Medical Licenses and COVID-19

If American clinicians are held to national standards, why are they required to hold a separate (and often costly) license for each state in which they practice?

This question has weighed heavily on the minds of policy experts over the past few months. State medical boards currently have the authority to review licensure applications. The medical licensure process is part of a long-established system in which states have jurisdiction for issuing professional licenses. Other occupations with similar state licensure systems include lawyers, teachers, cosmetologists, and counselors, among others.

Historically, state policymakers have been reluctant to allow health care professionals to practice across state lines. Proponents argue that the current system is necessary to protect patients. Others assert that the licensure process generates necessary state revenues.

However, just because the existing process is part of a traditional system does not mean it is free from problems. For one, occupational licensure has an ugly history rooted in racism. The legal licensure system as well as the medical licensure system have both been criticized for intensifying racial disparities within their respective professions.

Further, the existing licensure system is seen as a barrier to telemedicine, which has been growing rapidly. This growth is crucial to the future of American health care, as the US is projected to face a shortage of over 100,000 physicians by 2032. Allowing physicians to practice virtually across state lines would inevitably help some of the states hit hardest by this shortage.

The COVID-19 pandemic could permanently disrupt medical licensure as we know it. Between March and April of 2020, all fifty states (plus Washington, DC) implemented temporary policies to allow physicians and other medical personnel to practice across state lines. These policies intend to mitigate potential shortages of health care workers throughout the pandemic.

In some states, these changes were authorized through an executive order. In many cases, however, governors granted special authority to state licensing agencies through emergency declarations. These licensing agencies were then able to develop and implement their own policies for the duration of the statewide emergency. A handful of states, such as Nevada, New Hampshire, and Minnesota, had pre existing legislation allowing for relaxed licensure processes during a state of emergency. None of these state-level changes took the form of new legislation, likely because the legislative process is often slow-paced.

Half of the states chose to issue temporary emergency licenses to out-of-state medical personnel. With few exceptions, these licenses do not require a fee. The Federation of State Medical Boards is supporting these states by providing free access to its Physician Data Center. This allows state medical boards to instantly access and verify licensure information, which will expedite the temporary licensure process.

Fifteen states opted for a more liberal approach by temporarily waiving licensure requirements altogether. Out-of-state personnel wanting to practice in these states do not need to complete an application or pay a fee. No disciplinary action will be taken toward clinicians who practice in these states without an in-state license.

The remaining ten states (plus Washington, DC) adopted a more conservative approach. These states allow out-of-state health professionals to practice only in specific circumstances. In California and Hawaii, for example, out-of-state personnel can practice without a CA/HI license, but they must first be hired by a CA/HI health care entity. Arkansas likely chose the most stringent approach; to practice in Arkansas, an out-of-state physician must be licensed in a border state, and he or she may only practice on Arkansas patients with whom they have a pre-established relationship.

The states’ policies differed in various ways. For example, some policies applied to physicians only, while many covered a broader set of health care professionals, including social workers and mental health professionals. Likewise, states implemented these policies at different times. California and Oregon were the first to implement these measures on March 4th and 8th, respectively. In contrast, most states implemented these policies in late March, following the declaration of the national state of emergency. A handful of states, including Arizona and Arkansas, waited until early April to adopt these measures.

Despite these differences, one thing remains the same: each state has announced that its licensure changes will end once the pandemic is no longer deemed a threat. However, with so many Americans embracing telehealth as the new normal, does it really make sense to end these policies?

States should view COVID-19 as an opportunity to test the waters when it comes to licensure portability. Rather than ending these new interstate licensure policies outright, states should use data collected throughout the pandemic to assess the effectiveness of these policies. Forexample, states could examine health and financial outcomes of patients who saw an out-of-state care provider during the pandemic.

Researchers should pay close attention to outcomes in rural areas, as out-of-state physicians are likely to have a significant impact in these regions. If these policies produce positive outcomes, particularly in rural and underserved communities, perhaps they should be implemented permanently.

Regardless of whether states maintain their new licensure systems, health care in the U.S. will look different following the pandemic. Virtual care is here to stay, and our policies must reflect this new reality. With the need for health care reform on the horizon, why start from scratch when we could look at what has already been done?

Changing a long-standing system is daunting. However, this is a perfect opportunity to dismantle a process that has contributed to systemic racism, while also creating a new system that is more appropriate for our digitalized society. I urge policymakers at the state level to explore the effects of these temporary licensure policies. If this is a chance to improve health care, we must take it.