Bill Finerfrock: Welcome everyone to The Health Disparities Podcast hosted by Movement is Life. Our guest today is Dr. Josh Green, who is the Lieutenant Governor of the great state of Hawaii. Welcome Dr. Green.
Dr. Josh Green: Sure. Hey, thank you. Please call me Josh and I’m so happy to be here.
Bill: We appreciate it. We were just chatting. What a long haul to come from Hawaii and we’re recording this in Washington DC and it’s quite a trip.
Dr. Green: It is. It makes it a challenge sometimes to be an advocate on national issues from Hawaii, though Hawaii has a history of leading on certain health issues. Like we were essentially the first state to have universal healthcare coverage. That was The Prepaid Health Act of ‘74. So, we tried to weigh in, but people do perceive Hawaii as paradise and a beautiful place to visit, but we also have regular life going on over there. So it’s nice to you get to DC.
Bill: Yes. I wanted to explore that a little bit because you’re right. I mean, when someone thinks about Hawaii, it’s like, oh, it’s paradise. And the thought that there are health disparity issues, there are health access issues there, it almost seems like, oh no, that couldn’t possibly happen in paradise. Can you talk to our audience a little bit about what kind of health disparities exist in Hawaii and then you have the multiple islands and it may vary from island to island?
Dr. Green: For sure. So, Hawaii is yes, a beautiful place with beautiful people and a lot of great opportunities to care for one another. It’s the healthiest state, we have the longest lifespan and most of our indicators on healthcare matters are just transcendent because people have gotten a lot of primary care and coverage. However, we also have a lot of people that struggle. I went to Hawaii actually to be in The Health Service Corps, The National Health Service Corps because there was no access to care on the big island, our largest land mass in Hawaii, in the southern part. There were 8,000 people that had no healthcare provider, no physician, nurse practitioner, PA at all for a time and so they placed me there with The National Health Corps. What has happened in Hawaii is certain of our ethnicities struggle more. For instance, the Native Hawaiian community lives on average, a decade, less than the Caucasian or Japanese community and most of that’s because of poverty, health disparities, and all the things that we’re talking about at our conference and are talked about nationally. So, that’s been a huge issue. We also note that for instance, the Filipino community, which is very prevalent in our state, that community also really struggles with things like kidney disease and liver disease. So, there are certain health disparities that are magnified depending on which ethnicity is being affected. We’ve seen a lot of things with COVID that have been uncovered like our non-Hawaiian Pacific Islander community with a lack of access to care had a huge surge of COVID and a higher mortality rate. So, these are real problems that we face. Hawaii is interesting in that there’s no majority ethnicity, so Caucasians, Japanese community, the Filipinos, and so on, Hawaiians are all about equal in number plus or minus a little bit. And so, when you look at Hawaii, it’s a great melting pot, but there are these disparities.
Bill: The other thing that I think a lot of people don’t necessarily realize is how rural Hawaii is. When most of us in the lower 48 think about rural, we think about places like Montana and Wyoming and since I suspect most people have never visited Hawaii, their impression is what you see in a TV show or see in a movie which tends to be more the cities. Talk to us a little bit about how rural actually Hawaii is and some of the challenges that the state faces getting healthcare to people who live in the more remote areas.
Dr. Green: You bet. Well, there are several islands. For example, most people, like you mentioned, when they think of Hawaii, they tend to be thinking of Oahu or Waikiki. And, you know, we’ve had these television programs, which are great shows like Hawaii Five-O and other kind of entertainment that gives people this impression, oh, it’s a city, which Honolulu is a beautiful city, but most of the state is very remote and rural. Now, Big Island, for example, it’s called the Big Island, because it’s so large. It’s also called Hawaii Island is where I was assigned for the health corps and that area of Kau is actually a vast, vast land mass bigger than all the other islands together, essentially. And it has a desert in it. It has a volcano on the edge of it. It had less than four people per square mile, which is one of the definitions of frontier and that’s why there was a health core associated position. And so you have that. You have rural Maui over in Hana, which is again, a very rural area. What we tend to do in our rural areas in Hawaii is we have community health centers. It’s a big part of our system. We funded community health centers with tobacco settlement funds and tobacco taxes. And so we have a vibrant community health center system, so that doctors like me can come and work in the rural areas with nurse practitioners and PAs and get people the care that they otherwise wouldn’t get. We also don’t have a lot of access to behavioral healthcare. So, drug treatment and mental healthcare often kind of fall behind in the rural areas like a lot of our country, because it’s hard to get a psychiatrist or a psychologist to go to a place where they might not like technically have enough patients in the area to care for, but the need is there.
Bill: So, as we mentioned, you’re a doctor and you’re Lieutenant Governor of the state. I don’t know how many doctors there are who are in a similar position around the country. But how has your experience as a doctor affected how you do your work as Lieutenant Governor and looking at health policy potentially or other issues? Are there experiences that you bring to your job as Lieutenant Governor that are really informed by your experience as a physician?
Dr. Green: Yes. Being a physician in Hawaii informs everything I do as Lieutenant Governor. I first served in the state house. I finished my health corps assignment and then moved over to emergency medicine, which was always kind of a passion and love for me. And I in the house would work every weekend, pretty much of the whole year. And then as a senator, state senator, same thing, three or four weekends a month in the ER in rural areas. Number one, cause we were so short and two, because I always wanted to keep a real perspective. Our legislature like many legislatures isn’t full time, so it was able to do it. I mean it’s tiring, you know, bags under my eyes most of the time because of that. But it really is helpful to see people when they’re dealing with their greatest challenges, whether it was the methamphetamine explosion that occurred in rural America, which also occurred in Hawaii and is very, very problematic or the problems we had with controlled substances. A lot of people became addicted to opioids. The opioid epidemic, where there were tons of overdoses. Though Hawaii had the lowest rate in the country, it still was really difficult to handle. And lots of families, you know, were destroyed by that drug or those drugs.
So everything I do is a reflection of some perspective I have as a physician. That doesn’t mean it’s all healthcare related. Sometimes it’s economic and I’m able to discern where people’s economic challenges are. Other times it’s infrastructure questions just because a hurricane comes or a tsunami or interestingly in Hawaii, the volcano erupts and it takes out roads. And so I get to reflect on what the challenges are and then I’ve done this still as Lieutenant Governor, I just do a little less. I do two weekends a month. So, it still keeps me relatively normal. I think I’m the only physician in the executive branch now in the country. We did have one other, which was the governor of Virginia and their election just took place.
Bill: Yes, that’s right, Governor Northam.
Dr. Green: Exactly. But it’s been helpful for me. And then of course the pandemic occurred. Now, for many years, the Lieutenant Governor’s position was really a ceremonial position in Hawaii and you’re just there in case something happened to your governor, but with the pandemic, they did find a way to utilize me. So, I’ve been the liaison for the whole state, which means coming to DC, talking to excellent people like you guys, talking to our healthcare system and all the hospitalists that I work with routinely as a colleague. Keeping kind of the lid on COVID in Hawaii has been my task and I’m grateful for having had the job, although it’s been very rough to watch people struggle.
Bill: Yes. Yes. You mentioned that you came to Hawaii through The National Health Service Corps, so obviously you didn’t grow up there. When we were talking earlier, you grew up in Pennsylvania and I have to imagine there was a certain cultural shock. Talk to us about how coming from Pennsylvania and finding yourself in an environment that’s much more diverse environment than I suspect you experienced in Pennsylvania, making that adjustment, understanding the culture of the patients that you are working with.
Dr. Green: It was a great experience. I came to Hawaii when I was 30 years old. I just finished my residency at the University of Pittsburgh. Great residency program and had so many wonderful mentors, but I was looking for a new adventure. I figured at first I’d probably go work in one of our cities here in the east – Philadelphia, New York, DC just because culturally I was very well acquainted. My family is my mom’s Russian Orthodox, my dad’s Jewish. I grew up in one of those households that were very typical of Pittsburgh going to the inner city, in one of those cities would’ve made sense for me. But they didn’t need me really. There were a lot of extra providers that already fit that bill and I was contacted by this wonderful gentleman pediatrician out in Hawaii who had heard about me a little bit and invited me. I wasn’t married yet. I got married five years later to a wonderful local girl who’s a lawyer, Jamie, in Hawaii. But I was pretty unattached and I was able to go and I immediately had this incredible experience where most of my patients were Hawaiian or Filipino. All of my nurses were Filipina. And you know, I was definitely a fish out of water although a lot of people liked having a doctor from afar because I had a good education and was grateful to have been able to bring some skills to a very rural place. So, over the course of about six months I acclimated and before I knew it every moment of every day and every evening was filled with delivering care. So, it’s a good way to go if you’re a doctor and you want to be immersed into a culture because you just get thrown into it.
Bill: Well and because it’s an island and it’s pretty far away from everything else, it’s not as though you can easily go and go to an area where you’re perhaps more comfortable culturally. So, you’re really immersed literally in that environment. You mentioned that Hawaii was the first state to adopt a universal healthcare program. How does that work and are there lessons that you’ve learned in Hawaii that are applicable to the lower 48? I know when The Affordable Care Act was being debated people referenced that but everyone’s like, oh, well, Hawaii, it’s isolated, it doesn’t have border issues where you’re gonna have bleeding over and stuff. Tell us a little bit about your experience with the universal program and are there things that we can learn that would be helpful to the nation?
Dr. Green: Well, I think so. Interestingly, when President Clinton and future Secretary of State Clinton were working on the potential for a universal healthcare plan back in the, I guess that must have been the nineties, they had a lot of experience and a lot of guidance from Hawaii. The way Hawaii’s program works is it’s called The Prepaid Health Act, which is essentially, if a person works half time or more three weeks out of the month, they must be given healthcare insurance. And in our state we also have a very vibrant Medicaid program. So several years ago we had about one out of every six of our people on Medicaid. But then when the experience with COVID occurred and a lot of extra poverty and a lot of challenges with the economy, it’s now actually up closer to about one in really it’s getting toward one in three people who are on Medicaid. Over 400,000 out of our 1.4 million citizens need some assistance. But what that has meant is everyone is covered with a very, very small sliver of exceptions. And those individuals usually are choosing not to be covered for some other reason. They may have secondary coverage elsewhere, or they’re only part-time in Hawaii and they can’t really lay claim to being a citizen. Plus we have a lot of military.
So Hawaii is very well covered. It means that people can always find a healthcare provider as long as there’s a provider in that class to care for them. Sometimes that’s a challenge too, because we’re so rural we may not have a rheumatologist on the big island, or we might not have a hand surgeon on Maui, or we might not even have enough primary care providers in our rural communities like everyone’s, you know, struggling with. So, we do have challenges, but because people by and large are able to get primary care, get their vaccinations. The vaccination rate for Hawaii with COVID has been extraordinary. We have, as of this moment, it’s 71.5% of all of our citizens are fully vaccinated. 81.5% of our whole state is at least partially vaccinated. And 95% of all those who are eligible have at least had one shot. So, we’re super vaccinated because everyone can find a provider. So, if the country wanted to go this direction, they could. It’s an interesting situation. What it does is it does place a significant burden on the employer. However, you don’t have cost shifting all over the place, which means you don’t have to subsidize hospitals and other services. So, it’s one way to go. I’m not saying it’s the only way to go. And, obviously, The Affordable Care Act did certain other things.
Bill: Right. So, you mentioned availability of specialists. And one of the things that has occurred during COVID, we’ve seen a dramatic expansion in the utilization of telehealth and the public health emergency allowed the government to lift some of the limitations and restrictions. How typical is it in Hawaii? Has telehealth been generally available and how have some of the expansions affected the availability of telehealth?
Dr. Green: I’m glad you asked that question. It’s actually been quite extraordinary. Before COVID occurred before all of the isolation that people struggled with, only 1% of our healthcare providers were doing telehealth in the whole state. Now, it’s over 50%. And interestingly, Hawaii, because it’s partially a resort and retirement destination, not just for other people who have retired, but doctors and nurses, a lot of people come and have a license but don’t practice. They can keep their license up. Right? So, we have 4,000 full-time healthcare physicians. Sorry to not expand it to nurses, that number is like 13,000. But 4,000 physicians are licensed and practicing full time, but there are 9,000 fully licensed physicians. So, we have 5,000 physicians who are retired or on the bench or doing something else. A lot of that’s because they just don’t want to work full time anymore. They don’t want to pay for the infrastructure costs or the liability concerns that may exist, although there’s not really much malpractice in Hawaii to be frank. But that could change because with telehealth and I’m hoping to solve our shortage issue, we’re about 800 to 1,000 physicians or mid-level providers short in our state. I think that that can be remedied immediately if we’re fairly progressive on using telehealth and letting some of these providers just do that with our plans, whether it’s Kaiser or Blue Cross Blue Shield, which is called HMSA in our state or some of the other smaller plans.
These are real opportunities and I think America should take a hard look at this because though some people think it undermines direct care and direct delivery of care, they’re just so many people that really want to avail themselves of telehealth. Millennials, for sure, sometimes older people now, if they are becoming more tech savvy, they have no problem doing it. Or they have a son or daughter, niece or nephew that will help them get online and do it. So, I think that’s gonna be a big part of our future. It’s a lot easier to do than trying to expand your population of providers by say 20% or 30%, which costs a lot and takes many years.
Bill: There are a number of policy issues that affect the availability or the ability to use telehealth. One of those is also broadband and availability of high-speed internet. Do you have those issues in Hawaii and an availability of the internet in order to allow people to have that kind of robust interaction because they have high speed internet available.
Dr. Green: We do have that challenge and that’s actually part and parcel of the healthcare disparity question because once again, not only are people in rural areas less likely to have a healthcare provider, they’re also less likely to have broadband and so this is something that we wrestle with all the time. Now, we partner with military very vibrantly in Hawaii, particularly in the rural areas where they set up training facilities. And so that helps us, that helps us get in partnership, a lot of extra broadband coverage. Sometimes, it brings providers to us, but usually they’re military providers and work on the base. So, that is a central part of healthcare reform for us. Like to give access to healthcare doesn’t just mean to find a nurse practitioner or a family doctor, a lot of times it also might mean an internet connection now. So, as I talk to you about this, I’m actually gonna be having meetings here in Washington on that matter. I’m meeting with Apple computer to discuss some advanced programs that they might want to do with the state of Hawaii. Lots of great allies that I don’t know if it’s Hawaii that attracts them. It can’t possibly be me that’s attracting them to this proposal, but I think that there’s a lot of future because people are now viewing Hawaii as a safe haven after having the second lowest rate of COVID and second lowest mortality rate in the country, we’re pretty well protected. We did a decent job stopping the pandemic. We did have the ocean around us, which helped, but remember we have millions of people that visit. And I think a lot of people are going to decide that Hawaii will be another part of their experience, whether it’s their business experience or their life experience. So, we’re looking for people that have these kinds of capacities to come to Hawaii and be a part of our solutions. I think a lot of it’s going be tech.
Bill: Well, you know, I hadn’t thought about it in some ways. I mean, the fact that you’re surrounded by an ocean gives you kind of a moat, if you will, but your second point was, you know, tourism. And that had to be a struggle of finding that balance, because if it’s such a key part of the economic life blood to not shut that off, but yet maintain the ability to protect people or who’s coming in and what is their level of, you know, are they infected or not? So was that a pretty tough challenge?
Dr. Green: It was an incredible challenge. So, I remember sitting on a lanai, that’s what we call a porch in Hawaii, and watching cruise ships come in. And I had privy knowledge of some of the spread of the virus across the globe through security clearance and so on. So, I was seeing what was happening and I realized Hawaii was about to get crushed. So, we called many emergency meetings in the early days, and we decided to do almost the unthinkable, which was stop all travel to Hawaii for several months. That was in March of 2020. So, we dropped tourism numbers, 99.6%, which even as I say it and reflect on it was shocking because that was almost our entire economy. Now, we were making a calculated bet, which did work out that the federal government would come to the aid of all states and help us survive, which it did. Now, that kind of isolation was challenging. The health consequences were very challenging, but we shut down for a while. And then my team and I built a program cause I knew it couldn’t go on forever called The Safe Travels program or Hawaii Safe Travels. And what that was unique. Alaska was doing something like this and some of the islands in the Caribbean were also doing it where you essentially had a mandate where you had to be, there wasn’t vaccination yet remember. You had to be tested. We didn’t have a vaccine until towards the end or even beginning of 2021, right. End of 2020, beginning of 2021. So, what we did was we mandated that people have to get a PCR test, a nucleic acid amplification test within 72 hours of their travel to Hawaii. Had to be negative, of course. And then you could come in and be in Hawaii and, you know, live it up. So, that worked.
We went almost immediately back to like 70% of all of our capacity before people got comfortable and then we went to 110% of our capacity briefly, because people were dying to get out of cities and stuff. So, it worked. We normally get about 10 million visitors a year, which is probably even a little too much. Last 12 months from my perspective we got 82%. We got 820,000 people used the safe travels program. And it was important not just to bring visitors and tourism, which was critically important, but also because, you know, you had to go see your mom or your dad or family members or your people were taking their children to college. So, it was a pretty serious success and not perfect, but all but about 8% of the people were able to navigate the program. Those individuals had to go into quarantine, which believe me, they were upset about cause they all called me and told me how upset they were, but it was meant to keep us safe.
Remember we have a challenge of spread, not just from mainland US in Canada, but also, we’re a very serious hub for Japanese tourists, Chinese tourists, people from Korea, the Philippines. So, as a global destination, we had to be safe. We still have this program in place. We added vaccination status many months ago. And so now you can either be vaccinated or pretested. And interestingly, the federal government appears to have emulated our program for international travel, which goes live on November 8th.
Bill: Just a couple days.
Dr. Green: Yes. So, it’s been one of those things that we exported a decent idea, and it seems to have taken hold.
Bill: Good. Did all of that create some mental health challenges? You know, because as you were talking, we talked about the idea of tourists coming in, but you made the point that, well people who are on the island perhaps want to get off, either go visit family or just, I need a change of venue, of scenery and that restriction, that limitation that on the mainland again, if I needed to get out of Virginia, I could go to Maryland, I could go to North Carolina. You were pretty isolated. Did that create some specific mental health challenges?
Dr. Green: It did and it’s tragic to report. I have a keen awareness of increases in self-harm. We had a lot of additional domestic violence. All the call lines saw incredible increases and it’s part of human nature sometimes to struggle and suffer and take it out on ourselves or others that we love and not condoning it, it just happens. So, we saw big increases in depression, anxiety. I saw that in the ER constantly. Many people came to the hospital for those kinds of problems rather than the regular stuff like heart attacks and pneumonias. I saw many more people with behavioral health problems, new addiction and depression and suicide attempts than I saw with COVID. Even though I saw plenty of COVID and treated a lot of people with the virus, I saw many, many more with the consequences that came with COVID, which was the isolation. I actually, and I intend to talk about this tonight in our plenary session, I believe that the United States has gone through or is experiencing a pandemic traumatic response. Basically a post-traumatic stress disorder that’s brought on by the pandemic itself and mostly it’s isolation, although it’s also uncertainty. I caught COVID when I was 50, so a year ago. One of my dear friends at age 51 who is a very prominent writer here in the mainland died of COVID and he was an athlete and very healthy. So, it affects everyone differently, but the specter of catching a virus that you can’t see, the specter of having your economic survival be curtailed, because people are locking things down, that was really tough.
Bill: Yes. And you touched on the different effect it has on people. I mean, you hear the well, the comorbid conditions individuals and we get that. That makes sense. But then your friend as an example, who’s the same age roughly, healthy, otherwise unencumbered, and yet for him, the consequences, the effect is so much more dramatic than you. I think that’s part of what people struggle with, with this disease is the unpredictable nature of not only how it, in some ways almost seems to transmit, but also who it affects and how it affects them, how some people it’s a little bit of a cold and that was it, other people they’re on a ventilator and don’t survive.
Dr. Green: Absolutely. It’s so unclear even now why COVID affects some people tragically and others minimally that there’s just no telling. And that is one of the fear factors of this virus. I’m pretty sure that over time we’ll be able to characterize the virus more clearly genetically and we’ll find out what indicators there were. Some of the science suggests that like the ACE inhibitors, which some people have recommended may help. It might be those proteins in those interactions in our body that are affected more. And these are very genetic things. So, we’ll probably know in the future who was susceptible to coronaviruses and who wasn’t. There’s been a linkage to obesity, which tends to be a link to Type 2 diabetes and metabolism of sugars. I would not be surprised at all if that’s the case also. A lot of these things are metabolic and when it’s a metabolic disease, it affects the blood vessels. When it affects the blood vessels, it causes the stuff that will kill you. So, I think that’s probably what we’ll find, but we’re learning a lot. One of the few upsides of COVID is how much we learned about science, how much we learned about vaccinations and some of these technologies. But probably more than anything we’re learning about whether society can sustain and survive, incredible isolation and an impactful disease that affects you and your neighbor indiscriminately. We’re all connected. We now know that. And if we haven’t learned that lesson, how connected we are, then we’re really stupid because we should now know that we should handle social issues this way, because the homeless camp in your community, which could result in infection or violence or self-harm or possibly other challenges in a community, sometimes there’s theft associated with a camp that goes wrong or drug addiction, that can affect you too if you’re walking by, just like a virus can affect people. And that means we should look out for one another and try to heal our neighbors because we’re also healing ourselves.
Bill: Right. So, we’re getting close to our end here and I just, you know, was there anything we haven’t talked about, anything in particular that you’d like to share with our audience that we haven’t touched on?
Dr. Green: Well the health disparities question was there before COVID and it was amplified by COVID and it’s probably something that we’re gonna have to tend to even more than usual in the coming years. You were very wise to ask about mental health care. There’s no doubt that a lot of behavioral health, mental health care has been put on the backburner, other problems, too. People have not gotten their cancer screenings. People haven’t gone to see the dentist. They haven’t gone to have check-ins with their family and those people might be suffering and not have been able to share it because they haven’t seen each other. So, there’s kind of a catch-up game that will occur. But the flipside is when we strip away COVID we will see where our system is. It’ll kind of lay bare where our healthcare capacity really is, where it’s strong and where it’s weak. We now know a lot more about treating infectious disease and adjusting hospital populations and so on. But when we wake up from this COVID fog or this COVID experience, I hope that we will invest in public health like we haven’t ever before. That’s what I would say has got to be one of the take home messages from this whole experience. There’s a lot of challenges that will probably surprise us coming off of this experience, but it will make that an important focus of what we do in America. It will probably also spur a lot of innovation, just like you mentioned with telehealth, other industries. People won’t have to always be in an office to do what they do best. There’s just so many changes that will happen. So, I think that COVID was probably an accelerator, both on need for those who are very vulnerable and, also an accelerator on change matters, which America was kind of in need of. We had kind of gotten into a rut, I think. So, I’m excited for the future. My state, you know, thank goodness did very well. We’re grateful to have done well and we’re welcoming everyone back now. I can’t wait to see you guys come to Hawaii come, and have an experience, get into the culture. Know that we will make things safe for you. But it has been a wild ride, I can say that.
Bill: Well, we just are so honored to have you with us to do this podcast and your insight, your perspective both as an elected official and as a physician, I think give you some unique insight credentials and perspective that are valuable, not only for our audience, but the country as well. So thank you very much for joining us today.
Dr. Green: Thank you Bill. I appreciate it.
(End of recording)
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