What happens when accessing health care requires booking a flight instead of driving down the road?

In this episode of Plugged In to Public Health, we talk with John Desfor, a University of Iowa MPH graduate now working in rural health research and policy in Hawaii. John shares what rural health looks like in one of the most geographically isolated regions in the United States and why transportation access is one of the most critical and overlooked barriers to care.

The views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors, and do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Lauren Lavin:

Hello, everyone, and welcome back to Plugged in to Public Health. Today’s episode takes us far beyond the mainland of the U.S. into the part of rural health that many people rarely think about. I’m joined by John Desfor, a University of Iowa MPH graduate who now lives and works in rural Hawaii. John currently works with the University of Hawaii and focuses on rural health research and policy with a particular emphasis on transportation access and care delivery in highly isolated communities. In this conversation we explore what rural really means in a place like Hawaii, where accessing care can require booking a flight rather than driving down the highway. John walks us through how transportation barriers lead to misdiagnoses, delayed care, and worsening health outcomes, and why transportation should be treated as a core social determinant of health.

We also discuss the policy levers that could improve access, from insurance coverage to innovative alternatives, to injure island flights. I’m Lauren, and if this is your first time with us, welcome. Plugged in to Public Health is a student-run podcast that explores major issues in public health and why they matter to people both inside and outside the field. Before we get started, a quick disclaimer, Plugged in to Public Health is produced and edited by its students at the University of Iowa College of Public Health. The views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors, and do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health. So, let’s get plugged into public health. Well, thank you, John, for joining me today on the podcast. To start, could you introduce yourself for the listeners? You used to be here at the University of Iowa, and that’s how I know you, but you are definitely not in Iowa anymore, so why don’t you introduce yourself?

John Desfor:

Yeah, thanks, Lauren. Happy to be here. My name is John Desfor, previously Dickens when I was at Iowa, and I now live in Hawaii. I graduated the MPH program at Iowa in 2023, and I got on a flight and moved here the day after final of graduation and have been here ever since. And the best decision I’ve ever made. I love Iowa, but Hawaii is special. So yeah, I have a passion for rural health. I developed that in Iowa and continue that here. I work for the University of Hawaii now and love my job. I love what I do. I’m married. I have two dogs, 14 ducks. We’re building our house in a very rural place in the southernmost part of the big island and have the best life ever.

Lauren Lavin:

It’s so interesting that you talk about rural in Hawaii, because I would say that most people don’t associate those two things together. So, could you explain a little bit how rural is Hawaii and what that looks like?

John Desfor:

That’s a great question. And we could get into a lot of regulatory jargon on what rural mean, but to me Hawaii is the most rural place in the country. We’re the most isolated population center in the entire world.

Lauren Lavin:

I have heard that.

John Desfor:

We are thousands of miles away from the nearest bordering state, you could say, if you include water. We are extremely isolated from other economic healthcare spheres, and that’s the state as a whole. When you zoom in on the Pacific Ocean and you get to the islands themselves, you have Oahu, which is the main population center, which is extremely dense, population dense. Some definitions of rural considered to be an urban center. And if you walked through the streets, you would definitely think you’re not in a rural place.

But you drive 10 miles out in any direction and it becomes very rural. And then you get on a plane and hop to the other islands and it’s even more rural. And then you come to my island, the big island, and you have to drive about an hour and a half from the airport to where I am. And we are 30 minutes from the nearest clinic, 50 minutes from the nearest hospital in Ocean View, the town that I live in. And it feels very rural. If you look around, I don’t see any neighbors. We have one small market-

Lauren Lavin:

That’s what I was going to ask about.

John Desfor:

Yeah. Yeah. If you drive through a small rural Iowa town and you drive through their main street, it would look very similar actually to our little tiny strip in our town, besides the fact that there’s palm trees and you can see the ocean.

Lauren Lavin:

So small, so small bits.

John Desfor:

Yeah.

Lauren Lavin:

How many people live on the big island?

John Desfor:

About 200,000 people live on the big island. And it’s the size of Connecticut, actually, pretty much exactly, which I thought was interesting. Connecticut has a population of 3.6 million.

Lauren Lavin:

Oh, my gosh.

John Desfor:

So, pretty sparse.

Lauren Lavin:

So sparse. Interesting. And also, how did you end up in Hawaii specifically? You got on a plane. Why Hawaii?

John Desfor:

My wife actually, her family lives in a small town, and we visited them a few times back when I was in Iowa and we loved it. And I was able to find a job out here through my practicum, actually. During the last semester, my MPH got connected with some people at the University of Hawaii and that worked out. So we moved in with my in laws. I started working there. We bought a property and started building our house and now we’re all settled in here.

Lauren Lavin:

Wow. So, did you guys build the house yourself?

John Desfor:

Yeah. Yeah, just us two and some help from my father-in-law too for the heavy stuff.

Lauren Lavin:

Wow, that’s amazing. Okay. So, what actually brought you back to my attention was an article that I had read.

John Desfor:

When a miss flight becomes a misdiagnosis.

Lauren Lavin:

Yeah. So, can you give a little short summary of that article and what you explored within it?

John Desfor:

This has been my passion project for about a year and a half now. And it started when we were doing community listening sessions through the research center that I work with. It’s the University of Hawaii Rural Health Research and Policy Center. I’ll call it RHRPC because that’s what we use. I’m sure your listeners are used to all of the acronyms.

Lauren Lavin:

Oh, the acronym.

John Desfor:

Public health. It’s deceased. So RHRPC did listening sessions across all of the islands, basically wanting to know if we have the funding to do research in rural health, what topic would be most important for you to hear solutions on? And there were a couple of big ones, but transportation and travel access was almost unanimously top of the list. And so, we wound up getting funding from our State Department of Health to do a research project on it. We started with a literature review, and then we did a stakeholder qualitative analysis of over 40 interviews with the end goal of creating a document of policy options that would essentially give a roadmap for how to solve some of these issues. Our findings from the report were that a lot of rural places in Hawaii struggle with access to care. There’s huge workforce shortages. When you look at economies of scale, it’s not possible for each of the islands to have a built-out healthcare system.

It’s going to be centralized in one location, and that happens to the Oahu. And so for those on the, we call them the neighbor islands, they often have to fly to Oahu to receive specialized care. Even in Oahu, there’s a workforce shortage. So you may have to schedule with your dermatologist for a month out to get to your specialist appointment. And as you know, flights get delayed, flights get canceled. If your flight’s delayed two hours, you miss your appointment and you’re out of luck for another month until you can get to your next appointment. And obviously, in public health we know the importance of preventative care and addressing things upstream. And so when patients continuously miss out on those opportunities for diagnosis and addressing things early on, conditions get worse and healthcare outcomes decrease.

Lauren Lavin:

Yeah. Well, and it’s interesting. If you are working in the rural health space, transportation becomes a big topic. And how long is it okay to drive to get to the nearest healthcare setting? And I think it’s so interesting that in Hawaii you’re talking about a flight. I mean, we don’t want people to drive more than 30 minutes. And people are having to book a flight, which I mean, maybe they’re cheaper than a traditional flight, but it’s still probably a significant cost when everything’s also expensive in Hawaii. So can you speak to what the flight process is for something like that? Is it a traditional commercial airline that we fly in the U.S., or is that different?

John Desfor:

Yeah, it actually depends on the island. So, for the three biggest islands outside of Oahu, which is Kauai, Maui and Hawaii Island, okay, it’s basically like your traditional commercial flight. You go through TSA, you have your Southwest or Hawaiian Airlines, it costs about $120 round trip for a flight.

And you have to also consider that many people here, like you said, the high cost of living don’t have their own personal vehicles. And so that’s either an Uber ride to and from the airport that also costs 40 to $50, or you have to take the bus, which takes a long time. For us in Ocean View, the town I live in, it’s about a two-hour bus ride to the airport. And so, the costs add up quickly and-

Lauren Lavin:

And you’re missing work.

John Desfor:

Yes. Yeah, you’re missing work. Oftentimes you have to-

Lauren Lavin:

[inaudible 00:10:32].

John Desfor:

… childcare. And what winds up happening is most people just don’t do it, and they don’t go to their appointments. For those with Medicaid, our state Medicaid program is actually really fantastic. It covers most transportation needs. I think it’s about $100 for a roundtrip flight that they cover, so it’s only $20 out of pocket. However, the approval process is long and cumbersome and you have to get prior authorization and your provider has to sign off on medically necessary travel forms. And that’s just for Medicaid. If you have private insurance or Medicare, it’s almost always all out of pocket, all of those costs, which is just undoable for a lot of people. It doesn’t work with their budget. And that’s just for the main islands. If you go to the smaller islands of Molokai and Lanai, the flights are commuter planes, so they’re small, seven to 14 seaters usually.

And that airline that provides that service is plagued with delays and cancellations and a lack of reliability. So, someone will go through all of that process, book their flight, take time off work, pay for childcare. They’ll get to the airport and their flight’s delayed four hours, and they either try and go and call their doctor’s office and try and get them to reschedule, which some are able to do that, some aren’t. And then oftentimes they’ll wait that four hours, finally be ready to get on their flight, and then it’s delayed another two hours and they can’t go and they have to go home. So it’s just led to many people in Hawaii foregoing care until it’s an emergency. And then that has put a huge strain on our emergency system as well.

Lauren Lavin:

What does the emergency system look like in Hawaii for medical care?

John Desfor:

It’s actually, it’s really interesting. It’s kind of a patchwork system. There’s different systems for 911 operations across the state. It goes by county. So Honolulu County, which is Oahu, has their own county run department of EMS. Kauai and Maui counties contract out the 911 operations and ground ambulance to a company called American Medical Response. And then Hawaii County, it’s run by the fire department. So it’s all different systems. And one of the policy options we put forth in our research project was to create a statewide, centralized coordination center for all of those different systems. Because right now, for example, a tourist is enjoying the beautiful Hawaii coastline taking pictures and happens to not be paying attention and fall off the trail and then is stranded on the side of a cliff. The first response is a helicopter. Depending on the island, actually, the helicopter comes from a different origination and that helicopter can’t go straight to the level one biggest trauma center, which is on Oahu.

They have to transport to the nearest facility, and then that facility can make a call to do an interfacility transport if they’re not able to care for that patient and the injury is too severe for them. So, then another helicopter comes, picks them up from the helipad if they have a helipad, which is not always the case. If not, they have to be ground transported to the nearest helipad. And then that helicopter goes to Oahu and drops them off. And that’s only if the trauma center in Oahu has enough room in their emergency room, which often is not the case. So, it’s a big, complicated, messy, overburdened system.

Lauren Lavin:

Yeah. Well, and the whole time that you were saying that, I was just thinking about think about how much time has passed from that initial accident till you get to that, the place that you need to get care, whether you’re a tourist or a local. I think it’s a good thing that you brought up the tourism because Hawaii is a big tourist destination and there’s lots of activities to do there that, I don’t know, could lead to injury. And so I think that’s just important for people to remember, and I’m sure also creates a burden on the system that if tourists weren’t there doing dumb stuff, that some of that would be alleviated preps.

John Desfor:

No, that’s what I thought too when I moved here, is that, gosh, it’s got to be a huge burden on the system. But talking to a lot of the EMS providers, it’s actually not that much of a burden on the system.

Lauren Lavin:

Okay. Well, that’s important to know.

John Desfor:

Yeah, which is good. I mean, it’s still the case where that’ll happen, but it’s not to the point where they’re talking about specific solutions to address that issue.

Lauren Lavin:

Okay. Well, good to know. So, why do you think that transportation in particular remains a blind spot in coverage for insurance?

John Desfor:

That’s a good question as to why. I mean, the obvious answer is it costs money to the insurance company, and they’re incentivized to make money in our current healthcare system. And that’s why Medicaid, which is a public service, provides it and a lot of the private insurers don’t. If the incentives were different, coverage could look different. So for those who aren’t familiar with the Kaiser Permanente health system, they operate both their own health insurance and their health delivery system, so the hospitals and clinics, and it’s all one population-based system in which Kaiser makes money when their people are healthier, because they’re the ones that have to pay for the services that they provide to people. So, they’re incentivized to do things such as get one of their beneficiaries on Hawaii Island to Oahu to get that colonoscopy done so that they don’t develop colon cancer 10, 15 years down the road undiagnosed, and then that they have to treat that and it costs them more money.

So that’s one thing that I know actually Rupri at University of Iowa has focused on is transitioning to value-based payments and population-based health where it’s global budgeting in which insurers pay hospital a lump sum of money based on the amount of beneficiaries they have and a couple of other adjustment factors. And the hospital uses that budget in whatever way they wish, whether that’s fit care or preventative care. I think the main answer why it’s not covered is just not financially incentivized to do so.

Lauren Lavin:

And so, then you have to create some policy levers that either change the incentive or require it regardless. You also mentioned in that article that transportation is a critical social determinant of health, and that was something that I hadn’t really thought of before. So could you maybe expound on that and why you think it’s just as important as housing or food security?

John Desfor:

At the end of the day, we don’t live in a system where the doctor is the local town doctor and he has a car and drives to your house and does the whatever surgery or operation needs to get done to make you better. You have to get yourself to the hospital and unless you’re calling 911, you have to get there on your own. For my understanding, social determinants of health are the upstream factors that influence health outside of direct medical care. So for example, let’s say I fell down hiking and broke my ankle and I go to the hospital on the west side of the island, or I decide to go to the hospital on the east side of the island, and my surgery actually would’ve gone better if I went to the west side. That’s not a social determinant of health, that hospital just happened to do that operation better.

But let’s say that the only hospital that does that procedure is on the west side, and I can’t go to the east side, but the bus only runs to the east side because it’s four o’clock and the bus only leaves for the west side at three. So I can only go to the east side now because it’s four o’clock, but they don’t do that there. So then I have to wait till the next day and I get an infection and it gets worse. And so if transportation was better and there were more options for me to get to care, my health would’ve improved.

Lauren Lavin:

It’s just such a interesting scenario. Each time you say, I’m like, wow, it’s unique to anything I’ve ever heard. And I work a lot in the rural space, so I think this is really interesting. So in the case of rural Hawaii, what are the main levers that you think could reduce some of the problems with lack of transportation or missing diagnosis or preventative care?

John Desfor:

That is something that I’m really excited about and a passion of is that RHRPC, the center I work for is really invested in creating actionable and strategic policy options. So not just doing the research and proving that there’s a problem, but saying, “These are the specific actions we can take to address that problem.” And it’s not just saying, “Oh, insurance should cover transportation.” It’s saying, “CMS has the authority to require Medicare and Medicare Advantage plans to cover non-emergency medical transportation when deemed medically necessary.” They would do so through amending their final rule on the Medicare physician fee schedule, whatever it may be, and getting specific details into if it’s statutory change, what legislative action would need to take place, if it’s regulatory, what government agency would do that, does the federal government have authority to do that? Is it a state level? Do they have authority to make that regulation? What precedent is there for doing that?

So getting into the specifics of what exactly needs to change and how it needs to be done to make that happen. And I think that’s a great way to go about things, because in the policy world, there are very limited windows to make policy change. And if you have all of that shovel ready, this is what you can do. This is the research behind it. This is what the community has said. This is how it links up this policy option and this is how you get it done. Policymakers can just take that and go when the window arises. For example, federal government came out with a $50 billion rural health transformation program, which looking like you’ve heard of.

Lauren Lavin:

Pretty much yeah, I have.

John Desfor:

Yeah. Yeah. So it came out of the reconciliation bill in July that was also where the Medicaid cuts were happening. And as a offset for those, although financially the cuts to Medicaid come to work are way more than 50 billion, but-

Lauren Lavin:

I was going to say consolation prize. So your offset was[inaudible 00:22:17].

John Desfor:

Yes. Yeah. Yeah. Consolation prize is a good descriptive word for it. They came up with $50 billion for rural health across the country. So half of it is split up evenly between the states over five years, and the other half is kind of a competitive grant process where states can apply with what programs they would like to do. And it was a very short timeline from when they announced that funding opportunity and when the applications are due. I’m not sure when this podcast will come out, but they’re due tomorrow, November 5th. And I think they were announced that the actual NOFO was released in mid-September.

Lauren Lavin:

Yeah-

John Desfor:

Its a very, very short term.

Lauren Lavin:

Really court.

John Desfor:

Yeah. And it’s a 60-page application for billions of dollars and they are requiring all five years to be laid out with specific funds. The Hawaii State application is being run by the governor’s team and they needed help. What programs are we going to include? What is it going to look like? And they wound up splitting it into different categories and transportation was a category. And the Department of Health reached out to us and we had some ideas and we had all of these policy options ready to go. And so they were able to work with that and use that in their application. So, those are the types of things that I’m excited about when we look at transportation solutions and having those policy options ready. Yeah.

Lauren Lavin:

It’s such an incredible testament to funding that type of work before you see a window so that that stuff is ready for something that no one knew that this Rural Health Transformation Fund was coming, but that you had well-thought-out research-backed options to put into that, I think will probably go a long way in that application. And so it’s important that we have people like you doing this work.

John Desfor:

Yeah, no, that’s why I bring it up, because I am really passionate about it. And I think there’s a few Rural Health Research Centers across the country. Some are federally funded, some like us are scrapping for dollars where we can, but it is super important work. And I know even at the University of Iowa, our health management and policy department is small but mighty. And I think that department in particular has the opportunity to take all of the good work people in community health and epidemiology and all these different places are doing and take all of that and create the policies that can implement that change and support those ideas.

Lauren Lavin:

And what were the, I don’t know, policy mechanisms or exact policies that you guys proposed as solutions?

John Desfor:

Yeah, we had a couple, well, we had more than a couple. We had 29 policy options in total.

Lauren Lavin:

Oh, my gosh

John Desfor:

Split over four categories, non-emergent medical transportation. So that’s things like the airlines, emergency medical services, insurance coverage, and then we did a few on maternal and fetal health, because that was a specific population that had unique challenges of transportation. One example, one that I really like to talk about that was very interesting to me was exploring cost-effective alternatives to inter-island flights. When you look at a map of Hawaii and you think, how can we get a person from this island to this island more efficiently? It was not long before you’d think of, why can’t you take a boat from there to there? Wouldn’t that be faster than a plane? Wouldn’t it cost less? And the short answer to all of those is yes.

The long answer to that is there was an effort to create a super ferry, it was called, about a decade ago, and it fell apart for political reasons actually. There were some airline lobbying that I think happened and a couple of other environmental concerns for the channels between the islands, but essentially it fell apart. And so we created a few different policy options for looking at how can we have alternatives to inter-island flights. And so what policy options exist to bring the ferries back? Could there be funding for implementation of that or even a pilot of that? And then we also found interesting middle grounds where there’s these things called sea gliders, which are being developed currently. I think the first prototype just came out where they’re a nautical vessel, but they have wings and glide above the water and they’re electric vehicles. And it’s super interesting, and I could nerd out about it for a long time.

Lauren Lavin:

Oh, my gosh.

John Desfor:

But look up sea gliders if you’re listening, they’re super cool and a policy option that we proposed as well.

Lauren Lavin:

Wow. So some of the options involve moving away from traditional airline to some more innovative.

John Desfor:

Yeah. Yeah, exactly.

Lauren Lavin:

As soon as you said [inaudible 00:27:26] I was like, “Oh, Dell, why aren’t they paid?” But there’s competing interests that tell a bigger story.

John Desfor:

Yeah, exactly.

Lauren Lavin:

Well, that’s really interesting. Okay. So, my last question, and to wrap this up is, taking a step back, how generalizable do you think the experiences that you’re having in Hawaii are to other rural or remote regions in the U.S.? And what would you want people here on the mainland to maybe take from what you’ve learned in your years out there?

John Desfor:

That’s a great question. I think there are actually a lot of similarities. I think when we zoom in on transportation, it’s improving public transit. It’s having insurance cover transportation costs for patients. It’s improving workforce shortages across the country so that there’s more options available for patients where they live. It’s improving telehealth access. That’s universal across the whole country, and improving broadband coverage and ensuring payment parity for telehealth and ensuring that these telehealth coverage extensions that we got from the COVID public health emergency continue into the future and become permanent rather than extensions through the government appropriations process. And I think as an overall idea, it is the mission and vision of equal access to care for every American, regardless of where they live. Too often, I hear in rural health that people just, they chose to live in this area. They knew the consequences. They know it’s going to be hard to get healthcare.

They’re choosing this. They don’t say this out loud, but the connotation of that is they deserve worse healthcare because of where they live. And I think not only do I fundamentally disagree with that personally, but I think it goes against everything that we want as a country and we want in public health. And so I think that something I’ve really taken away from my work here and my work in Iowa too in rural health is that everyone deserves the same access to quality healthcare, regardless of where they live.

Lauren Lavin:

And that’s such a great note to end on. So thank you, John, for taking time out of your day to chat with me. There was a big time zone difference just for everyone, so I really appreciate it. This has been really insightful. I think it’s such an interesting conversation to have and one that has so many parallels to the work people do in Iowa and like you just mentioned, so thank you.

John Desfor:

Yeah, thanks. I’m glad I made it. I almost actually didn’t because of daylight savings time. We don’t do daylight savings time here, and so I have it wrong in my calendars. I’m glad that we made it work.

Lauren Lavin:

That’s it for our episode this week. A big thank you to John Desfor for joining us and for sharing his perspective on rural health in one of the most geographically unique settings in the country. In this episode, we discuss how transportation barriers shape access to care in Hawaii, why missed flights can become misdiagnoses and how policy solutions must account for geography, insurance incentives, and real world patient experiences. We also explored how lessons from rural Hawaii apply to rural communities across the U.S. and why equitable access to care should not depend on where someone lives. This episode was hosted and written by Lauren Lavin and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on our Facebook page. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode, please share it with classmates, colleagues, or anyone interested in rural health and health policy.

Have a suggestion for our team, you can reach us at cph.brandambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next time, stay healthy, stay curious and take care.