State Telehealth Restrictions Limit Care in Rural Areas and Drive Up Costs, Critics Say

A doctor updates chart. Rostislav_Sedlacek/Shutterstock

California resident Shellye Horowitz was diagnosed with hemophilia, a rare, potentially life-threatening genetic disorder that prevents blood from clotting.

Fortunately, she has been able to find a medical center that specializes in this malady. Unfortunately, that center is in Portland, Oregon, and her home state doesn’t want her speaking with doctors by phone across state lines, forcing Ms. Horowitz to undertake a day’s travel every time she wants to speak with her doctors.

Known as the malady that threatened the life of Alexei Romanov, the heir to the Russian throne, hemophilia can be deadly if not treated properly in the event of significant trauma, laceration, or a surgical procedure, though sometimes internal bleeding can be triggered even by minor injuries.

Given that hemophilia is particularly unusual in women, finding the right specialist was difficult. Residing in what she calls a “medical desert” in the north of the state, Ms. Horowitz said she was able to find a suitable hemophilia treatment center in Oregon.

“Women tend to get diagnosed late because a lot of individuals didn’t realize that women can have hemophilia—it was once thought to be an X-linked recessive disorder,” Ms. Horowitz told The Epoch Times. “There are a small number of [treatment centers] that have created these phenomenal interdisciplinary clinics that bring together OBGYN and hematologists, and work together to figure out how to treat women with bleeding disorders.”

But as long as she is physically within California’s borders, her home state does not allow its residents to have medical conversations with doctors located outside the state. While Ms. Horowitz often travels to Portland for treatments, it is a long distance for her to travel simply to discuss things like test results and medications or for pre- and post-treatment consultations when she could simply communicate with her doctor by phone or via email.

“They have no problem with me driving up to Oregon for care, and they have no problem with any patient accessing care outside of the borders,” she said. “They just will not allow us to get on a telephone or internet to talk to a provider and access care that way unless they have a California medical license.”

California is not alone in restricting this practice.

In all, about 30 U.S. states have some prohibition against “telehealth,” which is defined as “the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, health administration, and public health.” During the COVID pandemic, states were—for a brief time—willing to look the other way on telehealth, as patients and doctors avoided face-to-face contact.

A 2021 study by McKinsey, a management consultancy, stated that “during the tragedy of the pandemic, telehealth offered a bridge to care.”

That experience, the report states, demonstrated that, as a supplement to in-person treatments, telehealth can provide more accessible and more affordable health care. For many Americans, particularly those living in remote locations or who cannot afford frequent travel for treatments, telehealth offers a way to reduce their medical bills and recuperate at home.

The demand for telehealth comes at a time when doctors are retiring in record numbers, creating fears of a physician shortage. A 2022 survey by AMN Healthcare found that the average wait time for patients to get an appointment to see a doctor was 26 days, a 24 percent increase since 2004.

Despite this, once the pandemic receded, many states reinstated the prior enforcement regimes, often causing out-of-state doctors to refrain from speaking with patients by phone. Johns Hopkins Medical Center in Baltimore, Maryland, for example, said it had to “scramble” in 2021 to abruptly cancel more than 1,000 phone and video appointments with patients in neighboring Virginia when that state rolled back COVID waivers on telehealth conversations.

Doctors Risk Losing License

Some states enact harsher penalties than others for violating telehealth rules. On the tougher end of the spectrum, doctors who violate California’s telehealth laws risk losing their licenses and may face criminal charges as well.

“I have a lot of experience with patients I’ve treated, where an interstate telehealth visit would be completely sufficient to make sure they’re doing well and to provide them with any advice they need on aftercare,” Dr. Sean McBride, a radiation oncologist at Sloan Kettering Cancer Center in New York, told The Epoch Times. “States like California have reiterated that there is criminal sanction for unlicensed conduct of telehealth, other than by physicians duly licensed in their state.”

During their illness or after treatments, many cancer patients are too sick or exhausted to travel. For them, it is a significant benefit to be able to contact physicians by phone or email for consultations.

“Patients from out of state will go back to their home state, and some of their follow-up visits can be done over telehealth,” Dr. McBride said. “You can talk to them about some of the side effects they’re experiencing and make recommendations on how to handle it, and make a determination about whether they need to come in person and travel for an in-person visit.”

“The upsetting thing is that state licensure laws essentially criminalize what is an ethical obligation to continue care,” he said.

Some hospitals and medical centers have had to implement policies in which an administrator asks patients at the beginning of the call where they are located. If patients say they are not physically in the state where the physician is licensed, the doctor often cannot proceed with the call.

In response, the Pacific Legal Foundation (PLF) recently filed suit against California and New Jersey in an attempt to roll back what they say are some of the most draconian telehealth laws. PLF is representing Dr. McBride and Ms. Horowitz as plaintiffs and charging that restrictive telehealth laws are a violation—both of doctors’ free speech rights and of the commerce clause of the Constitution, which restricts states from impeding interstate commerce.

“What’s happening here is that individual states are erecting a barrier around their borders and saying that out-of-state physicians cannot assist patients in that state,” Caleb Trotter, a PLF attorney, told The Epoch Times.

“It’s just simply unrealistic to expect [doctors] or even their hospitals to do a survey of all 50 states to know that, in this state, you can send a text, but in this state, you can’t do anything unless you get licensed,” Mr. Trotter said. “It results in physicians being unable or unwilling to use telehealth technology to communicate with patients in multiple states.”

Advocates of strict medical licensure laws argue that without them, states would struggle to properly regulate the qualifications of physicians within their borders. However, according to Mr. Trotter, medical license requirements are similar among U.S. states, and it would be easy for states to confirm that any particular physician is licensed and in good standing within his or her home state.

“Whether you get licensed in Vermont, Alaska, or California, the substance of what makes a physician qualified to be licensed is basically the same,” he said. “They have to go to accredited medical schools; they have to do their residency; they take the same national exams, so there’s really, from a substantively qualified view, no difference between a doctor in California versus Maine.”

One aspect of current telehealth laws is that state licensing requirements are typically determined by the physical location of the patient, not the doctor. One solution could be to reverse that and allow doctors to speak with patients by phone as long as the physician is calling from a state in which he is licensed.

A Possible Solution

Another possible solution is one enacted by states like Florida, Arizona, and Delaware, which, instead of requiring an in-state license for out-of-state doctors to practice via telehealth, allowed doctors to register with the state for this purpose, providing state medical boards with information to ensure they are licensed, insured and in good standing in their home state, Mr. Trotter said.

In addition, an institution called the Interstate Medical Licensure Compact (IMLC) may also provide a way to navigate interstate medical care. Originally conceived in 2013 by state medical boards, the IMLC has become an agreement among 40 participating states to streamline the licensing process for qualifying physicians who want to practice in multiple states.

The IMLC states that its mission is “to increase access to health care—particularly for patients in underserved or rural areas … The Compact makes it possible to extend the reach of physicians, improve access to medical specialists, and leverage the use of new medical technologies, such as telemedicine.”

Doctors who want to practice across state lines can complete a single application for all states within the IMLC. States that have not yet taken steps to join the Compact include California, Oregon, Alaska, New Mexico, Virginia, South Carolina, and Arkansas.

New York, Massachusetts, and North Carolina have introduced legislation to join the Compact but have not yet passed it.

The background to this case is the dramatic increase in licensing requirements across many professions throughout the United States.

A September 2023 labor report by the Federal Reserve states that “with little fanfare, occupational licensing spread from only 5 percent of the workforce in the 1950s to well over 20 percent today.”

The Obama administration conducted a study on occupational licensing in 2015 and concluded that “there is evidence that licensing requirements raise the price of goods and services, restrict employment opportunities, and make it more difficult for workers to take their skills across state lines.

“Too often, policymakers do not carefully weigh these costs and benefits when making decisions about whether or how to regulate a profession through licensing,” the study stated.