In the days before insurance, doctors were far more connected to the community.

During times of emergency, a neighbor would run to the doctor’s house for help: "Come quick, Mom is in labor again!" or "Old man Sasaki fell off his tractor. He can’t walk. I think he broke his leg." Before there were specialists, the same doctor would deliver a baby, set a broken bone, remove an appendix and tend to mental health problems. In the absence of insurance companies, grateful patients might pay in cash but more often would settle up by sharing what products and services they had to offer: a couple of turkeys, a new saddle, a bit of carpentry or perhaps a basket of mangoes.

Traditionally, small businesses, including medical practices, have been a major factor in making the United States the great economic powerhouse it is today. According to the U.S. Small Business Administration, this sector still accounts for just over half of all U.S. sales. Smaller enterprises tend to encourage initiative, readily adopt creative solutions and have the ability to turn on a dime. As distinct from publicly traded monoliths that work to impose a culture of consumption, smaller establishments tend to respond to local needs and more readily become part of the social fabric they serve.

In contrast, enterprises of greater size have enhanced access to capital, more leverage, abundant resources for research and development, and may be in a superior position to effect process change, redesign work flows and employ specialty workers. Their holy grail is economies of scale. That is, the bigger the company, the more streamlined it can become, thereby reducing costs and increasing profits.

What is true about American health care is that beginning with the formation of Medicare in 1965, the country doctor has disappeared while resources and control have shifted progressively to big health care organizations, leaving small health care businesses under threat. The same is true for pharmacies. My grandfather operated a pharmacy in Tucson from the mid-1940s until 1966. Shortly, after selling the store and retiring, independent pharmacies nationwide were either acquired or put out of business en masse by large chains.

The strengthening economy, in concert with the crisis and opportunity of health care reform, has capital from the mainland eyeing Hawaii. Today the giants are stirring. Bruce Anderson’s abrupt departure as CEO of Hawaii Health Systems Corp., which manages Hawaii’s public hospitals, reportedly resulted from differences of opinion on Banner Health’s proposal to privatize selected facilities. Banner Health is based in Phoenix and operates 23 hospitals on the mainland.

Today private medical practices in Hawaii are faced with an unremitting onslaught of challenges, most having to do with the edicts of large organizations both public and private.

Providers are working to catch their breath after paying big dollars to large companies to shift to electronic health records. Concurrently they are also working to fulfill the requirements of HMSA and Medicare. The requirements are loaded with carrots and sticks, but, typically, resources needed for implementation exceed returns. Getting paid by carriers for services rendered in good faith remains as arduous as it ever was. To this we now add competition from publicly traded companies based on the mainland.

True, American health care was broken before health care reform. It was inefficient, expensive and did not provide reasonable access to enough of those in need. It must be fixed but the change is painful. Many clinics will close. Numerous providers will seek employment in large organizations. Some will throw up their hands and retire early. Others will leave the islands in search of better opportunities. These are trying times for the small business in health care.

The time of the country doctor may have passed, but the spirit of compassionate service combined with creative ingenuity and the ability to adapt endures. The healing of American health care will be forged from the dynamic tension between health care giants and the small health care businesses that are tough enough to survive.

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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.