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State funding for the Waianae Coast’s only emergency room has stagnated for the last 16 years even as subsidies for other rural health centers in Hawaii have increased, a Civil Beat review of budget records has found.

The Waianae Coast Comprehensive Health Center on Oahu’s Westside started receiving state funds to cover overnight emergency room operations in the 1980s. Since 2008, its allotment has averaged about $1.4 million a year.

A health center in Hana that gets state funding for services that include urgent care saw its four-year contract with the state rise more than 19% between 2016 and 2020, to $5.4 million; a four-year contract with the Molokai General Hospital that includes emergency services went up 3% during the same time period.

Meanwhile the center in Waianae, which serves nearly 50,000 coastal residents, has had to pull operating revenues – including from patient services – to cover millions of dollars in budget shortfalls each year to keep its emergency services staffed between 12 a.m. and 8 a.m. daily.

“We do what we can but we can’t reach our dreams,” said Stephen Bradley, director of medicine at the Waianae Coast center.

Health center executives would like to use those funds to instead increase mental health resources after a string of deadly shootings – which they have called a public health crisis. Those executives held a press conference last week where they outlined a roadmap for trauma recovery and called for more government support.

Top of mind is an expansion of a program that places clinical psychologists in area schools.

Bradley said in an interview that they’ve asked the Department of Health why the emergency room subsidies have not increased, but they haven’t been given a clear explanation even after providing data points on how their costs to operate the ER have increased.

In response to questions from Civil Beat about disparities in funding for the health centers, the DOH said in a written statement that the Waianae center could receive more if it documents its uncompensated costs between midnight and 8 a.m.

It costs the center about $5.7 million a year to operate emergency services during those hours, according to health center officials. In addition to the emergency room, the center needs to keep its lab and other services such as medical imaging open overnight.

Officials at the Waianae health center are projecting a $4.5 million shortfall this year for their overnight emergency services alone.

Overall, operating the emergency room requires about $13.3 million a year.

Hawaii has 14 federally qualified health centers that provide medical services to people with low income or those without medical insurance. They’re paid for in part by the state’s tax on tobacco products. That covers primary care services at the health centers and helps subsidize emergency care in Waianae and in Hana on Maui.

That funding source has grown over the years, with a current cash balance of about $18.8 million. Spending is capped at $12.4 million and actual expenditures topped $10.5 million last fiscal year, according to a .

“There is room for the Department of Health to actually increase the allocation to Waianae,” said Eric Abe, policy director of the Hawaii Primary Care Association.

The Waianae Coast Comprehensive Health Center recently signed another four-year contract locking its emergency room subsidy at $1.4 million a year through at least 2028.

The Only Emergency Room

Waianae Coast Comprehensive opened its emergency room in 1976 with limited hours. The Legislature began allocating funds to the center in 1986 to keep its ER open 24 hours a day.

“Waianae residents are the only people on Oahu who are not within 30 minutes of a full service hospital,” lawmakers wrote in a committee report on the budget that year. “The upgrading of this facility will lead to increased accessibility to quality medical services.”

Without traffic, it’s about a half-hour drive to the next nearest emergency room at The Queen's Medical Center - West Oahu in Ewa. Pali Momi in Aiea is at least 45 minutes away. With traffic it can take more than an hour.

Last year the Waianae center had more than 21,000 emergency room visits.

Surgeries can’t be performed there, Bradley said. But the emergency room can handle most other critical incidents before releasing people back to their homes or to other hospitals.

 “Anytime the TV comes on and you hear so and so is brought to the local hospital  — well, the local hospital is Waianae’s emergency room,” Bradley said.

Other Programs Grow Slowly

The impasse over emergency room funding is stalling the health center’s expansion at schools on the Waianae Coast. It currently has three clinical psychologists, four advanced practice registered nurses and one social worker to cover six campuses. 

The goal is to be in every school on the coast, including elementary schools, which would require about six or seven additional clinical psychologists, along with other health professionals.

Under a partnership with the state Department of Education, those teams work out of offices and rooms that they convert into satellite clinics at the schools. The center pays for all the medical equipment in those clinics.

Workers say they help teens dealing with relationship issues and transitioning from middle to high school. They’ve also worked to develop unique solutions for their high population of Native Hawaiian students with a particular focus on culturally based education.

For the last two years, the health center ran a leadership program for high school students called Hooulu Na Mamo. 

“We teach them how to malama themselves, how to take care of themselves through traditional practices,” said Ariel Panui, a social worker at the satellite clinics. “They can have a foundation and become better leaders. The more they learn about their own culture and themselves the better leaders they will be for future generations.”

Other Health Centers Saw Increases

The annual state contract with Hana Health is now at $1.8 million, up from $1.1 million last fiscal year based on the center's documented cost reports, according to the DOH.

Cheryl Vasconcellos, executive director there, said the state’s subsidies account for about 25% to 30% of her clinic’s annual budget.

Vasconcellos said Hana Health’s role is much different than Waianae’s. For one, Hana Health serves a much smaller population. The goal is also just to stabilize patients before they are taken to Maui Memorial Medical Center, which is several hours away. 

Vasconcellos said she’s thankful for the state’s support.

“Hopefully it will increase going forward, like all of us want,” she said.

Support for hospitals serving rural populations under the Hawaii Health Systems Corp. has increased. The health system includes hospitals in rural parts of the Big Island as well as on Maui, Lanai and in urban Honolulu. The Legislature increased the general fund allocation for the health system’s hospitals from $105 million in 2016 to $160 million in 2024.

The Waianae center, however, is not part of that health system and doesn't get funding through its appropriations.

Looking For Ways To Stay Viable

Lawmakers have looked for other ways to help buoy the Waianae health center’s emergency room.

In 2023, the Legislature approved a $1 million grant for overnight operations. The health center received funds for a renovation project.

But permanent funding increases have been hard to come by.

In 2019, lawmakers proposed earmarking $5.2 million in the state budget each year for emergency services at Waianae Coast Comprehensive, but that measure failed to pass. Another measure in 2022 to give additional funds to the center annually also failed.

Although the center has had to move money around to cover those deficits, it’s still financially healthy. Its most recent tax filings show $94.3 million in total revenues against $89.1 million in total expenses. Its revenues included $13.3 million in government grants.

“We’re a strong health center, and we’ve overcome the fact that we have not had an increase in these subsidies,” said Nicholas Hughey, the center’s executive vice president.

Civil Beat's coverage of Native Hawaiian issues and initiatives is supported by a grant from the Abigail Kawananakoa Foundation.

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