Hawaii doctors warn aging crisis is outpacing geriatric care system

Hawaii has the longest life expectancy in the United States — a point of pride that physicians say is also creating an urgent challenge.

As the state’s population ages faster than the national average, doctors say the health care system is not structured to meet the growing demand for geriatric care, leaving kupuna facing long waits for appointments and physicians struggling with overwhelming caseloads.

“We have a higher percentage of people over the age of 65, but we also have a lot of what we call ‘super-agers’ — people in their 80s, 90s and beyond,” said Kamal Masaki, chair of the Department of Geriatric Medicine at the University of Hawaii John A. Burns School of Medicine. “Our growth rate is higher than the national average … We know the aging population in Hawaii is really going to continue expanding over the next few decades.”

At the same time, Masaki said, the state faces shortages across nearly every part of elder care.

“It’s not just physicians,” she said. “It’s nursing, nurse practitioners, social workers, pharmacists — even the front-line staff like certified nursing assistants. The entire workforce that takes care of older patients is short.”

The 2025 Hawaii Physician Workforce Report suggests the state actually may have more geriatric specialists than needed, estimating a statewide demand of 32.4 full-time geriatrician positions compared with a supply of 46.7. On Oahu, for example, demand is listed at 22.8 with a supply of 40.9.

But physicians working in the field say those numbers don’t reflect the reality patients face.

Masaki said the estimates rely heavily on national modeling and do not capture the state’s unique demographic trends.

“Geriatrics is a critical shortage specialty across the United States,” she said, adding that the shortage is expected to worsen as the number of geriatricians decreases each year while the population continues to age.

Even on Oahu, she said, patients often wait months for appointments.

“The number of geriatricians is not enough to keep up with demand,” she said.

One of the state’s main efforts to build the workforce is the geriatric fellowship at JABSOM, one of the largest programs of its kind in the country.

The fellowship has seven funded training positions each year, and nearly half of its graduates over the past decade have stayed to practice in Hawaii or the Pacific.

Even so, shortages remain severe — particularly outside Oahu.

On Hawaii island, for example, there are only three practicing geriatricians. Kauai has three. Maui currently has none.

One of the physicians serving Hawaii island is Kaimana Kalei, a Hilo-born doctor who practices at the Veterans Affairs clinic and chose geriatrics after helping care for his grandmother.

“I wanted to give back to my community,” he said. “Taking care of kupuna is important in our culture.”

But the demand is overwhelming. Kalei said he manages about 900 patients — more than half of whom are kupuna.

Even though he specializes in geriatrics, he is primarily working as a primary care physician.

If the specialty isn’t strengthened, he said, the burden will continue falling on primary care doctors.

“If geriatrics isn’t prioritized, it’s just going to fall on PCPs (primary care physicians),” Kalei said. “That means more burnout, more stress for providers and more stress on the health care system.”

Masaki said care for older adults must be shared between geriatric specialists and PCPs, noting that geriatricians receive specialized training in managing the complex medical and social needs of older patients. Without that support, she said, primary care doctors may not have the time or expertise to address those complexities.

Complex patients

Geriatric care often requires more time than standard appointments allow.

Older patients frequently have multiple chronic illnesses, long medication lists and complicated family or caregiving situations.

“The patients are much more complex — they’ve accumulated 10 diseases and they’re taking 30 medications,” said Aida Wen, a geriatrician at The Queen’s Health Systems and director of the fellowship program. “Patient care and patient evaluations take a lot longer and require a lot more detail. You got to make phone calls, you got to make referrals, you got to put in authorization for X, Y and Z.”

Appointments often involve coordinating care with multiple specialists and family members.

“It’s the only specialty in which you do more and get less,” Wen said.

Because reimbursement systems often reward volume rather than time-intensive care, geriatrics is among the lowest-paid specialties — discouraging many young physicians from entering the field.

To help address that barrier, the Nohara-Abaya Loan Repayment and Scholarship Award provides $50,000 to physicians pursuing geriatric medicine.

Two recipients, Kalei and Kiana Choo Loy, said the support helped them pursue careers in elder care.

Choo Loy, now a geriatric consultant at Straub Medical Center, still carries more than $200,000 in student loan debt.

She said finding a job was difficult because relatively few positions exist.

“The system isn’t really funding geriatricians,” she said.

Choo Loy said Hawaii needs to invest more in geriatric medicine, noting that expanding the specialty ultimately could save the health care system millions of dollars by preventing complications and hospitalizations among older patients. But with so few geriatricians available, wait times for consultations can stretch for months. In some cases, she said, kupuna may wait up to six months for the next available appointment — a delay that can be dangerous given how quickly health conditions can change in older adults.

Dementia cases rising

The demand for specialized care is also increasing as dementia cases grow.

An estimated 31,000 people in Hawaii are living with Alzheimer’s disease or another form of dementia, according to the Alzheimer’s Association.

Kore Liow, founder of Hawaii Pacific Neuroscience and a member of the state Executive Office on Aging, said Alzheimer’s disease is now the sixth-leading cause of death in the United States and is among the top causes of death that still has no cure.

About 6 million Americans currently live with Alzheimer’s disease, and roughly one-third of older adults eventually die from Alzheimer’s or related dementia.

“It’s actually more common than prostate cancer and breast cancer combined,” Liow said.

The disease also carries enormous financial costs.

Medicaid spending for patients with Alzheimer’s can be roughly 16 times higher than for patients without the condition, he said.

The rising number of cases — often called the “silver tsunami” — is largely driven by the aging population.

Hawaii researchers are also participating in efforts to develop new treatments.

Liow said doctors in Hawaii recently infused the first patient in the state with an experimental research drug called trontinemab, which uses “brain shuttle” technology designed to reduce side effects seen in current treatments.

The state is one of about 35 research sites nationwide participating in studies.

“It’s important that we continue doing research in Hawaii,” Liow said.

He added that Alzheimer’s affects all populations but research shows slightly higher prevalence among Native Hawaiian and Pacific Islander communities — who are also often diagnosed later because of barriers to care.

Aging population

To prepare for the state’s aging population, educators at JABSOM are working with dozens of partners through the Pacific Islands Geriatric Workforce Enhancement Program.

The initiative trains students across multiple fields — including nursing, pharmacy, social work and public health — while partnering with clinics and community organizations to promote “age-friendly” health systems.

The approach focuses on four key elements of elder care: what matters to the patient, medications, mobility and mentation, including cognitive health.

More than 50 partners are involved, including organizations such as the Alzheimer’s Association and AARP.

Students are also placed in rural clinics and community health centers in hopes of encouraging them to practice on neighbor islands.

Physicians say expanding geriatric care will require long-term investment and a shift in how health systems measure value.

“The health care systems that employ geriatricians have to be committed to the fact that this is not going to be a moneymaker,” Masaki said.

But she said better elder care can prevent hospitalizations, reduce complications and keep older adults independent longer — saving health systems money over time.

For Choo Loy, the issue ultimately comes down to caring for Hawaii’s kupuna.

“Our elders deserve the time and attention they need,” she said. “The system needs to support the people who are trying to provide that care.”