Rural Health Transformation Program

Buy capacity, not contracts.

Hawaiʻi's Rural Health Transformation Program award is the largest single investment in rural care the state has seen. My work on it, with Esther Y. Smith, MD, comes down to one question asked of every dollar: after this investment, will rural Hawaiʻi have more usable healthcare capacity than today, particularly primary care, and will it remain after the funding ends?

The Task Force is not an applicant for RHTP funds and asks for none. It convenes and makes the money deployable; it asks for no grant, no contract, and no administrative role.

The RHTP Clock

$188.9M awarded for Budget Period 1

$58.0M announced to date (30.7%)

Initiative	Lead	BP1 allocation	Announced to date
RICA	Department of Health	$53.0M	$13.0M
RHIN	SHPDA	$45.4M	—
HOME RUN	JABSOM	$45.0M	$45.0M
RVBI	SHPDA	$25.0M	—
Pili Ola	UH Mānoa	$12.5M	—
RRN	Department of Human Services	$3.2M	—

45 days

Budget Period 1 obligation deadline

108 days

CMS-0057-F prior authorization API compliance date

127 days

Hawaiʻi Legislature convenes

Updates on public announcements only. Last checked 15 September 2026.

Sources: CMS; Office of the Governor releases of 6 January and 1 September 2026; Hawaiʻi RHTP briefing, September 2026

DIRECT

What the program is

Public Law 119-21 created the program. Funds flow from CMS through its Office of Rural Health Transformation to the Office of the Governor and the Department of Budget and Finance, and then to the Hawaiʻi Rural Health Transformation Program, which coordinates six initiatives across five state agencies and the University of Hawaiʻi.

RICA

$53.0M

Rural Infrastructure for Care Access

Lead: Department of Health

Statewide medical communications center; mobile integrated health and community paramedicine; technology-enabled vehicles including mobile clinics and mobile dialysis; behavioral health crisis access

RHIN

$45.4M

Rural Health Information Network

Lead: SHPDA

Interoperable EHRs, infrastructure and security, health information exchange, care coordination tools

HOME RUN

$45.0M

Workforce

Lead: JABSOM

Education and training awards with a five-year rural service commitment; nurse residencies; a target of 1,000 new rural health workers

RVBI

$25.0M

Rural Value-Based Innovation and AHEAD Readiness

Lead: SHPDA

Readiness infrastructure, advanced primary care, hospital global-budget readiness, aligned with AHEAD

Pili Ola

$12.5M

Telehealth

Lead: UH Mānoa

Remote monitoring, employer and school-based access points, behavioral health, maternal care, e-consults

RRN

$3.2M

Rural Respite Network

Lead: Department of Human Services

Medical respite beds; Kauaʻi and Hilo first

Initiative allocations sum to $184.1M; a program oversight team holds $4.5M

Period	Obligation window	Expenditures
Budget Period 1	December 2025 to October 2026	to September 2027
Budget Period 2	October 2026 to October 2027	to September 2028
Budget Period 3	October 2027 to October 2028	to September 2029

Federal rules the state briefing lists

·Administrative costs at or below 10 percent
·Provider payments at or below 15 percent of each budget period and only for items insurers do not pay for
·Capital at or below 20 percent, existing rural facilities, renovation and equipment, no new construction
·No supplanting of existing funding
·Workforce funds for rural ZIP codes only

Source: Hawaiʻi RHTP briefing to the Task Force, September 2026; CMS Rural Health Transformation Program materials

DIRECT

The Rural Health Capacity Test

Capacity is the amount of necessary care a system can reliably deliver. It is not organizations, contracts, facilities, clinicians, or platforms on paper. The test asks the same question of every proposal, in six parts:

1Does it create measurable rural capacity?
2Does it make an existing rural provider more capable?
3Does it reduce the work required to deliver the same care?
4Does it reduce travel or delay for the patient?
5Does it connect rather than duplicate?
6Is there a credible path for it to remain after the funding ends?

The negative question

Could this project meet every contractual deliverable without improving patient access? If yes, the metrics are wrong.

How proposals are rated

DemonstratedClaimedNot addressed

Described, never scored, and published with sources.

Units of capacity

·Appointment capacity
·Rural clinician-hours
·Days to appointment
·Services available locally
·Referrals completed
·Clinician administrative hours per encounter
·After-hours capacity
·Off-island trips avoided

Training counts, licenses, platforms, committees, and encounter volume are process measures. They are fine. They are not capacity.

Developed by David Isei and Esther Y. Smith, MD. Offered without restriction, with attribution.

Four instructions

Preserve capacity

Keep the rural clinics and screening services that exist today from closing while the program spends.

Build capacity

Add clinicians, hours, and services where the shortage is measured, not where the paperwork is easiest.

Connect capacity

Spend on connection only where it removes work from clinicians or makes care possible that was not.

Measure capacity

Publish a baseline by island before the first federal reporting cycle, and measure against it.

What the Task Force has asked the state to do

1Adopt the Capacity Test as the common evaluation framework now.
2Commission the Medical Economic Evaluation the state's own briefing names as an independent measurement function, with a public baseline by island offered at no cost, and if the function is institutionalized it is a state procurement in which the Task Force is not the vendor.
3Design the Budget Period 3 portfolio now around the gaps the state's briefing names: palliative care, community mental health and substance use, obstetrics, workforce housing, and sub-specialist access.