Hill hails interstate telehealth as easy way to boost local medical care

from Grassroot Institute of Hawaii, June 27, 2025

One easy, virtually cost-free way to improve healthcare access and quality in Hawaii would be to remove the state’s regulations on interstate telehealth, according to Malia Hill, Grassroot Institute of Hawaii’s policy director and author of a new white paper on the subject.

Speaking on Sunday, June 22, with host Johnny Miro on the H. Hawaii Media radio network, Hill pointed out that Hawaii residents were temporarily allowed to access doctors in other states via telehealth during the COVID-19 pandemic, and the results proved to be safe and beneficial.

She said in restoring the practice, the state could address any safety or professional concerns by creating either a registration or reciprocity program. In the former, healthcare providers verify their licenses and qualifications with each other; in the latter, each of the states agrees to recognize the licenses of the other.

She said making interstate telehealth permanent would be especially helpful to patients in rural areas or who need to see a specialist. It also would resolve Hawaii’s shortage of physicians and its “serious shortage” of medical specialists. 

Moreover, she said, allowing interstate telehealth could be done without creating costly departments or programs. All that is necessary, she said, is to remove the regulatory barriers.

Some people, Hill said, “look at problems … and say, ‘We need a new program, we need a new project.’ [But] the way we [at Grassroot] like to look at things is to say, ‘Well, what are we doing that’s making it harder? You know, what can we remove?’ And that’s a low-cost way to do it because it really costs almost nothing to remove barriers. Even a registration program can be greatly mitigated in cost of managing it by the fee required to belong to it.”

Hill told Miro that Hawaii rules prohibiting interstate telehealth are mostly a matter of legislation not keeping up with technology, since the regulations were formed at a time when effective face-to-face contact with healthcare providers was limited to in-person visits. 

TRANSCRIPT

6-22-25 Malia Hill with host Johnny Miro on the H. Hawaii Media radio network

Johhny Miro: Happy to have you along on this Sunday morning. [It’s] time for public access programming on our H. Hawaii Media family of radio stations — five on Oahu, five on Kauai, five on Maui. HawaiiStream.FM [and] Live365[.com] are [other ways] to pick us up if you’re away from the terrestrial radio. I’m Johnny Miro. 

We have another Grassroot Institute important story to cover today. And it’s a report, a white paper, just put out, and it’s urging lawmakers here in Hawaii to see their mainland doctors online, as the practice work[ed] very well and safely during the COVID-19 crisis, and could do so again, according to the white paper released by the Grassroot Institute of Hawaii.

And we have the policy director and the author of that white paper, Malia Hill, saying the temporary measures that were allowed, the cross-border care during the COVID-19 crisis, demonstrated that states can, safely and effectively, improve healthcare access by expanding telehealth beyond geographic licensing restrictions. 

So we’ll get the essential argument of that and how the temporary cross-border telehealth measures, I guess, impacted patient access here during that time frame; what challenges we’ll be facing if after the expiration of that pandemic-era healthcare waivers, and how Hawaii’s participation in the Interstate Medical Licensure Compact help, and maybe fall short, in expanding telehealth.

A lot of things to touch on. Malia, good morning to you, and thanks for joining us once again.

Malia Hill: Good morning. Thanks for having me.

Miro: White paper, very extensive, gave it a good read. So why do these rules, in your opinion, rules against getting telehealth from mainland doctors, exist? And is there a safety issue?

Hill: Well, you know, I think it’s one of those things where, you know, what grew up to regulate doctors, you know, the rules about licenses, it just hasn’t really caught up with the technology. 

You know, before it was, we had this ability to, you know, instantly communicate. And we’ve done so much in terms of, you know, especially in the healthcare realm, being able to use technology to diagnose and treat. You know, the licensing rules were made up for a different time when, you know, you wouldn’t really contemplate doing anything other than just going to see a doctor, physically. 

So, the system really hasn’t caught up, and so we have this rule that doesn’t really make sense given what the potential is. And it basically says, “Hey, you can only get telehealth from a Hawaii-licensed doctor.” And, we have to look at that and say, “Does that make sense at all, given what we know now, what we can do now?”

And we had this chance to see how it worked to go across the border during the pandemic when Hawaii, along with pretty much every state, lifted the rules about going to a doctor in another state and getting telehealthcare, and it worked fine. It was safe. There were no issues with it. 

So we now know, you know, there’s no real safety reason to have those rules in place. It’s just a relic of a system that hasn’t quite caught up with the times.

Miro: Sounds like it. If the Legislature doesn’t want to simply get rid of the rule against the interstate telehealth, Malia, what could they do to make a difference then?

Hill: Well, there’s a couple of things they could do. And yes, the easiest thing to do is just say, “Hey, if you have a medical license, you can get telehealth. You know, it doesn’t matter what state you’re in. A Hawaii resident can go to you.” But I understand that’s a big, that’s a very big ask, so there are lesser things they can do. 

I think the most comprehensive thing they could do short of that is just creating a registration program. That would be a state program that would allow out-of-state providers to meet qualifications, things like, you know, a license in good standing, to register with the state medical board and agree to, you know, various terms that the state sets — pay fees and so on — before they can offer telehealth services to residents. 

You wouldn’t have to have a full Hawaii medical license, but it would still give some amount of oversight to the state in terms of who could offer telehealth in the state.

Short of that, they could, you know, just lift the restriction for certain kinds of care. You know, mental health providers or maybe temporary care. 

They could lift the restriction for people who have an ongoing relationship. Let’s say you are really a resident of Iowa, but you’re spending a significant amount of time in Hawaii, but your doctor’s in Iowa. You shouldn’t have to stop that relationship with the doctor in Iowa because of this rule about, you know, your telehealth relationship has to be with a Hawaii medical licensed provider.

Miro: We can’t be the only state kind of, being, you know, slow rolling this out. How many states currently have exceptions or alternatives to full licensure for out-of-state telehealth providers, Malia?

Hill: There are 27 states that currently have some kind of exception, and it varies. There are states that have this very minimal kind of thing where it’s just special cases or certain kinds of consulting and second opinions, and then it goes all the way up to states like Florida, which implemented the registration program I talked about.

Miro: And what are the implications here of maintaining Hawaii’s in-state licensure requirement for that telehealth?

Hill: Well, the problem really is a practical one because, you know, we have a shortage of physicians. We have a serious shortage of specialists, and we have issues with healthcare access in rural areas, which in Hawaii is pretty much everywhere except Honolulu. 

And this restriction on telehealth that, you know, only someone with a full Hawaii license can provide telehealth, means that if you need a specialist and you are anywhere where that specialist isn’t, you have to travel. You have no choice but to physically travel or hope that you can get the right kind of referral system and such to get to that specialist.

If you were to lift this restriction on licensed telehealth, Hawaii-licensed telehealth, it would give people the opportunity to go outside of Hawaii for specialty care, and given the serious shortages we have, it just seems like a no-brainer.

Miro: And you just mentioned that benefit. Who else do you think would be benefiting the most from changing the rules about interstate telehealth?

Hill: Well, I think the data shows that the people who really benefit from these kinds of reforms are, basically, people in rural areas, people where it’s already kind of difficult to access healthcare in general. It gives those patients an opportunity to see specialists that they just don’t have the ability to visit. 

When they looked at the data from the pandemic, they basically found that the biggest increase in the use of cross-border telehealth was among rural patients and especially cancer patients, followed by some other very specialized conditions. So it’s a real benefit for people who have access issues or who need, you know, very specific specialty care.

Miro: Very important topic, of course, healthcare, telehealth, as its Grassroot Institute of Hawaii policy director, Malia Hill, just put out a white paper on this topic.

And there’s got to be some pushback, like maybe some local healthcare experts, Hawaii State Medical Board, how do they play into this whole thing?

Hill: You know, it’s an interesting thing because one of the big proponents of it comes from the medical community. There are people who really see the potential of telehealth in that community and are pushing for increasing it. Just to give a little more information there, telehealth is not just talking to your doctor on Zoom. It’s pretty much anything that allows for the use of technology between remote, two different locations. 

So there’s things like remote monitoring, allowing someone to, you know– [inaudible] X-rays to some degree is telehealth. So, it’s a really broad topic and that’s why it brings in a lot of interest from different areas.

I get mixed answers from doctors. I think there is some concern about, you know, making sure that patients in Hawaii are receiving good care from good doctors who have good licenses and, you know, good standing. And I think everyone would want that. 

So there’s a way to do this that answers those concerns, answers those pushbacks without just throwing the baby out with the bathwater. We can address the safety concerns, we can address all of those kinds of issues, and still open the door to interstate telehealth.

Miro: So, for the most part, you’re getting mixed reviews from these local physicians that you’re talking to?

Hill: Well, actually, I have had some doctors reach out and say, “This is excellent,” right? “This is what we need.” There are doctors who are very much in favor of looking at the licensing as a whole and telehealth in particular, and expanding it because they see it as a way to increase healthcare access, especially doctors on neighbor islands. It has a lot of potential there, and specialists.

Miro: OK, any, you know, potential risks or downsides of loosening Hawaii’s in-state licensing requirements for these telehealth providers?

Hill: I don’t think it’s anything other than what you would say with any licensing. 

Florida … earlier telehealth registration program, which is, you know, the biggest approach, that would be, you know, one you could look at and say, well, problems with this are safety concerns, then we can note that. But when they looked at it in the first two and a half years of this registration program, there were only 16 complaints reported for out-of-state providers compared to 57 over the same period for in-state providers. And none of those complaints for telehealth providers resulted in any kind of disciplinary action. 

So it’s really just a matter of saying, you know, with the proper safeguards, this is something that is very, very doable.

Miro: A few more questions for Malia Hill from Grassroot Institute of Hawaii, the policy director. 

Maybe you touched on this, can you repeat it again? How could reciprocity agreements with other states improve healthcare access for Hawaii residents?

Hill: Well, reciprocity agreements are a really interesting thing and they’ve been used in other states. But basically what it is, is a couple of states getting together and having a private agreement like, “Hey, your license is good here,” to just simplify it a little bit. 

So what Hawaii could do is work with a few other states — you know, California leaps to mind because of its proximity and size — and come up with an agreement where you would recognize each other’s licenses. And that would greatly expand the pool of doctors to which Hawaii patients would have access. 

Any kind of recognition or reciprocity where Hawaii basically says we are going to recognize the licenses, the medical licenses of these other states, basically just brings those doctors in those states into the pool of doctors that you could visit. And for a state with a doctor and specialist shortage, that’s a really promising route.

Miro: And as you mentioned, for the people that are in the rural areas, at geographic isolation, how does the report frame that relationship between those areas, the geographic isolation, and the healthcare access throughout the islands, in your opinion?

Hill: Yeah, that’s one of the things that we hear about the most. I mean, if you’ve been watching the news lately, you’ve seen that a couple of things about doctors on the Big Island, pharmacists from Molokai, … you know, it’s always this question of them trying to get care and trying to fight the regulations that make it hard. 

These regulations, like the regulation against out-of-state telehealth, you know, they may have these great intentions behind them — you know, it’s always about the safety and making sure everyone’s safest. But when you are somewhere where you have to travel, for everything, to see a doctor, where you might have to get on a plane to see a specialist, it requires a little thinking outside the box. 

No other state has the same issue we have where if you are, you know, on Kauai and you need a specialist oncologist, there just might not be one. You’re going to have to get on a plane. You might have to fly to California to get one. And I think it really behooves Hawaii policymakers to just face up to the reality of that and say, you know, in what way are regulations making it hard for people to get care they need? Does it make sense to have this restriction?

Miro: Yeah. When it comes down to care, that’s one thing. And then of course, the cost, you know, because for the private medical practices, that’s a big thing, of course, with some of the regulations here. So in what ways, Malia, could expanded telehealth options be considered a cost-effective solution for Hawaii?

Hill: Well, that’s something we really specialize in at Grassroot. I think when people look at problems, you can look at them and say, you know, “Well, we need to build more, we need to make more, we need a new program, we need a new project.” 

The way that we like to look at things is to say, “Well, what are we doing that’s making it harder? You know, what can we remove?” And that’s a low-cost way to do it because it really costs almost nothing to remove barriers. Even a registration program can be greatly mitigated in cost of managing it by the fee required to belong to it. 

So this is a very low-cost way, just removing barriers, to increase the number of doctors in Hawaii, and you do it without having to launch a program or having to, you know, invest a bunch of taxpayer money. You’re just getting rid of a regulatory barrier that doesn’t make a lot of sense to begin with.

Miro: So, basically, summing up: During the pandemic, with the telehealth, it worked kind of seamlessly. And then now, pretty much it’s not being utilized as it was, there’s more challenges. And according to the white paper, it’s best to try to get this telehealth working as it was a few years back. Is that correct?

Hill: Exactly.

Miro: All right. How can people find the white paper and the report and the rest of your work?

Hill: You can find it on our website, we’re grassrootsinstitute.org and you can find the paper there and contact us there and see a little bit more of our work.

Miro: Malia Hill, the policy director Grassroot Institute of Hawaii joining us. A very important topic, healthcare. grassrootinstitute.org, grassrootinstitute.org. 

Thanks for, once again, calling in and discussing this matter, and have yourself a great remainder of your Sunday. We’ll talk to you soon.

Hill: Thank you. Thank you for having me again.