Should state lines stop doctors?

How temporary reforms to lessen healthcare burdens from COVID-19 could translate to broader healthcare access in America

As I write this piece in my makeshift home-office, I am entering week three of self-imposed quarantine due to COVID-19. Like my coworkers and countless others around the world still fortunate enough to remain employed, I am learning to adapt to this new normal. No one is sure how long it will last, or how the way we work will change for good once it is over. Many industries are facing a much more significant shift than simply moving employees to remote work.

Arguably no industry has had to adapt as much, or as quickly, as the healthcare industry has in response to this global pandemic. It may never quite look the same.

What began as rumors of an outbreak in China at the end of 2019 has evolved into a worldwide health crisis that has ground the world economy to a halt. Doctors, nurses, and other healthcare professionals have suddenly found themselves on the front lines of the fight against COVID-19. The outbreak has taken a staggering toll on healthcare staff and resources around the world.

In Italy, whose nearly 12,500 deaths account for over a third of worldwide fatalities attributed to the virus, doctors have been coming out of retirement to bolster the country’s struggling healthcare professionals. The virus has infected around 6,300 healthcare professionals, and in some of the hardest-hit areas in northern Italy, more than one out of every six doctors has been infected.

Thankfully Italy has seen its number of new cases level off in the last couple of days, but the situation here in the US is continuing to worsen. Fear of physician shortages, like those seen in Italy, has led policymakers to suspend certain state restrictions around licensing for physicians. For example, Massachusetts Health and Human Services Secretary Marylou Sudders asked medical schools within the state to graduate students early to assist with prevention and care efforts. The state of Massachusetts is also offering those students an expedited 90-day license.

These efforts are being made by states to improve access to healthcare professionals at a time when there is an urgent need for the work they provide. And while the COVID-19 pandemic is placing an unprecedented strain on our healthcare system, we should ask ourselves whether some of these laws, which have been removed to improve healthcare access, should be done away with for good.


Healthcare Professional Shortages are Nothing New

Even before the outbreak of COVID-19, the United States suffered from inadequate access to physicians. The US Department of Health and Human Services maintains a database of the number of primary healthcare providers per county that it uses to determine the quality of access available. Areas where populations far exceed the number of physicians are designated as Health Professional Shortage Areas (HPSA). According to the latest quarterly figures, over 80 million Americans live in HPSAs. That is nearly one-quarter of the country. To overcome that shortage, the report estimates an additional 14,600 practitioners are needed. The map below shows HPSA severity by county. Dark blue counties are those with the greatest need for additional physicians.


Source: Health Resources & Services Administration

Almost two-thirds of all HPSAs exist in rural areas, and as you can see from the map, the southern states seem to have the highest number of impacted counties. And the healthcare situation for these states may still get worse before it gets better.

The Chartis Group, a consulting firm that focuses on rural healthcare, estimated in February that over 450 rural hospitals are at risk of closing. Many of those are in the already struggling southern states. That study does not take into account the impact of the pandemic on these hospitals, however. Considering the fact that caring for COVID-19 patients is expensive and causing financial losses for hospitals around the country, the future for many of these areas does not look promising.


Removing Unnecessary Roadblocks Could Improve Access

One thing that nearly every state seems to agree on is the fact that a healthcare professional that is licensed and in good standing in one state should be allowed to practice in another. So far, forty-three states have temporarily suspended requirements for physicians to be explicitly licensed within their state, instead choosing to enable physicians with out-of-state licenses to acquire a short-term permit to practice within their state.

What is it about the COVID-19 pandemic that uniquely qualifies this as a useful response? Won’t those same physicians have the same qualifications and abilities to practice medicine? Rather than providing temporary inter-state licensing, states should set in place permanent measures to allow not only doctors but other healthcare providers like nurses and physician assistants to practice in their state if they are in good standing with a licensing board in another state.

This is already happening for nurses in parts of the country. The Nurse Licensure Compact (NLC) is an interstate commission of thirty-four states that have agreed on a uniform license. Think of it like a driver’s license — once you pass your test in any given member state, you are recognized as a competent driver (nurse) in all other states.

The NLC has been in place for over 15 years without any decline in health outcomes for member states. The compact provides many benefits for both states and nurses. Getting licensed in a new state costs time and money — a few hundred dollars and, depending on the state, a few months of waiting instead of working. Cross-state recognition of licenses also means during times of crisis, there is no need to pass special legislation before nurses can begin working in disaster areas.

Another key benefit this agreement affords nurses is broader access to patients through telehealth. This benefit is likely to be increasingly valuable in the future as virtual access and tools continue to improve. For those unfamiliar with telehealth, it’s similar to setting up a google hangouts call with your doctor. Rather than having to drive to an office, the conversation, diagnosis, and prescription can take place virtually. This is hugely beneficial in rural areas like those mentioned above, where there is no easy access to a doctor’s office. It can also often be done at a lower cost than in-person visits.

According to the overwhelming majority of state laws, however, it is illegal for a doctor in, say, Alabama to provide medical advice via telehealth to someone in Ohio unless the state medical board in Ohio also licensed that doctor.

Telehealth could be a huge step towards providing healthcare to rural populations and underserved communities. Still, current licensing laws limit where and how physicians would be able to implement telehealth services.

The COVID-19 pandemic will no doubt have a lasting impact on how we conduct our lives for years to come. It is a valuable opportunity to assess where the weak points in our healthcare system exist and gives us a chance to make changes that ensure we are better suited to care for those in need. Removing artificial barriers in the way of physician care by allowing those in good standing to practice across state lines is not only useful during this crisis, but it could also improve access for tens of millions of Americans in the future.

CGO scholars and fellows frequently comment on a variety of topics for the popular press. The views expressed therein are those of the authors and do not necessarily reflect the views of the Center for Growth and Opportunity or the views of Utah State University.

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