. Others are putting off their medical care altogether. Doctors, meanwhile, have been forced into the role of travel agent, urging off-island physicians to schedule visits with their patients at times that coincide with Mokulele’s flight schedule and nagging insurance carriers to quickly approve travel coverage requests before the airline’s flights book up.

“We’ve had multiple instances where the patient is not able to get a flight because the insurance company took too long to approve the travel,” said Jared Medeiros, associate medical director at Lanai Health Center. “When this happens and there are no more tickets available for the day of the appointment, the appointment gets pushed back. The patient just has to kind of wait it out. But a week, two weeks, a month — it really makes a difference.” 

Last year a Lanai resident who needed medical care from a specialist in Honolulu missed a May 9 appointment, and then two rescheduled visits on May 16 and July 12, because there were no open seats left on any of the flights to Oahu by the time the insurance carrier approved the patient’s travel coverage, according to Medeiros. The patient finally made it to a third rescheduled visit on July 26 — 79 days after the original appointment.

Medeiros declined to provide details of the patient’s health care issues due to privacy concerns. But he said the unreliability of air travel contributes to poorer health outcomes for Lanai residents.

“We’re not asking for a surgical center to be built here,” Medeiros said. “We’re not asking for a mammogram facility to be built here. We’re just asking for another option so that Lanai residents can travel as easily as everybody else in the state does. Like, what is going on at the Department of Transportation or the FAA for Lanai to not have another option? Why won’t Southwest fly here? Why won’t Hawaiian fly here?”

In the most recent legislative session, which ended last week, lawmakers killed a bill crafted by Sen. Lynn DeCoite that sought to incentivize more air carriers to service Hawaii’s less populous islands by offering to airlines operating out of the Molokai and Lanai airports.

Instead, the that labels the void in consistent, available flights between the rural islands and Honolulu as a health and safety issue. It also urges the to create a working group to find solutions.

“I’ve reached out to so many different airlines from United to Hawaiian to Delta to Alaska and some smaller commuter airlines that I had hoped would consider coming to these airports,” DeCoite said. “I still have no takers.” 

The problem goes beyond . Also to blame is a statewide doctor shortage, a consequence of Hawaii’s high cost of living and limited medical training opportunities that have plagued health care facilities across the islands since long before the pandemic.

At last count, Hawaii has the equivalent of 2,856 full-time doctors. But the state estimates it needs an additional 776 physicians to meet patient demand, according to that tracks Hawaii’s medical professional needs. The greatest shortage is in primary care, with 162 doctors needed across all islands..

In a span of three months last year Molokai lost a pair of longtime physicians when they unexpectedly died. Their absence is difficult to overstate. Together the doctors had provided comprehensive, day-to-day health care to nearly half the island’s population. 

There are now fewer than four full-time primary care physician equivalents on Molokai, according to Kelley Withy, a medical doctor and professor at the University of Hawaii’s . Of the doctors left, more than half are of retirement age. 

No one is waiting in the wings, despite efforts to entice a new crop of doctors to practice medicine on the island with student loan forgiveness and rural medicine mentorship programs.

“This is, in my opinion, the biggest issue on Molokai,” said Kimberly Svetin, president of family-owned Molokai Drugs. “If we don’t have enough doctors or at least nurse practitioners on-island, people are going to start leaving because they need health care.”

A statewide shortage of doctors also means longer wait times for appointments. So when a flight delay causes a patient to miss a doctor visit, the added delay is that much more significant if the patient had already waited weeks or months for the appointment.

Some doctors routinely fly to the neighbor islands to prop up patient access to care. But in many cases the state’s medical workforce is not robust or flexible enough for doctors to peel away from treating patients on more populous islands. It’s also difficult for doctors to travel with the necessary equipment.

“When I even go to my own doctor’s appointments I encourage them to come to Molokai,” DeCoite said. “For some doctors, they feel that the issue is in coming over to see only five or six patients and then what if their flight home is delayed or canceled and they get stuck with a $400 hotel room bill? And then that disrupts all their appointments the next day in Honolulu.”

Delivering more specialized care to patients comes with its own set of complications.

It’s not just about funding the purchase of a device, such as a CT scanner. The equipment requires an appropriate facility — a CT scanner, for example, typically needs to be in a room with a lead barrier on the walls, ceiling, floors and doors to reduce radiation exposure to the patient. The equipment also needs technicians to operate and maintain it.

“It’s just cost prohibitive to have these high tech, advanced services when you have a small population,” Raethel said. “The problem, for example, is you can’t just hire one cardiovascular surgeon because they would have to be on call 24 hours a day, seven days a week. And so you have to hire at least two cardiovascular surgeons, even if you don’t have the volume to support even just one surgeon. The economics of it just don’t work out.”

A silver lining from the pandemic has been the expansion of telemedicine. The ability to access treatment over the phone or internet has helped shore up neglected health care infrastructure in rural communities that are a plane ride away from the nearest medical specialist. 

But there are many illnesses and ailments that can’t be diagnosed or treated remotely.

A flight delay on Mokulele Airlines earlier this year caused Sean O’Keefe, 43, of Molokai to miss an appointment with his cardiologist in Honolulu — his first doctor visit since undergoing a stenting procedure to open the narrow arteries supplying his heart. 

O’Keefe called his doctor’s office and secured a new appointment time later in the day. But when he arrived behind schedule at the Honolulu airport, he said the ground transportation company hired by his health insurer couldn’t accommodate his new schedule. So he missed his second appointment, too. O’Keefe said he waited at the airport for three hours for a car to pick him up. 

In the car on the way to a hotel, O’Keefe said his doctor’s office called him with a third appointment slot at a different medical center. But O’Keefe said the shuttle driver refused to drive him to a facility outside of what was agreed upon with the insurer.

He was finally able to see his doctor the following day after spending the night in a hotel.

“This has caused me so much anxiety,” O’Keefe said. “Three or four days before any flight to see my doctor I’m so anxious that I can’t sleep.”

Civil Beat’s coverage of Maui County is supported in part by grants from the Nuestro Futuro Foundation and the Fred Baldwin Memorial Foundation.

Civil Beat’s health coverage is supported by , Swayne Family Fund of Hawaii Community Foundation and the Cooke Foundation.