A bill introduced this legislative session would have required local medical school graduates to work as physicians in Hawaiʻi for two years after graduation.
While supporters said it would have helped tackle Hawaiʻi’s physician shortage, the bill has died this session.
Senate Bill 101 applied to students paying in-state tuition at the University of Hawaiʻi John A. Burns School of Medicine, commonly called JABSOM. They would have to work as a physician in the state for two consecutive years after finishing their residency or fellowship.
As of 2023, the UH System reported 3,599 physicians that provide active patient care across the state. But not all of these are full-time workers, meaning there’s roughly 3,022 full-time equivalents of care providers. After some data model adjustments, this leaves a reported shortage of 757 FTEs statewide.
Eric Abe, the public affairs and policy director for Hawaiʻi Primary Care Association, believes that students who get to pay a lower price while attending medical school have a responsibility to serve their home state.
“Our organization believes that it's totally appropriate that if taxpayer dollars are going to be used to help Hawai’i residents obtain the professional training needed to become a physician or a health care worker, it's very much appropriate to have them actually serve in the state that they benefited from getting that training,” Abe said.
But JABSOM Dean Sam Shomaker said he is concerned that enacting this requirement would be daunting for many students. He said implementing this commitment might have an adverse effect, leading to even fewer local physicians in the future.
“We wouldn't have as many local applicants as we have now,” he said. “If they were forced to commit to coming back here after they finished their training, some students just wouldn't want to commit to that long-term, not to mention how difficult it would be to enforce that.”
JABSOM is a four-year program, and residencies range from three to seven years. If a student decides to do a fellowship, that would add one to three years. This means that under this bill, the commitment to staying in Hawai’i post-residency would have to be made by students often more than 10 years in advance.
Dr. Lee Buenconsejo-Lum, the associate dean for academic affairs and family medicine professor at JABSOM, said she had no idea what specialty she wanted to pursue when she started medical school, and that asking students to commit so far in advance wouldn’t be smart.
“I would say there’s probably less than 10% of people who come in who know what specialty they want to do and actually end up in that specialty,” she said. “We want them to go through medical school with their eyes and hearts and brains wide open, not tied down.”
Each year, JABSOM gets over 2,000 applications for its class size of 77 students. Local students make up 90% of the class and pay the in-state tuition fee of roughly $37,000, versus the out-of-state tuition of $74,000.
The cost of living, specifically housing prices and student loan debt, plays a large part in deciding whether or not a student can afford to stay in Hawai’i for their residency and beyond.
“Even for folks that grew up here and have deep family ties here, they can pay off their debt faster, actually own a home, and afford to send their kids to good schools in places back on the continent,” Buenconsejo-Lum said. “When you’re $200,000 in debt, you can’t just stay in the place that has the highest cost of living and arguably the lowest wages.”
But for Abe of the Hawaiʻi Primary Care Association, the physician shortage is “past crisis.” He said action needs to be taken in some form. He explained that telehealth has become the default for providing health care services for many areas, but this poses its own problems because rural areas have weaker cell service, so telehealth is not always reliable.
“We've been at a critical state for the past generation, and it's getting so bad that even providing basic health care or basic services to communities is a major problem,” Abe said.
He noted that some of the poorer areas that have higher reports of crime and gun violence are hit the hardest.
“Many of those physicians are saying it's too dangerous to go there so it's not worth it,” he said. “Something like 85% to 90% of our clients are all Medicaid recipients, meaning there's no money for physicians to make off of most of the clients we serve.”
Alternative ways to fight the shortage
Nearly 9 out of every 10 JABSOM students qualify for need-based aid, and roughly 20% receive full-tuition scholarships. Without this financial assistance, Shomaker said the majority of the local students wouldn’t be able to afford medical school.
Currently, JABSOM is working to provide more scholarships to students who commit to working in the state, especially on the neighbor islands. Shomaker said the goal with these scholarships is to combat the shortage and relieve financial pressure, while ensuring that the student’s decision to stay in Hawaiʻi is more voluntary than required.
Another tactic that JABSOM is pushing for is increasing the number of residency and fellowship training options offered locally. Shomaker believes there is a direct correlation between where a physician trains and where they end up staying, but many specialties aren’t offered in Hawai’i because of its geographic isolation and patient volume.
Abe believes legislation is the most powerful and direct change. He has seen similar bills die in the past and is encouraging lawmakers to keep pushing.
“What we really need from our lawmakers is stubbornness,” Abe said. “They need the ability to just keep pushing the issue, to try to maybe look outside of the box and try to address the problem in small doses. The problems themselves are so big that if you try addressing it straight on, you’re just going to get crushed.”
Shomaker emphasized that, despite the persistent shortage, the state has the highest physician retention rate in the country and JABSOM students continually prove their dedication to Hawaiʻi and its people.
“We have students who are tremendously committed to this state,” Shomaker said. “In most cases, they have every intention of coming back, but they need to have the freedom to pick the specialty they want and come back on their terms and not be forced to do so in a way that would distort their career opportunities.”
