Strong Demand for Care Homes to Continue Well into the Future, How to Get Started, Opportunities, Rewards and Challenges
by Edwin Quinabo
The graying of America is providing both opportunity and urgency to the care home industry. The silver tsunami is also taking place in Hawaii where according to the latest demographic data there are approximately 294,654 people aged 65 and older in the state. Public health officials project a growing demand in the care home indus-
Former RN established foster home for holistic, dignified and patientcentered care
Sheillamari Prepuse is the owner of E’ola Care Home Inc., a CCFFH – Community Care Foster Family Home. Prepuse established her foster home six years ago. Prior to that, she worked as an ER and Dialysis Nurse for over a decade. “I chose to leave the bedside because I wanted to care for people in a way that hospitals and large facilities don’t always allow. As an RN, I’ve seen
try that by 2030, over a fifth (20%) of Hawaii residents will be seniors. Statistics suggest that demand for senior care will only rise, especially since Hawaii has the highest life expectancy age in the nation at 81.3.
The care home business is both a service of professional care and an entrepreneurial venture. Hawaii has several categories of care homes such as Adult Residential Care Homes (ARCH), Expanded ARCH, and Adult Foster Homes.
firsthand how the system often struggles with staff shortages, rushed care, and limited time to truly connect with patients. While I gained invaluable experience in the hospital, I felt called to build something more personal, holistic, and rooted in community,” she said.
Prepuse was also attracted to the entrepreneurship which rendered more flexibility and income opportunities. “Owning a foster home also provides financial control by providing potential for higher income, scalabili-
Care homes cater to seniors who require help with daily living but do not need hospital level care.
ty and equity instead of capped wages. Lastly, it took me away from task driven nursing roles and allowed me to create a system of care that is more holistic, dignified and patient-centered that complements traditional medical care,” she said.
Caregiving was a call from God
Rosemarie Sebastian runs Sebastian’s ARCH LLC, a Type 1 Adult Residential Care Home. Her care home was established in 1978 by her mother-in-law. Rosemarie became her main substitute caregiver from 1998 until her mother-in-law retired in 2021, then Rosemarie took over. She said taking over the family care home made sense because it worked well for the existing residents not to be placed in another home, she had the care home already set up and it worked well to care for her chil-
dren at the same time while running her care home.
“Also, I have come to realize that our clients are mentally disabled. Most of them come from homelessness and without family. Perhaps God has a greater calling for me—that being a caregiver, I can help care for His less fortunate people,” Sebastian said. She said a career in the care home business is worth pursuing if you like the idea of being self-employed and having flexibility.
Passion to care for the elderly
Cheryll Apuya, caregiver of a Type 1 ARCH, got into the care home industry when her children were young. “I got to take care of them and stay with them 24/7 while running my care home. I was always there for them and rarely missed their school activi-
Are Women More Prone to Autoimmune Diseases?
Autoimmune diseases are health disorders that occur when your immune system attacks your body instead of defending it.
The immune system is the body’s first line of defense against diseases by recognizing and destroying foreign entities like bacteria, viruses, and other harmful substances.
Autoimmune diseases are common, especially because there are so many different types.
Some of which are in the form of rheumatoid arthritis, systemic lupus erythematosus or lupus, multiple sclerosis, type 1 diabetes mellitus, Crohn’s disease, ulcerative colitis, psoriasis, thyroid disorders (Graves’ disease and Hashimoto’s thyroiditis), myasthenia gravis, scleroderma, and vasculitis.
Autoimmune diseases can cause a wide variety of symptoms. They can affect your body at almost every part from head to toe. Thus, symptoms depend on the specific affected area.
Yes, women are more prone to
autoimmune disorders. It is estimated that around 1 in 15 people in the U.S. has an autoimmune disease.
Scientific studies consistently show that the majority of autoimmune diseases occur more frequently in women, with estimates suggesting that up to 80% of affected individuals are female.
There are multiple reasons for this gender bias. This is due to a complex interplay of genetic, hormonal, immunological, and environmental factors.
Females have two X chromosomes. The presence of this is a major contributor. This results in abnormal regulation of certain genes related to the immune system.
Sex hormones, especially estrogen, further modulate immune responses. Estrogen enhances pro-inflammatory immune activity and lowers autoimmune regulation.
This amounts to increased susceptibility to autoimmunity.
Women exhibit stronger lym-
phocyte activation and cytokine production, resulting in stronger immune responses, with higher antibody levels further predisposing them to loss of self-tolerance.
The female predominance of autoimmune disorders is most pronounced during reproductive years, implicating hormonal fluctuations as a major driver, but genetic and epigenetic mechanisms are also essential.
Endocrine transitions such as puberty, pregnancy, and menopause further influence immune function and disease risk in women.
Environmental factors, including viral exposures, drugs, toxins,
and lifestyle changes, may also interact with these genetic and hormonal mechanisms to further increase the risk of autoimmunity in women.
The cumulative effect of these factors results in a higher prevalence and severity of autoimmune diseases in females.
There is no well-established prevention or cure for autoimmune diseases. But there are treatments available. The management depends on the symptom and the specific disorder.
The treatments are long-term since the condition typically lasts a lifetime. Some autoimmune diseases enter remission, with a long period of time between symptom flares.
This is not the same as a cure, but it might mean the symptoms impacting the patient’s daily routine and activities are less pronounced.
In summary, the female predisposition to autoimmune disorders is driven by X-linked genetic factors, estrogen-mediated immune modulation, and sex-specific differences in immune function and tolerance.
To get more information, your health care provider is the best source regarding inquiries and concerns related to your medical problem.
By Nestor Heraña Jr., MD, FACP
ties.” Apuya believes caregiving is worth pursuing as a career “only if you have a passion to care for the elderly. If you’re just in it for earning money, this vocation is not for you.”
Kupuna care will be an ongoing demand
Ruby Lei Brister is an E-ARCH Operator who has two expanded licensed care homes, arch and ICF levels, providing 24-7 care. Both of her care homes are in East Honolulu. She says she offers hospice services at both locations. “This career will only be more in demand year after year. It’s worth pursuing if you have patience and perseverance to go through the licensing process. I am reasonable and affordable with my care homes. Other operators charge a lot more than I do. I believe it’s not about the money. It’s about the care we provide,” Brister said.
Responsibilities
Responsibilities for operating a care home depend on the type of residents accepted, their varied needs, as well as the type of care home. The general responsibilities include hands-on support with personal care and mobility, medication assistance, providing meals, ensuring a safe place and comfort, coordinating with healthcare providers to provide health care services. Residents could also require assistance with hygiene care, toileting, housekeeping and laundry. Records and reports for each resident are maintained, and doctors’ visits and vaccinations are carried out as instructed by residents’ primary care physicians.
Licensing, regulation and getting started
Licensing, regulations and start-up depend on the type of care home but typically requires education with certification, hands-on experience and ongoing professional development. Operators typically have a background in healthcare like nursing. Some enter the field after working in some caregiving capacity. The state mandates specific training like first aid, CPR, medication management and infection control. Other areas needed for some care homes also include fire safety, client rights, fiscal and insurance and records requirements.
Regulation compliance usu -
ally covers resident safety, nutrition, privacy and quality of care. If regulations aren’t met, it could result in a violation of fines, license suspension or closure.
To make a formal application, it must be done through the Hawaii Department of Health, Office of Health Care Assurance, State Licensing Section. They will send you an application packet and information on requirements. The DOH regulates care homes.
Challenges
Care home operators say this type of business typically requires a balance of compassion and business acumen. Operators are challenged to meet ongoing regulatory requirements, inspections and quality-of-care issues. They say having a care home has high operational costs and start up costs. Typically, a care home operator purchases or temporarily rents a home. Besides the purchase of a home, money must also be spent on improvements to make it care home ready. Liability insurance is costly. Expenses like food are high as Hawaii ranks number one in the nation in the cost of groceries. Owners of care homes report challenges in recruiting and retaining qualified caregivers to assist them. While there’s demand for caregiving, there is also competition among providers. Some caregivers also talk about the challenge of residents’ behavior.
Prepuse said, “In general, CCFFH’s main challenge is the low reimbursement rate from Medicaid coupled with the non-existent resources and support from the state. There’s also the problem of the antiquated, bias and restrictive HAR rules (implemented by DHS) that need to be updated and revised because it does not reflect the current needs and environment of CCFFH. Not to mention, the exploitation of the health plan who nickel and dime or low-ball providers for Medicaid payments and the third-party placement agencies that charge up to half of month’s rent for referral and placement. Finally, the divisive and fragmented caregivers’ associations and their leaders cannot see eye to eye and unite for a goal.”
Apuya said caregivers are unable to take long vacations and the fee for their services isn’t much if the client is a Medicaid resident.
Similarly, Brister said, “the
state needs to compensate more for Medicaid-resident foster homes in the community that are not private pay.
Sources of payment for caregiving services
Care home operators have various sources of payment for their services: 1) Private Pay, set between the care home and the resident of their family; 2) Medicaid Payments, rates set by the state, are usually lower than private pay; 3) VA Benefits; 4) Supplemental Security Income (SSI) as partial payment; and 5) Other Public Funding.
Sebastian shared dollar figures, “we get paid whatever is set forth by Social Security (SSI portion) and State (State Supplement). Today, Type I ARCHES receive $1,676 per month for Room and Board from each client. If we choose to take private clients (same LOC), we would be able to charge about $2,800 to $3,000 a month or even higher. But if we care for SSI clients, our pay is limited to $1,676 per client per month. E-Arch homes can charge as much as $5,000 or higher per month, per patient, but their level of care is ICF level, not Type 1 Arch.” The rule of
thumb is if a resident requires more care, the fee for service becomes higher.
State saves money via care homes
Prepuse said, “Someone online made a rough calculation of how much the foster care home industry saves the state every year. If the foster care home industry roughly took in 2K SNF/ ICF patients that should have gone to nursing facilities and if these nursing facilities are getting paid $450/day and CCFFH are only getting paid $68/day that is roughly a savings of $300 million a year.”
Official data is not provided by the state on savings for services via DOH licensed care homes paid by the state.
A resounding theme among some care home operators who receive pay from the government is to have increased pay, which is one of the main goals caregivers have been presenting annually to the State Legislature. Prepuse said, “Where does the state get the money to pay for our raise? The simplest answer? Take it from the funds that the state saves from utilizing the foster care home industry.”
Understanding Cholesterol: Types, Risks, and Management
By Jon Avery Go, MD
Cholesterol is a fat-like, waxy substance found in every cell of the body. It plays a vital role in building cell membranes, producing hormones (such as estrogen and testosterone), synthesizing vitamin D, and forming bile acids to aid in fat digestion.
While cholesterol is essential for health, too much or too little can cause medical problems. The body produces cholesterol naturally, but it also comes from animal-based foods such as meat, dairy, and eggs.
Cholesterol does not dissolve in blood; it travels through the bloodstream in particles called lipoproteins. The two main types are Low-Density Lipoprotein (LDL) Cholesterol and High-Density Lipoprotein (HDL) Cholesterol.
LDL cholesterol is often called “bad cholesterol” because it carries cholesterol from the liver to the rest of the body.
If too much LDL is present, it can deposit cholesterol in artery walls, leading to plaque buildup and nar-
rowing of the arteries (atherosclerosis). This increases the risk of heart attack and stroke.
High-Density Lipoprotein (HDL) cholesterol is known as “good cholesterol” as it transports excess cholesterol from the bloodstream and artery walls back to the liver for removal.
Higher HDL levels are generally protective against cardiovascular disease.
High cholesterol—especially high LDL—can be dangerous because it often has no symptoms until serious problems occur.
Long-term high cholesterol can cause atherosclerosis (hardening and narrowing of arteries), coronary artery disease, heart attacks, strokes, peripheral artery disease, and reduced blood flow to organs and tissues.
In general, healthy individuals should aim for LDL cholesterol numbers under 130 and HDL cholesterol numbers above 60.
Common approaches for high cholesterol include changes to your lifestyle, such as exercising regularly, having more vegetables and less red meat in your diet, and weight management.
The American Heart Association labels cholesterol risk categories based on a person’s 10-year risk of cardiovascular disease.
This takes into account a patient’s age, race, sex, smoking status, blood pressure reading, medication treatment, total cholesterol, LDL cholesterol, HDL cholesterol, and history of Diabetes.
Those with intermediate
risk (7.5-20%) and high risk (more than 20%) of developing cardiovascular disease, medication management generally with a statin is recommended to lower risk.
Maintaining healthy cholesterol levels requires both dietary and lifestyle changes.
A heart-healthy diet includes limiting saturated fats (found in red meat and butter), avoiding trans fats, increasing the consumption of fiber-rich foods, and eating healthy fats from sources like olive oil, nuts, and fatty fish.
Exercising regularly can help in maintaining a healthy weight, where a 5-10% weight loss can significantly improve cholesterol levels. Quitting smoking and limiting your alcohol intake can positively impact your cholesterol health.
Cholesterol is vital for life, but balance is key.
High LDL increases cardiovascular risk, while low cholesterol can disrupt essential body functions.
Through healthy eating, regular exercise, and, when necessary, medication, most people can keep cholesterol levels in a range that supports heart and overall health.
Regular monitoring is essential—because cholesterol problems are often silent until they cause major health events.
Adults should have their cholesterol regularly checked every 4–6 years, or more often if they have a higher risk.
Hepatitis B: The Silent Illness in Hawai‘i’s Filipino Community
By Rainier Dennis D. Bautista MD, DABFM, FAAFP
He was in his early 50s, a quiet man who came to my clinic after putting off doctor visits for years. He worked two jobs, rarely took sick days, and appeared strong and healthy. He told me he rarely felt ill.
But when we ran routine blood work, the results revealed something he never expected: he had been living with chronic hepatitis B since childhood.
His liver was already showing signs of damage. The virus had been silently attacking his body for decades, without a single warning sign.
His story is not rare. Many Filipinos in Hawai‘i are living with hepatitis B without knowing it. About 6% of Filipinos here carry the infection, a number more than ten times the national average.
When we talk about the health of Hawai‘i’s Filipino community, we often focus on high blood pressure, diabetes, or heart disease. Yet hepatitis B remains in the shadows, even though it is a leading cause of liver cancer, one of the deadliest cancers in our state.
How It Spreads
One of the biggest misconceptions is that hepatitis B is mainly a sexually transmitted infection. That stigma has led to silence and fear.
In reality, most Filipinos living with the virus today were infected at birth or during childhood.
In the Philippines, where hepatitis B is common, many mothers unknowingly pass it to their babies. Children may also acquire it in the household through shared razors, toothbrushes, or small cuts.
It does not spread through hugging, sharing meals, coughing, or mosquito bites. It is passed through blood
and body fluids, often in ways no one could control.
Why It’s Dangerous
Hepatitis B can remain hidden for decades while steadily injuring the liver. Without treatment, it can lead to cirrhosis, liver failure, or cancer. The tragedy is that many patients feel well until the disease is far advanced. Just like this man, who never imagined he was at risk.
What You Can Do
A simple blood test can reveal your hepatitis B status. It shows whether you are immune, still at risk and need vaccination, or living with the infection and needing medical care. For many people, testing is covered by insurance or offered at low cost.
If you are unprotected, the hepatitis B vaccine can prevent infection. The series of three shots over six months is safe, highly effective, and given to millions worldwide. For those already infected, modern medications can keep the virus under control, protect the liver, and allow for long, healthy lives. The earlier it is discovered, the better the outcome.
Breaking the Silence
Too many in our community avoid talking about hepatitis B because of stigma. But this is not a shameful condition. It is not a punishment. For many, it is an infection inherited in childhood, through no fault of their own. Silence
only allows the disease to spread further.
If you are pregnant, make sure your newborn receives the hepatitis B vaccine within 24 hours of birth. If you or your parents were born in the Philippines, ask your doctor about testing, even if you were vaccinated later in life. And if someone in your household has hepatitis B, every family member should be tested.
A Community Response
In Filipino culture, we believe in bayanihan—lifting one another. That spirit is exactly what we need to protect our families from hepatitis B. Talk about it. Share the facts. Encourage your loved ones to get tested and vaccinated.
The man I described at the beginning of this sto-
ry is now under treatment. With the right care, his liver is being monitored, his virus is controlled, and he has hope for the future. His life is a reminder that hepatitis B doesn’t have to remain hidden.
With knowledge, compassion, and timely medical care, we can protect ourselves and safeguard future generations. Together, one conversation, one test, and one vaccine at a time, we can make a lasting difference.
DR. RAINIER DENNIS D. BAUTISTA is a Board-Certified Family physician in Hawai‘i, where he serves as a Clinical Professor at the University of Hawai‘i John A. Burns School of Medicine and President of the Philippine Medical Association of Hawai‘i. He is dedicated to advancing community health, mentoring future physicians, and addressing healthcare disparities in diverse populations.
Hyperkalemia: What is High Potassium?
By Valerie Tan, MD
Potassium is an essential mineral for the body and a type of electrolyte needed for its vital functions.
It is naturally present in many foods and is also available as a dietary supplement. It is present in all body tissues and is required for normal cell function because of its role in maintaining the proper fluid status inside the cells and for maintaining electrochemical gradients of the cells.
Most potassium is intracellular (inside the cells), amounting to approximately 30 times the extracellular (outside the cells) amount.
About 90% of ingested potassium is absorbed by the intestines, but it is primarily excreted in the urine. Some is excreted in the stool, and a very small amount is lost in sweat.
The kidneys control potassium excretion in response to changes in dietary intake, with potassium excretion increasing rapidly in healthy people after potassium consumption.
Healthy kidneys can adapt to variable potassium intake and will decrease excretion if there is a depletion of total body potassium.
There is a small amount of obligatory potassium loss regardless of body stores, and thus it is important to have an adequate potassium intake.
Hyperkalemia (high potassium level) is defined as a serum potassium level above the upper limits of normal, usual-
ly greater than 5.0 mEq/L to 5.5 mEq/L, with normal levels being 3.5-5.0 mEq/L.
While mild hyperkalemia is usually asymptomatic, high potassium levels may cause life-threatening cardiac arrhythmias (irregular heart rhythm), muscle weakness, or even paralysis.
Common Causes of Hyperkalemia
High dietary intake - Potassium is primarily obtained through the diet. Common potassium-rich foods include meats, beans, tomatoes, potatoes, and fruits such as bananas, mangoes, papayas, and avocados. Increased dietary potassium intake is a very uncommon cause of hyperkalemia in people with normal kidney function, but it can be an important cause in those with kidney disease.
Use of potassium supplements, either as multivitamins or dietary salt substitutes such as those found in “low salt” or “no salt seasonings”, herb-
al supplements like noni, can produce hyperkalemia in a patient with impaired kidney function, especially if the eGFR falls to <30ml/min.
Medications that decrease potassium excretion - Certain medications can interfere with potassium excretion, especially in those with kidney disease, and lead to hyperkalemia.
Examples of these are angiotensin-converting enzyme (ACE) inhibitors such as lisinopril or benazepril; angiotensin receptor blockers (ARB) like losartan, olmesartan, and valsartan; mineralocorticoid receptor antagonists like finerenone; aldosterone antagonists like spironolactone; and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, diclofenac, and celecoxib.
Medical conditions that decrease potassium excretion - Medical conditions such as diabetes, acute or chronic kidney disease, and genetic conditions that cause low levels or decreased response to the hormone aldosterone can cause hyperkalemia, especially when combined with high dietary intake and intake of certain medications such as those mentioned above.
Diabetics are at high risk for developing hyperkalemia due to a variety of factors. Insulin deficiency (as seen in Type 1 diabetes) or insulin resistance (as seen in Type 2 diabetes) causes decreased intracellular shift of potassium.
A healthy diabetic diet typ-
ically involves eating foods that are low in salt but are naturally high in potassium.
Medication regimens for diabetics typically involve the use of ACE inhibitors or ARBs to manage hypertension and decrease the risk and/or slow down kidney disease progression. For those who already have kidney disease, this can lead to further impaired potassium excretion.
Shifting of potassium from cells - Since potassium is primarily stored inside the cells, the majority of which are in the muscles, significant muscle injury, such as crush injury from accidents, medication side effects, or even excessive exercise, can cause the intracellular potassium to shift outside the cell, causing hyperkalemia.
Although mild hyperkalemia can be asymptomatic, severe hyperkalemia or a sudden, acute increase in potassium level can cause weakness, paralysis, and abnormal heart rhythms, leading to cardiac arrest.
Hyperkalemia is typically diagnosed on routine laboratory testing, and if it is only mild to moderate, it may be treated by medications that bind potassium so it can be excreted through the stool, making medication adjustments and limiting or completely avoiding high potassium foods. Severe and symptomatic hyperkalemia, even if mild to moderate, requires treatment in the emergency room.
Potassium is a vital mineral in the body, and it needs to be kept in a narrow normal range for the body to perform vital functions.
Abnormal levels, especially high levels or sudden increases, can have detrimental health effects, so discuss with your provider if you are concerned about your risk for hyperkalemia.
DR. VALERIA TAN is a board-certified Nephrologist and works at Hawaii Nephrologists, LLC
Caring for the Health of Migrants Under Attack
By Arcelita Imasa, MD
Hawaii has long been a haven for migrants.
From the plantation era to today’s diverse communities, people have come here from around the world seeking safety, work, and a better future.
Migrants from the Philippines, Micronesia, Latin America, and elsewhere are now an essential part of island life— caring for our kupuna, working in hotels and farms, and enriching the culture that makes Hawaii unique.
But along with these contributions come health challenges that too often remain invisible.
Many migrants in Hawaii struggle to see a doctor or dentist. Some don’t have health insurance, while others fear high medical bills. Language barriers and long wait times add to the stress.
For Micronesian families under COFA (Compact of Free
Association), shifting healthcare policies have also created confusion about what services they receive are covered.
Migrant workers are the backbone of Hawaii’s industries, like caregiving, agriculture, and hospitality. Yet these jobs are physically demanding and sometimes unsafe.
Long hours, exposure to chemicals, and heavy lifting lead to injuries and chronic health problems. Too often, workers push through pain
rather than risk missing work or losing income.
Being far from home adds another layer of strain. Many migrants live with the stress of separation from loved ones, the pressure to send money back home, or the uncertainty of immigration status. This takes a toll on mental health, leading to anxiety, depression, or loneliness. Unfortunately, culturally appropriate mental health services remain scarce, and stigma persists.
Migrants’ right to health is no different from anyone else’s: access to medical care, insurance coverage, and social supports like food assistance.
But as migrants, they face added vulnerabilities—Hawaii’s high cost of living, job insecurity, layoffs in healthcare and other sectors, and the responsibility of sending remittances to family overseas.
A Climate of Fear
In recent months, the vulnerabilities of migrants have deepened. The passage of the One Big Beautiful Act threatens to restrict healthcare access for many.
ICE agents have become more visible near hospitals, schools, and community spaces. Reports of immigration raids on farms have already endangered lives and livelihoods.
Two of my patients, who are both low-wage workers, have “self-deported” out of fear that they would be arrested and find themselves without support.
Immigration lawyers report
soaring caseloads as arrests, detentions, and deportations increase. On Oahu, detention facilities are taking in more detainees transferred from the mainland.
The full extent of ICE activity in Hawaii is hard to capture, but its chilling effects are undeniable.
It is only a matter of time before we learn collectively that migrants are delaying or avoiding care, cancelling appointments, or skipping the ER, even in emergencies, because they fear being detained. This is not only a humanitarian crisis; it should be considered a public health threat.
Hospitals’ Role and Responsibility
As a healthcare worker, I have been told by administrators to “not interfere with ICE” and “not get in the way” when agents show up.
These directives are framed as safety precautions. Staff safety is important, but this policy is incomplete. It leaves a huge ethical gap.
It is frightening that, while no ICE arrests inside Hawaii healthcare facilities have been documented so far, these sites are only considered “sensitive locations,” where enforcement is supposed to be limited but not prohibited.
Photos of ICE vehicles on hospital grounds, shared through community tracking networks, remind us that the threat is real. If hospitals limit their response to passive observation, this does little to ease our fears or protect vulnerable patients.
Hospitals should not stop at non-interference. Non-interference is not neutrality; it abandons our duty of care. If ICE can intimidate patients on hospital grounds, then hospitals are complicit in driving people away from lifesaving treatment.
We can and must go further. We must train our people to require judicial warrants before ICE can enter patient care areas. We must train staff on immigrants’ rights and ICE tactics.
How to Save Money on Precription Drugs
By Rhea Bautista, MD
Prescription drug prices can take a big bite out of family budgets in Hawai‘i. But there are many ways patients can lower costs, from using insurance formularies wisely to exploring discount programs and asking for generic alternatives.
Use Your Insurance Formulary
Every health plan in Hawai‘i has a formulary – a list of medicines covered by your insurance. The formulary is divided into tiers. Lower-tier medicines usually cost less, while higher-tier or specialty drugs can cost much more.
Always check your plan’s drug list before filling a prescription. If your medication is not covered or is in a high tier, ask your doctor if another option is available.
Ask About Generics and Alternatives
Generic drugs have the same active ingredients as brandname medicines but usually cost far less. Doctors can also sometimes prescribe therapeutic alternatives—different drugs that treat the same condition but come at a lower cost.
Use Discount Programs and Cards
Several free programs help families in Hawai‘i save on
drug costs.
GoodRx: Offers coupons and price comparisons at local pharmacies. (goodrx.com)
Hawai‘i Rx Card: A free statewide discount card available to all residents. (hawaiirxcard.com)
Hawai‘i SHIP: Provides Medicare guidance and financial assistance information. (hawaiiship.org)
Talk to Your Doctor and Pharmacist
Always bring an updated list of all medications, vitamins, and supplements to your appointments. This helps your doctor look for lower-cost combinations or remove unnecessary medications. Pharmacists can also suggest generic versions or help you understand if splitting a higher-dose pill safely could lower costs.
Look for Patient Assistance Programs
Drug manufacturers and
nonprofit groups often run programs to provide free or reduced-cost medicines for patients who qualify. Ask your doctor’s office or search online for the drug name plus “patient assistance program.”
Patient Tips Box: Smart Ways to Save
Check if your drug is on your insurance formulary. Ask for generic or lower-cost alternatives. Use GoodRx, Hawai‘i Rx Card, or other savings programs.
Always carry an updated medication list, including vitamins. Save receipts and estimates—appeal if costs are higher than expected.
By using formularies, discounts, and smart conversations with providers, Hawai‘i families can stretch their healthcare dollars further and reduce the stress of paying for needed medicines.
RHEA BAUTISTA, MD is a healthcare strategist and entrepreneur serv
ing as Director of Business Strategy and Growth at MDX Hawai‘i, co-founder of SB Solutions, and Executive Director of the Philippine Medical Association of Hawai‘i. She also advises the Primary Care Clinic of Hawai‘i on quality improvement.
FactorsLeadingtotheDeclineofChildren’s, YoungAdults’MentalHealth
by Jay D. Valdez, PsyD
There’s been an alarming decline in our children’s mental health. It was a trend before the pandemic, but the pandemic magnified it due to its disruption of everyday life.
Children were isolated at home, social gatherings were prohibited, mental health services were either paused or limited, and people lost their jobs, leading to increased tension and stress in the family.
But what led to this problem in the first place? It starts with family.
Parents help shape the formation of a child’s personality and well-being. Pediatric psychiatrist and psychoanalyst Donald Winnicott termed the phrase “good enough parenting.” It means parenting doesn’t need to be perfect, but rather responsive to the child’s needs.
However, factors such as divorce, marital problems, physi-
cal and mental disability, drug abuse, physical and emotional abuse, and poverty all have detrimental effects on parenting.
The strongest predictor of a child growing up to become a happy, satisfied, and functioning adult is their parents’ ability to rear their child in a safe, supportive environment.
In 2022, the U.S. Department of Health and Human Services indicated that divorce and separation are the most common reported events that increase the incidence of anxiety, depression, behavioral problems, and attention deficit hyperactivity disorder in children aged 6-17 years old.
Parents are the primary caregivers during a child’s formative years, and a developing child’s brain is primed to receive and internalize information from their environment.
Factors cited above impede the child’s formation of
a healthy sense of self. Poverty makes it difficult for parents to provide basic needs such as food, water, shelter, human touch and interaction, which are needed to cultivate a child’s emotional, mental, and physical well-being.
In the abuse of alcohol and drugs, feeding the addiction becomes the parent’s priority, leading to dysfunctional child-parent dynamics, child neglect, and abuse.
Likewise, a parent with a mental or physical disability will not have the capacity to appropriately respond and raise a child, much less mitigate childhood challenges.
One such challenge is the impact of the internet and the media.
Numerous studies suggest that low self-esteem, poor body image, eating disorders, depression, and anxiety have been directly linked to the amount of time children and young adults spend on the internet.
Furthermore, elementary school children have been using it for many years. They are the most vulnerable because their brains aren’t fully developed, and it is linked to poor self-control. The majority of information in the media and what is portrayed as what’s popular, desired, and beautiful on the internet is vastly inaccurate.
Children and teens, especially girls, use this information as the standard by which they compare themselves, and because these standards aren’t realistic, they begin to believe that they fall short of what is desirable and beautiful. They make negative judgments about themselves, devalue themselves, devalue their cul-
ture and family of origin, and feel inadequate.
This also leads to a snowball effect, and they start catastrophizing or believing their life and circumstances are worse than they really are. They see and interpret their world through catastrophic lenses and assume others see them the same way.
They engage in confirmation bias, meaning they’ll only believe information that supports their beliefs and ignore the rest, leading to a self-fulfilling prophecy or behaving in ways that align with their biases.
Social media is a serious issue because it’s embedded everywhere and is impossible to escape. Other problems include internet addiction, online gaming addiction, cyberbullying, sleep deprivation, musculoskeletal problems, and social isolation.
While there are advantages and disadvantages of the internet and social media, the same is true for social policy, which some argue also contributes to the mental health decline in our youth.
Social policies are programs created by the government to improve the welfare of its people. Opposing views assert that these policies have led the country further from its traditional beliefs and family values.
These polices include issues around gender equality, LGBTQ rights, secularization, and minimization of religion, and emphasis on social and political growth through economy and trade rather than on social and community resources.
In the current political and social climate, it’s difficult to predict whether our country is on the right path.
Regardless, it might help children if wanna be parents were required to attend a class on parenting and factors that affect healthy childhood development - just a thought.
DR. JAY D. VALDEZ is a psychologist who practices in Waipahu. He works with adults suffering from anxiety, depression, relationship problems, and trauma; he also does marital counseling.
Breaking the PCOS Silence in the Aloha State
by Anna Melissa Lo, MD
Here in Hawaii, we take pride in looking out for one another, whether it’s sharing leftovers after a beach day, helping after a storm, or just being there to listen when someone needs to talk. However, when it comes to women’s health, there are still issues we don’t discuss enough. One of those topics is about polycystic ovary syndrome, or PCOS.
Polycystic ovary syndrome (PCOS) affects about 1 in 20 women of childbearing age. However, many are unaware that they have it. It occurs when the ovaries produce more male hormones than expected, disrupting the body’s natural hormone balance. This can lead to symptoms like:
- Irregular or missed periods
- Weight gain or difficulty losing weight
- Excess hair in the face, chest, or back
- Hair thinning on the scalp
- Acne or oily skin
- Darkening of the skin in the neck or armpits
Women with PCOS may have tiny pockets of fluid in their ovaries, often called cysts, which can be seen on an
We must adopt “safe zone” or sanctuary policies to reassure patients that hospitals are places of healing, not surveillance. We must equip the front desk and security staff to properly handle ICE requests. Even small steps, like checking for warrants, can make immigrant patients feel safer.
Beyond the Hospital Walls
Oahu urgently needs a stronger migrant support system involving immigrant rights groups, rapid response networks, and legal aid organizations.
ultrasound.
Why Understanding PCOS Matters
PCOS is not just about periods or appearance. It’s related to other common health concerns, like obesity, hypertension, high cholesterol, diabetes, and heart disease. Some women also may have trouble getting pregnant.
The good news is PCOS can be managed, and the earlier it’s diagnosed, the better. So, being proactive about your health and seeking early diagnosis is key.
Why Many Women Stay Silent
Here in Hawai‘i, and much like in Filipino culture, we value strength and resilience. But sometimes, that means we downplay our struggles or think, “It’s fine, I can deal with it.”
Many women with PCOS are told their symptoms are “just part of life” or are given tips to “try harder” to lose weight, instead of getting a proper evaluation.
Starting The Conversation
If you think you might have PCOS, it’s important to talk to your doctor. Diagnosis is made with a combination of medical history, blood tests, and an
Community members can help by building relationships with migrants, sharing hotlines and resources, and standing ready to respond when ICE appears at hospitals or elsewhere.
We must also acknowledge the harsh realities of detention. Across the country, overcrowded centers fail basic hygiene standards. Food is unhealthy, nutrition is neglected, and medical care is delayed or denied. Detained migrants face family separation, trauma, and depression; their children often require therapy.
ultrasound. While there is no “cure,” symptoms can be managed with the proper care.
Treatment can include lifestyle changes (like balanced eating and regular exercise), medications to regulate periods or help with fertility, and strategies to manage symptoms like acne or hair changes.
Most importantly, treatment is tailored to your needs — it’s not one-size-fits-all.
For Friends and Family
If someone you love has PCOS, your support matters. Listen without judgment, avoid making comments about weight or appearance, and ask how you can help.
PCOS can be frustrating and sometimes isolating. As a community, we can also play a role in supporting women
People die in detention— many from preventable causes. This is what happens when health is ignored in the name of enforcement.
An Attack on All of Us
The ongoing attack against migrants is an attack on all of us. Legal status, “doing it the right way,” or years of loyalty to this country offer no protection under policies designed to punish and exclude the migrants. We must demand a healthier society—one where everyone, regardless of immigration status, can live with
with PCOS by promoting open conversations, understanding, and acceptance.
The Bottomline
Breaking the silence about PCOS in the Aloha State means that more women can get answers, feel understood, and take steps toward better health. If you notice symptoms in yourself or someone you care about, don’t dismiss them. Start a conversation, seek care, and spread awareness — because every wahine and binibini deserves to feel her best.
DR. ANNA MELISSA LO is an endocrinologist at the Primary Specialty Clinic of Hawai‘i. She cares for people with hormone-related conditions like diabetes, thyroid issues, and PCOS. Dr. Lo believes in providing competent and compassionate care to all her patients.
dignity.
Migrants are not just workers; they are our neighbors, caregivers, coworkers, classmates, and friends. When we safeguard their health, we strengthen the health of the entire community.
Here in Hawaii, we know that aloha means caring for everyone as part of one ohana. Caring for migrants’ health is caring for Hawaii itself.
DR. ARCELITA IMASA is a practicing family physician and the secretary of the Hawaii Workers Center’s Executive Committee of the Board. She grew up in the Philippines before migrating to Hawaii with her family more than a decade ago.
“You Have Cancer”
By Marel Ver, MD
The sentence “You have cancer” is one of the most devastating sentences a person can hear.
Even more disturbing is when the diagnosis is from work-up or treatment of something that may be a minor concern or from what appears like a completely different issue.
As a general surgeon taking emergency on-call in West Oahu, I see an unfortunate amount of hepatobiliary (pancreas, liver, gallbladder), stomach, ovarian/uterine cancers, and even lymphomas presenting to the emergency room with bowel/abdominal problems.
They often present with complaints of pain, bleeding, and/or intestinal blockages/ obstruction. These patients have symptoms because the cancers have grown large enough to change normal anatomy. Sometimes, the cancers compress or sit on other organs, causing problems.
My priority as the surgery consultant is to manage the presenting problem and then work backwards to figure out the cause. Work-ups aimed at diagnosing exactly what is happening can include imaging, labs, biopsies, endoscopies, and even surgery.
In my outpatient clinic, I also see a fair amount of lumps and bumps that occasionally end up being lymphoma, skin, thyroid, or metastatic cancers.
Sometimes cancers like kidney cancers are only seen as an incidental finding on a CT scan for something else. Like the in-hospital problems, work-ups will often include a lot of testing.
Symptomatic cancers are often large in size or have spread to other organs, which makes them late-stage cancers.
The most widely used cancer staging system is the TNM system. The T refers to the primary (main) tumor size. The N refers to the number of lymph nodes that the cancer spread to. The M refers to whether
the cancer has metastasized or spread to other parts of the body.
There are different TNM stages for each type of cancer. In general, the higher the stage, the larger and more spread the tumor is. Stage IV cancer is metastatic cancer, in which the cancer has spread to other parts of the body.
A person’s life expectancy decreases as the stage increases. In general, Stage 0 and earlier-stage cancers are potentially curable. Life expectancy 5 years after diagnosis is significantly decreased in stage IV cancers.
As per the National Comprehensive Cancer Network (NCCN) guidelines, treatments may vary substantially due to the type of cancer and identified stage at work-up. Main cancer therapy options include surgery, chemotherapy, and radiation.
In late-stage cancers, unfortunately, surgery for the cure of the cancer may not be an option.
However, surgery and other procedures may be offered for palliative or symptom management, aiming to improve the quality and/or length of life as the patient continues to live with cancer.
The University of Hawaii Cancer Center and the Hawaii Department of Health collect data for the Hawaii Tumor Registry. This registry was es-
atic cancers are operable at the time of diagnosis.
Interventional endoscopist Dr. Aaron Small helps to treat late-stage cancer patients.
When appropriate, he offers endoscopic stents and drainage procedures for the intestines for the purpose of relieving pain and suffering and allowing for simple joys, like eating and being able to stay home with family.
A diagnosis of cancer, and notably a late-stage cancer, is life-changing and scary for the patient and family. As a patient, learn about your disease and your treatment options.
tablished in 1960.
Since 2018, more than 7,000 Hawaii residents have been diagnosed with invasive cancer yearly, with more than 2,000 cancer deaths. Cancer is the number two cause of death in Hawaii (20.1% in 2021), just behind heart disease (20.9%).
Nearly 67,000 Hawaii residents are cancer survivors.
Much like the rest of the United States, breast, prostate, and colon cancer are the most frequent cancers. However, Hawaii has a higher incidence of stomach, liver, and bile duct cancer compared to the mainland.
Thyroid cancers are more common in Filipino females. Native Hawaiian females have the highest lung cancer incidence and mortality rates. Lung cancer is the leading cause of death in the state overall. Whites have the highest rates of melanoma due to the effects of sun exposure on their non-pigmented skin.
Of note, in darker-skinned people, melanoma can be missed on the palms, soles of the feet, and in the web spaces between fingers and toes.
West Oahu surgical oncologist Dr. Christina Wai reports that in her practice, she has a high volume of colorectal cancer. There are occasional pancreatic cancers.
Biliary and gallbladder cancers are rare. In general, only about 10-15% of pancre-
Know the risks and benefits of doing something versus doing nothing. Sometimes medical treatments like chemotherapy can be physically overwhelming and can affect quality of life.
Fortunately, many current cancer treatments are more effective and more tolerable as research and science advance. Inquire about clinical trials. Lean on family and friends, if available, for support.
I must mention not be afraid to request a language interpreter. Many patients understand and can communicate in simple English, but an interpreter may be more helpful for challenging conversations where the details matter.
Patients often decline interpreter services because they are embarrassed and fear being viewed as less educated. Interpreter services are often free services, so don’t be ashamed or hesitate to have an interpreter as an extra resource in the room.
The last thing you want is to misunderstand important information that may impact your life.
My colleagues and I agree that there are only a few cancers that we can really prevent, and thus stress the importance of screening. Anecdotally, in our practices, Filipinos are hesitant to complete screening tests due to work, family, or time constraints, but especial-
Hawaii’s 2025 Colorectal Cancer State of Health
By Melvin Palalay, MD
In 2005, my patient, a healthy Filipino male, was turning 50. Reflecting the standards of that time period, I advised him to get his first screening colonoscopy.
He was busy working at the bank and raising a young daughter, so he always had some excuse to push it back. With continued encouragement through several years, the patient finally agreed to set up the screening colonoscopy.
In 2008, my patient reported back to my clinic to review the results. I quickly informed him that he did not have cancer, but he did have a particularly aggressive type of pre-cancerous growth in the colon, specifically a tubulovillous polyp.
This particular type of polyp (a growth of tissue in the colon) has a higher-than-av-
erage rate of transformation to cancer!
I added that because he had the polyp removed, his risk of developing cancer fell to 0%. Needless to say, the patient and his family were quite relieved, and he has continued to maintain his regular surveillance checks every 5-10 years.
We call patients like him Previvors, since they have tak-
en steps to prevent the onset of cancer. Whenever I see the patient in follow-up, the old Ben Franklin saying always comes to mind, “an ounce of prevention is worth more than a pound of cure.”
Colon and rectal cancer is no joke. When combining men and women, statistics will show that it is the third most common cancer diagnosed in the United States.
The recent trends indicate that this cancer is also beginning to show up in younger populations of patients, such that the screening age has dropped to the age of 45 years. It is also notable that most of the colon cancers are sporadic and only 10% of cases are familial or genetically-linked. Colon cancer remains a highly curable disease and I would encourage everyone to have an honest discussion about timeliness in screening.
Unfortunately, based on a review, the majority of colorectal cancers in Hawaii are diagnosed at an advanced stage (usually deeper tumors with lymph node involvement or metastatic), ~52-65%. Native Hawaiians and Pacific Islanders are disproportionately affected by late-stage presentation, in particular.
I’d advise you to seek advice from your health care professional on what test would be best for you.
(continue on S14)
ly since “nothing is bothering them” and the fear of “finding a problem.”
Screening tests are often simple medical tests performed to detect health conditions early so that the disease can be prevented or treated more easily.
We recommend screening tests per NCCN guidelines for breast, colon, prostate, and lung cancers, as they are the most common new cancer cases in the US and in Hawaii.
Screening tests have minimum age recommendations for “average risk” patients who have no personal history or family history of health conditions related to cancer.
If a person has “increased risk,” like having a family history of the specific cancer, a history of cigar or cigarette smoking, or having other specific related health conditions, then we may have to start screening earlier.
Screening for breast cancer for the average risk woman (no family history of breast cancer) starts at 40 years old with a mammogram. The age
for screening for colon cancer has now decreased to 45 years old. Colon cancer screening can be performed with colonoscopy, stool sampling, blood tests, or imaging.
Colonoscopies are the most invasive but provide the most information. Screening for prostate cancer starts at 45 years old with a blood test and rectal exam. A CT scan for lung cancer screening is recommended for patients over 50 years old who have been smoking for >20 years (or 20 pack years).
Screening for cervical cancer (caused by the human papillomavirus) depends on age and health history, but generally starts with a Pap test at 21 years old. Fortunately, the HPV vaccination (Gardasil 9) available for adolescents and adults helps to prevent HPV cancers in males and females later in life.
However, for uncommon or rare cancers, screening tests are not routinely recommended. Therefore, it is very important to pay attention to your own body.
Growing cancers are hy -
permetabolic and use up a lot of the body’s energy. This can lead to generalized symptoms like weakness, poor appetite, and unintentional weight loss.
Go to your doctor for these concerns or other symptoms like pain, bleeding, or a new lump. Screening body CT scans or MRIs are generally not recommended (nor covered by insurance), but specific imaging can be ordered if there is a medical indication.
Medical oncologist Dr. Mel Palalay stresses the importance of knowing your risks, which include your family history, race, and social/environmental factors.
He wants patients to strongly advocate for themselves to their PCP, especially if symptoms persist. Obtain second opinions as necessary.
In addition, my advice is to be physically and mentally healthy. Be positive. Don’t take time for granted. I previously wrote an article Ensuring a Meaningful Life (HFC Sept 16 2023), addressing the importance of advanced care planning with your family.
Cancer not just affects the patient, but also the whole
While the colonoscopy procedure remains the gold standard, there are other means of screening, including stool tests looking for blood, DNA material, and imaging with CTs to address the integrity of the colon.
Know your family history. Be aware of signs that may indicate a problem such as blood in the stools, constipation, diarrhea, changes in bowel patterns. If you develop iron deficiency without full explanation, you will need to pursue additional testing. I implore you to work with your health team.
Colon cancer remains a significant problem in Hawaii. The incidence is 29.2 per 100,000 persons per year in Hawaii, while the mortality rate is ~10 per 100,000 persons per year (age-adjusted). There has been a 46% rise in colon cancer incidence among those aged 45-54 years, par-
family. Emotions will run high and all over the place for everyone. This is okay and expected.
If you have a loved one with cancer, be there for their support. Being a caregiver is tough. It’s okay to seek support, too.
Lastly, take control of your health as it affects your life. The Healthy Hawaii Strategic Plan 2030 makes simple recommendations to prevent cancer.
Stop smoking/vaping. Limit alcohol. Protect/limit your exposure to UV sunlight, radiation, and chemicals. Protect yourself from some viruses and bacteria by taking vaccinations when recommended, using protection during sex, and treating infections in the body. Eat a well-rounded diet, stay active, and avoid obesity.
I’d like to acknowledge and thank my Hawaii colleagues cited in this article and those who helped me put this together.
MAREL VER, MD is a board-certified general surgeon practicing in Oahu and a past PMAH president. Her wide range of practice exposes her to important issues that inspire her to write to empower the community.
ticularly in females.
There is evidence that you can reduce risk by increasing dietary intake of fiber, whole grains, and dairy products, and reducing the consumption of red or processed meats, and lowering alcohol consumption. Higher calcium intake and yogurt will confer a protective effect.
In summary, I hope the resounding message of this piece is that colorectal cancer can be prevented and that early detection will result in improved survival and overall quality of life.
Please share this message with others and you may save a life.
DR. MELVIN PALALAY is a hematologist and oncologist physician partner with Hawaii Cancer Care AON. He is certified by the ABIM and has been a passionate supporter of the Philippine Medical Association of Hawaii and Hawaii Society of Clinical Oncology. He has offices in Kakaako and Aiea, on Oahu.
(HAWAII’S ....from S13)
I Was A Healthy 19-Year-Old College Student. A Virus Almost Killed Me.
By Karen Svoboda
It was April 1990. A month before finals during my freshman year at college. I felt… wrong. More than a cold, it felt like my body was “off,” not horrible, just uncomfortable. My choice was do I push through and take the test I had after lunch, or do I go to the infirmary and use it as an excuse to skip the test?
I was lazy. I chose the infirmary. It saved my life.
I ended up going from a fever of 99 to 104 in about three hours. I took an ambulance to the hospital and was dismissed with aspirin.
The nurse at the college infirmary encouraged me to stay the night there rather than return to my dorm, and at about 4am, I woke up unable to breathe.
I don’t know if you’ve ever been unable to breathe, but it’s terrifying and incredibly painful. It felt as though there was a metal band around my ribs holding them tightly closed around my lungs.
I was again rushed to the hospital. The oxygen I was given in the ambulance allowed me to breathe, but the real pain was just beginning.
By that afternoon, I couldn’t move my head, my leg was swollen twice its size, and a small cut on my shin had erupted into an open wound.
Anything that touched my skin was painful. A nurse kept accidentally bumping my bed, and every small jarring nudge made me want to cry.
They did all the tests, and finally, they did a spinal tap. That was it. Bacterial meningitis.
My leg was so infected that I needed surgery and a drain installed to remove the infection under my kneecap.
I spent a month in the hospital, where I was unable to leave my bed at all. I had a bizarre spotted rash on my hands and feet, and my situation was so unique that photos of my hands were taken and included in a medical journal.
Everybody in my dorm, anyone in the infirmary, as well as my ambulance drivers, had to take medicine to prevent the disease from infecting and likely killing them.
Apparently, the pill turned their urine bright orange (my friends called it “orange crush pee”).
After I was finally let out of the hospital, I was quarantined in the state and could not return home. This meant that my summer vacation was spent in my college infirmary while my oth-
er friends were at summer jobs or internships or just living life.
I was in a wheelchair. I was given IV penicillin, which I eventually developed an allergy to, and to this day, I have to use penicillin alternatives when I have an infection.
I should have never lived to see 20. But by the grace of God and an amazing medical team (including the wonderful and kind nurses who kept me from being too lonely over the summer), I survived.
The moment my children could receive the meningitis vaccine, I made sure they got it.
Nobody, especially not a child, should have to suffer unnecessarily like that, and I will not put my children at risk over political ideology and fear-mongering that takes the place of science.
RFK Junior is a person without a conscience, and after more than a few children’s lives are lost, he will be remembered as such.
