Answering the question of what to do with Maui Memorial Hospital opens an interesting window into the world of local power politics.

The Hawaii Health System Corp.’s Maui board last week announced that Kaiser Permanente would be the health care outfit to proceed with negotiations to run medical services on Maui, Molokai and Lanai.

Important stuff, vital to those living on Maui that also shows the importance of politics deciding who wields power.

Picking a private entity to run the hospital has been a nearly decade-old fight at the Legislature. Public unions now staff the hospital, which is usually over budget, requiring emergency state subsidies. Replacing it with a private hospital threatens the union workers jobs, while not having adequate health care threatens everyone on Maui.

Gov. David Ige stepped into the latest debate during the last legislative session, according to legislative sources, at the behest of the Hawaii Government Employees Association and helped draft a bill that gave him responsibility for brokering a hospital deal. The announcement came from the Maui board, but Ige’s office was handling much of the negotiations.

Within hours of the Maui hospital announcement, Lt. Gov. Shan Tsutsui, the former state Senate President and Maui Democrat, launched a press release asking Ige to "consider halting negotiations" and doubting whether Kaiser "possesses the same level of commitment to the well-being of the residents of Maui" as did the other suitor, Hawaii Pacific Health.

"I believe that greater transparency should take place," said Tsutsui.

Ige’s administration is not yet a year old, but already there are signs of strains in the relationship between the governor and lieutenant governor.

Tsutsui, who is also a rumored candidate for Maui mayor in 2018, when his term as LG concludes, flatly said he would not run against Ige.

"It is not going to happen, it is not in the cards. I just want the state to come up with good decisions," said Tsutsui in an interview.

Instead, Tsutsui said, he wants first that both hospital candidates be kept in the running because it gives the state a strong negotiating position, and second, the state must open up.

"Because this is a time of uncertainty, this is the time that the governor’s office and the board should be sending out a lot of information," said Tsutsui.

Observers on Maui are saying the community worries that giving the business to a multi-state medical group such as Kaiser creates a monopoly that would be the dominant health care employer and provider in the county.

"I don’t have any concerns about Kaiser being chosen," said House speaker and Maui representative, Joe Souki. "The decision was unanimous and that was because they felt it was the better proposal."

How all this turns out has implications beyond Maui.

First, public hospitals on Hawaii island have started negotiations to move to a private, nonprofit setup. How the Maui deal works out will be a guidepost for Hawaii County, which has serious health care concerns.

Second, Ige is now balancing not just the health worries of Maui residents, but the political pressure of several unions. How he decides will help define his relationship with the unions, the Democrats in the Legislature looking for leadership, and his second-term viability.

Richard Borreca writes on politics on Sundays, Tuesdays and Fridays. Reach him at rborreca@staradvertiser.com.