For those living in rural areas of Hawai‘i, a missed flight is not just an inconvenience — it can become a missed diagnosis, delayed treatment, or a life-altering emergency.

Our team at the University of Hawai‘i System Rural Health Research and Policy Center has spent the past year exploring the impacts of transportation and travel access on rural health in Hawaiʻi, which has culminated in a four-part report series that summarizes extensive discussions with stakeholders as well as policy options related to emergency medical services, non-emergency medical transportation (NEMT), insurance coverage, and maternal-fetal health.

System Fails Those Who Need It Most

EMS professionals work tirelessly to serve their communities 24/7 within challenging systems and limited resources. In some rural areas, residents may wait up to two hours for EMS to arrive, which can prove fatal for those suffering heart attacks or strokes.

As one Hawaiʻi Island emergency medical technician told us, “EMS systems are being over-utilized, and service levels are unsustainable.”

For air EMS services, the state has a limited number of helicopters equipped for aeromedical transport, creating dangerous bottlenecks when multiple patients need emergency air transport simultaneously.

When community members need routine health care not available on-island, they often must travel long distances by car or by plane for more comprehensive services on Oʻahu or Maui. Residents often need to travel with a companion and lodging can be expensive and is rarely covered by insurance.

Costs for lost work and child care and/or elder care also add up. Frequent airline delays and cancellations — due to weather, mechanical issues, or limited aircrafts — often force patients to postpone or forgo critical appointments and surgeries. Molokaʻi and Lānaʻi are particularly affected by unreliable air service.

The patchwork of insurance coverage for transportation creates barriers to healthcare access. Patients with Medicaid, the primary statutorily-required provider of non-emergency medical transportation, often face delayed transportation approvals in addition to limited coverage for companions or lodging. Traditional Medicare, on the other hand, does not cover NEMT, and most private insurers rarely cover medical travel for patients or associated costs.

Solutions Within Reach

While transportation is among the most critical social determinants of health, especially in rural areas, solutions exist. Federal, state, local, business, and philanthropic funding streams are available if we have the will and budget to act.

We offer many policy options that could make a significant difference for patients, families, and providers in rural Hawaiʻi.

Expanding EMS capacity requires significant investment in both ground and air resources. Counties and the state could conduct needs assessments and invest in ambulances and rapid response vehicles in most in-need areas.

For air services, the state could explore creating a public air ambulance service, as proposed by Hawai‘i Senate Bill 3126 (2024). Creative preventive programs that expand the reach of primary care providers, such as paramedicine programs or expanded teams with clinical pharmacists and community health workers, could reduce EMS burden by addressing patients’ health issues earlier.

Building on a promising pilot program through the state Department of Health, the state could create subsidized inter-island flight programs for Hawaiʻi residents’ medically necessary travel. The state Department of Transportation could co-administrator programs in partnership with DOH to assist with airline engagement and airport coordination while exploring alternative, sustainable transportation modalities such as water planes, seagliders, and ferries.

Community-based organizations could be funded to coordinate travel arrangements for rural patients. State and federal agencies could improve airline accountability through systems to register community complaints and contribute to oversight of Essential Air Service programs. Infrastructure investments, like extending Molokaʻi Airport’s runway, could also expand service options.

Federal policymakers could mandate non-emergency medical transportation in traditional Medicare. State legislators could require private and employer-based insurance plans operating in Hawai‘i to cover transportation, lodging, and companion travel for necessary care. The Med-QUEST Division could streamline Medicaid NEMT approvals from weeks to days.

For mothers in rural areas, state grants could support community-based organizations to provide housing for pregnant patients who must travel for care. Healthcare systems could incentivize maternal-fetal health specialists to travel to neighbor islands and leverage centralized scheduling and resource-sharing platforms.

The creation of regional telehealth hubs and mobile maternal health clinics could bring prenatal and postnatal care directly to rural areas, while healthcare providers could expand telehealth capabilities to provide remote monitoring and consultations to reduce patients’ travel needs.

Expanding telehealth availability is critical, including providing telehealth equipment to rural facilities, offering training and technical assistance for providers, lifting federal and state restrictions on telehealth, leveraging libraries as telehealth access points, and expanding broadband coverage to ensure reliable connections for remote prenatal care.

The Path Forward

Hawaiʻi’s geographic challenges are unique, but they are not insurmountable. With coordinated investment and policy action, we can ensure that all residents — regardless of which island they call home — have equal access to the care they need.

To learn more about our project and recommendations, please visit here or email [email protected]. The public is also welcome to attend an upcoming webinar on this project hosted by the Hawaiʻi Public Health Institute on Aug. 18, 2025 from noon to 1 p.m. Click here to register.