State lines should no longer be barriers to health care

Telehealth policy remains front and center in the health care debate. Before adjourning for the August recess, the House of Representatives passed an extension of Medicare’s telehealth authorities by an overwhelming margin of 416-12. It’s a bipartisan issue that has support from legislators, providers and patients. 

While much of the debate has centered around payment for telehealth services, there are a growing number of voices calling for facilitating access to care across state lines. During the pandemic, all 50 states used emergency authority to amend their licensing requirements for out-of-state practitioners. Some states dropped them altogether, allowing doctors, nurses physician assistants and other providers to treat patients via telehealth regardless of their location. This initially served as a “load balancing” mechanism to ensure care was available when local practitioners were overwhelmed by COVID.  

However, as University of Michigan researchers recently found, regular forms of care across state lines shot up 572 percent. Suddenly, we didn’t need to drive to see our doctors. We could see a specialist for a consultation, receive follow-up care, keep in touch with our doctors about chronic disease or primary care needs or see a mental health professional no matter where the provider was located. There was no longer a need to arrange for childcare, time off from work, gas or parking just to access needed health care services. At a time when in-person interaction was discouraged, telehealth enabled continuity of care for patients.  

The Veterans Administration has led the way in expanding the boundaries of care. While I was secretary, the VA changed outdated regulations that prevented veterans from accessing qualified providers simply because of geography. Veterans are now able to see their providers without regard to location.  

This flexibility was critical during the COVID-19 pandemic. Prior to the pandemic, an estimated 14 percent of the VA’s 182,100 licensed health care professionals did not hold a state license, registration or certification in the same state as their main VA medical facility. Licensure flexibility allowed the VA to move clinicians into hotspots or areas with staffing shortages, conduct visits in patients’ homes, and more.  

In June 2020, the VA announced that telehealth video appointments using VA Video Connect increased by 1000 percent, from approximately 10,000 to 120,000 appointments a week between February and May of 2020. This regulatory relief provided benefits to our nation’s service members, and it should also be available to help all Americans.   

As COVID-related state licensing flexibilities have expired, patients and providers alike have felt the impact. Recently, more than 230 organizations sent letters to all 50 governors asking them to maintain the ability to practice across state lines for the duration of the federal public health emergency. Providers themselves believe that access to care will be harmed without these flexibilities. In a recent survey, 84 percent of health care providers said that care across state lines should remain an option for patients.  

There are ways to maintain the critical role that state licensing boards play in protecting patients while also permanently allowing providers who are licensed and in good standing to practice in multiple states. There are current bipartisan proposals developing in Congress from a federal approach that would create the infrastructure for a national compact that states could join, much like the drivers’ license compact. It is a balanced approach that does not encroach on state authority while guaranteeing consistency across states.   

Under a national compact based on mutual licensure recognition, a medical provider who is duly licensed and regulated in one state could treat patients in any state that adopts the federal structure. The laws where the patient is located would apply to the visit, much like a driver’s license in the Interstate Driver License Compact model. A driver with a Michigan license is not entitled to drive the Michigan state speed limit of 75 miles per hour while in another state just because they have a Michigan license. The driver must abide by the laws of the state where they are driving. This same concept would apply to health care. A licensed provider using telehealth from one state would adhere to the state laws and standards of care set by the medical board where the patient is located. 

Dozens of patient groups and regional health care providers are pushing for change. For example, in August 2020, 184 cardiologists from top institutions around the country urged the leadership of the U.S. Senate and House to find a way to allow for licensure reciprocity across state lines. The former secretary of Health and Human Services Alex Azar even sent a letter to state governors at the beginning of the pandemic pleading with them to create licensure flexibilities.  

The pandemic proved that practicing across state lines improves access to care while maintaining patient safety. The VA has shown the way forward in modernizing licensing. There are balanced ways to make the pandemic flexibilities permanent, so let’s allow all Americans to experience the benefits of expanded access.    

The Honorable David J. Shulkin served as undersecretary of Health for the U.S Department of Veterans Affairs in the Obama administration and the Secretary of the Department in the Trump administration.