Senate Health Committee chairman and physician Josh Green has amassed more campaign contributions than any other member of the Hawaii Legislature, tapping into a rich pipeline of donated cash from doctors and others in the health care industry.

Now critics, including AARP Hawaii and the Hawaii Psychological Association, are crying foul — alleging that campaign cash and Green’s position as a physician practicing at a Hawaii island hospital present unacceptable conflicts of interest for the lawmaker.

Those organizations lobbied hard this year for bills they contend would improve care for elderly residents and the mentally ill, only to watch helplessly as Green killed both measures when they arrived at his Senate Health Committee.

Those bills were opposed by physicians or hospitals, which each account for large portions of the campaign donations Green has accumulated.

A Honolulu Star-Advertiser analysis of Green’s campaign spending reports shows he collected $91,000 from physicians and physicians groups since he became Health Committee chairman in 2011, and collected another $27,000 from hospitals and medical groups.

By the end of 2014, Green had banked $503,743 in campaign funds, which is more than double the amount of cash held by any other member of the Legislature.

Green (D, Naalehu, Kailua-Kona), denied the campaign money he received had any bearing on his decision to kill the bills. He said there are important problems with both measures — House Bill 1072 and Senate Bill 296 — which is why he blocked them.

In both cases, Green said his experience as a physician "informs what is safest for society, and that is my only consideration — not who supports me, not who writes letters of support. What I base my decisions on is real experience about what would be good decisions as a legislator."

Gerry Silva, state president of the AARP in Hawaii, said members of his organization are disturbed both because Green works as a hospital physician, and because the organization is aware he received significant contributions from doctors and hospitals. Green works weekends at Kohala Hospital, which is part of the state’s network of hospitals operated by the Hawaii Health Systems Corp.

The Hawaii Health Systems Corp. opposed the AARP bill, as did the Healthcare Association of Hawaii, which lobbies on behalf of the state’s hospitals. Also opposing the bill was the Hawaii Medical Association, the professional organization for Hawaii physicians that lobbies on behalf of doctors. Each of those organizations made political contributions to Green.

EVEN IF THERE IS no formal finding of a "conflict of interest," Silva said, Green’s actions suggest he is answering to the needs of the hospitals instead of the needs of the larger community.

"In my mind, there is definitely a conflict, and I am just unable to understand why he couldn’t have taken the appropriate way out, which is to recuse himself," Silva said. "There may not be a conflict, but in my mind there is certainly the perception of a conflict."

The AARP has 150,000 members in Hawaii, and the organization says it is promoting Senate Bill 296 on behalf of the 247,000 caregivers in the state.

AARP is concerned that hospitals sometimes release patients without giving them or their caregivers the training they need for proper home care. Senate Bill 296 would allow patients to identify their caregivers if any are available, and would require hospitals to notify those caregivers when the patients are released. It would also require the hospital to provide basic homecare instruction to the designated caregivers.

The idea is that caregivers would then know how to properly cope with tasks such as changing dressings, medication management, and maintaining feeding tubes and intravenous medication systems, Silva said.

Green said the problem is the bill "could create a situation that could very likely make it more difficult for people to get care because we would be occupying a lot of the time of hospitals for caregiver support."

"In my hospital, if we did that, if we put the caregiver bill in, it would have been catastrophic for care, because they have no staff, no resource to provide that care. We would have been able to see fewer patients, with longer delays," Green said. He said it was his experience as a working physician that "led me to feel it was not ready," adding, "I’ve never had a (campaign) contribution that informed my decision more than that experience."

The caregiver bill has little hope of passage this year, but Silva said AARP will continue to press lawmakers to pass the measure.

"We’ve got to pursue this," Silva said. "We just cannot abandon all of these caregivers. They need the recognition and support that this bill would provide, and we’ve got to see this thing through."

The Hawaii Psychological Association has a similar complaint about Green’s handling of House Bill 1072, which would allow psychologists to prescribe drugs for people suffering from mental illnesses. The association has lobbied unsuccessfully for many years to get Hawaii lawmakers to approve that practice, which is already allowed in New Mexico, Louisiana and Illinois.

That prescriptive authority is now reserved for physicians and psychiatrists in Hawaii, but advocates say there are too few psychiatrists on the neighbor islands or rural areas to provide care to all of the people who need it.

They contend that allowing psychologists with special training to prescribe drugs will improve care for the mentally ill.

Marie Terry-Bivens, president of the Hawaii Psychological Association and a clinical psychologist on Kauai, said Green has supported similar bills in the past, but killed the measure this year.

"I don’t know him personally. I don’t have anything against him at all, but my question is, why?" Bivens said. "He’s been on record supporting this. It passes the House. It goes to the Senate. It’s in his hands, and he refuses to hear it, saying there are other things that are ‘more important.’ More important than mental health?"

Terry-Bivens said she finally concluded Green has a conflict of interest and is being lobbied by the Hawaii Medical Association. Bivens also contends there is "no doubt" that the volume of campaign contributions that physicians made to Green "is a factor."

"If you have a possible conflict of interest, I think the ethical thing to do is to let somebody else hear it so it doesn’t even appear that way," she said. "I don’t have anything against him, but I don’t understand this."

Advocates of HB 1072 asked Senate President Donna Mercado Kim to remove the bill from Green’s control, but Kim said Green does not have an actual conflict in connection with the measure.

Kim said a true "conflict of interest" in the state Senate exists only in cases where somehow a lawmaker would obtain some personal monetary gain from an official action or passage of a measure.

"If that is not present, then there is not a conflict, and members are required to vote on all measures," she said. "In this case, the bill does not affect him monetarily. He is not a psychologist, and he wouldn’t be gaining."

As for the concept of a "perception of conflict," Kim replied that any lawmaker may be subject to that perception when they accept any type of contribution from any group that advocates for an issue at the Legislature.

"If you get endorsed by all the unions, and you vote and support their measures, then there is that perception of conflict, which we are accused of all the time," she said. "There are so many special interest groups, and people are elected sometimes based on their interests, or based on the groups that they belong to, and they come in and some will many times support that industry. If you have teachers supporting the teachers …or plaintiffs’ attorneys who support tort reform or don’t support tort reform — I mean, it’s prevalent throughout."

Kim said lawmakers are supposed to be part-time members who are part of the fabric of the community, "and therefore they are part of certain professions, special interest groups, and how do you police that?"

She added, "You have to keep in mind that every member here is part time and they all have employment of some form. Many have occupations, and their industry lobbies as well, and we all accept contributions that we are allowed to by law, and that in itself does not create a conflict."

Green said there is a continuing debate over whether psychologists without medical training can safely prescribe medication. Advocates say the psychologists would be required to undergo two tiers of training before they could write a prescription, but Green said physicians are still "much better trained to prescribe medication."

Psychologists have been seeking prescriptive authority in Hawaii for decades.

Green acknowledged that in 2011 he supported a bill similar to HB 1072 that would have allowed psychologists prescriptive authority, but said he changed his position because the bill changed. The old version of the bill would have allowed psychologists to prescribe just a few drugs at community health centers, while the bill this year involves all drugs in partnership with doctors, he said.

"Before, I had only been in for a couple of years, and I didn’t see all of the details yet," he said. Still, Green said he respects the psychologists, and plans to consider the bill again next year.

"I’m not saying that we shouldn’t do it. I’m saying that it’s not a clear slam-dunk," he said.

Green contends the physicians and the psychologists need to come to some sort of basic mutual understanding on the issue, "and they didn’t do it yet … I need some consensus because they work together taking care of the patients."

Christopher Flanders, executive director of the Hawaii Medical Association, said his organization has consistently opposed bills to grant prescriptive authority to psychologists.

"The use of medications is a dangerous business, and you have to know what you’re doing, and we just don’t feel the psychologists are adequately trained in the management of prescriptive medications to safely give them," Flanders said.

Every drug has side effects, people have unexpected reactions, and "you have to know what to do when things go bad," he said. "Particularly with the psychiatric drugs, when things go bad, they go bad in a hurry, so you have to know what you’re doing."

Green understands those issues surrounding the bill, which is why he took the position he did, Flanders said.

The medical association has had differences with Green, he said.

"He’s just not a rubber stamp for the medical association, and we don’t tell him what to do," he said.

Green emphasized that he is not in "lockstep" with the physicians, citing as an example his recent disagreements with his fellow doctors over proposals to provide prescriptive authority for naturopaths.

Traditionally it has been lawmakers at the highest levels of House and Senate leadership or those who control state spending who tend to attract the most campaign contributions. By contrast, the health committees in the House and Senate traditionally were not seen as lynchpins of power at the Legislature, and were generally not the focus of large amounts of campaign donations.

Observers say that changed during Green’s tenure as chairman.

A Honolulu Star-Advertiser analysis of Green’s campaign spending reports shows he raised $195,650 from doctors, hospitals and the medical industry since he became Senate Health Committee chairman in 2011. That amounts to more than half of all contributions made by the medical system to all senators or Senate candidates during the same period.

Green said he accumulated large amounts of campaign cash because he has been "virtually unopposed" in his home district in West Hawaii. He said he had to spend very little money to win re-election during his 11 years in office.

Green acknowledged he is considering seeking higher office, but declined to say which office he might seek other than to say that "my wife prefers we stay near home." He said he has continued to raise funds steadily because "I don’t have the capacity like some people in public office to raise millions of dollars quickly, for instance, (former) Gov. (Neil) Abercrombie. I’ve never had or tried to have that capacity to raise a million dollars in a year."

Edwin Bender, executive director of the National Institute on Money in State Politics, said similar complaints about conflicts of interest are frequently made across the country in cases like these. The institute is a nonpartisan, nonprofit that compiles campaign donor information from all 50 states, and encourages public debate and discussion of campaign spending practices.

"It is a prime example of how we fund our campaigns is in conflict with establishing the trust of the people the lawmakers are elected to represent," he said.

Bender said it is understandable that a doctor running for office would raise money from other doctors, and a builder would raise money from other builders. But once they are elected, "they have to be able to step outside of that sphere to represent the people of their state, and their best interests."

He pointed out that the U.S. Supreme Court upheld laws that limit campaign contributions to prevent either real corruption or the "appearance of impropriety."

"It’s that ‘appearance of impropriety’ that is at play here," Bender said. "You have a case where it’s pretty obvious the Senate Health Committee chairman is probably not breaking the law. He’s doing politics the way politics has been done in Hawaii and across the country for decades."

However, observers may still have reason to be concerned, he said. The challenge for lawmakers is to balance raising money for a campaign with the task of representing the people who actually elected them "in a way that helps them trust that you aren’t just representing the people who gave you campaign money."

"That’s a judgment for the public to make," Bender said. Members of the AARP and the Hawaii Psychological Association "are raising a flag, and he should take note of that."