New York state has quickly become the epicenter of the coronavirus pandemic in the United States, with most COVID-19 cases concentrated in the New York City area. Last week, the scale of the crisis prompted New York Gov. Andrew Cuomo to use emergency powers to suspend restrictions on health care workers who are licensed out of state. Until at least April 22, health providers licensed in other states are now free to practice in New York.
The swiftness with which these barriers to health care labor mobility were swept away in the face of surging demand raises the question of why they existed in the first place. Restrictions on the ability of nurses and doctors to work across state lines reduce access to health care in times good and bad. When this crisis subsides, and emergency measures end, states like New York should consider embracing free movement of health care labor on a permanent basis.
New York’s restrictions on out-of-state care were unworkable
New York City hospitals are struggling with an unprecedented surge in demand. As of April 5, New York City had 64,955 confirmed COVID-19 cases, accounting for more than half the cases in the state and about one-fifth of the country’s total known cases. And while there are hopeful signs that social distancing measures have begun to slow the infection rate, the pressure on New York’s health care system will continue to grow for the immediate future. The shortage of health care workers is compounded by the contagiousness of the virus, which is leading many doctors and nurses to fall sick and become patients themselves.
The crisis has forced New York to reexamine, at least temporarily, how existing rules constrain the state’s supply of health care workers. Using powers granted under the state’s declaration of a state of emergency, Gov. Cuomo temporarily lifted the state’s barriers against health care workers licensed in another state. Under Executive Order 202.10, physicians, nurses, and other health professionals who are licensed in another state will be able to freely provide care in New York state.
New York is among the states furthest behind on ensuring labor mobility for health professionals, failing thus far to sign onto either the Interstate Medical Licensure Compact (IMLC), the Nurse Licensure Compact (NLC), or the Advanced Practice Nurse Compact (APRNC). The NLC ensures mutual recognition of licensure for registered nurses and licensed practical nurses. This compact ensures that health care licenses for registered nurses and licensed practical nurses are fully portable, meaning services can be delivered across state borders in a seamless fashion, without large fees and delays. While the IMLC doesn’t ensure similar portability as NLC, it still helps by providing a streamlined multistate licensure process for physicians. Finally, the recently established APRNC will extend fully portable to advanced practice nurses once a total of ten states join the compact.
**A 2019 Arizona law ensures expedited reciprocal licensure approval for all healthcare professions.
New York’s restrictions on the free movement of health care workers became unworkable in the face of COVID-19. New York’s State Board of Medicine requires that out-of-state health professionals looking to practice in the state submit an application with a $735 fee, and then wait for an average of two to four months before receiving a New York medical license. This application fee is among the highest in the country, not to mention the $600 renewal fee required every couple of years. Similar roadblocks exist for out-of-state nurses looking to practice in New York. While the nurse licensure application fee is only $143, the state requires prospective nurses from out-of-state to receive additional education on child abuse prevention through one of the state’s approved providers.
Under the status quo ante, health care practitioners in a neighboring state would need to wait months before they would be approved to save lives in New York. These barriers extend to telehealth providers across the rest of the country as well, who would otherwise help to ease demands for nonambulatory care. Had Gov. Cuomo failed to suspend these restrictions, New Yorkers would have had a much more difficult time getting the human resources they need. And while other states are implementing similar suspensions, they’d be better prepared if these steps were taken prior to the crisis. It still takes time for hospitals to identify and contract with health care workers from out of state. In order to respond more effectively to future crises, barriers to interstate delivery of health services ought to be lifted on a permanent basis.
Congress can encourage states to recognize out-of-state providers
The barriers to interstate commerce in the American health care system make for a peculiar and harmful state of affairs. The European Union ensures the free movement of medical physicians across its 27 member countries. The United States, meanwhile, has so far failed to achieve the same within its own borders.
The NLC has undoubtedly been the most promising development with regard to the free movement of health care labor, creating a genuine free-trade zone in nursing services across a broad swath of the U.S. Because NLC licenses are fully portable, nurses licensed in Kansas can provide services in Missouri or any other NLC member state without additional mandates, fees, or delays.
Progress on labor mobility for nurse practitioners (NPs) and physician assistants (PAs) has been uneven. NPs and PAs provide a growing share of the country’s primary care services so minimizing cross-state barriers is crucial to ensuring patient access. While the APRNC will extend the NLC’s model of full license portability to NPs once seven more states join the compact, no compact currently exists for PAs. Last year the federal government approved funding for the Federation of State Medical Boards (FSMB) to develop a framework for PA license portability. One troubling sign for this forthcoming framework for PAs is the FSMB’s inability to deliver on full portability for physicians. Unlike nurses, PAs share state medical licensure boards with physicians, meaning the same issues that limited the impact of the IMLC are liable to arise again in the context of PAs.
Efforts to ensure cross-state mobility for physicians has been comparatively disappointing. While IMLC streamlines the medical licensure process across member states, it stops far short of the fully portable multistate license available to nurses through the NLC. The primary contribution of the IMLC has been in streamlining paperwork. Back when the IMLC was first proposed by the FSMB back in 2002, license portability was stated as the central goal of the project, but resistance from state medical boards forced the IMLC’s ambitiousness to be dramatically scaled back. As a result, physicians licensed in IMLC states still face all the same fees and delays as those licensed by medical boards in states outside the compact. Even if every state joined the IMLC, receiving medical licensure for the entire country would still cost a physician over $20,000 in application fees, with similar total charges every few years in the form of renewal fees.
As the Manhattan Institute’s Chris Pope points out, the most substantial barrier to wider genuine free interstate trade in medical services is the reliance of state boards upon the application fees that they charge, ranging from $35 in Pennsylvania to $1,425 in Nevada. With annual fee revenue for state medical boards totaling roughly $350 million, recognizing cheaper licenses could lead to massive declines in revenue for the boards whose prices are undercut by cheaper states. Pope argues that Congress could offset this perverse incentive by appropriating funds to licensure boards that lose out during the transition.
Cuomo’s temporary suspension of unworkable labor-mobility restrictions on health care professionals illustrates why these restrictions should never have existed in the first place. Such restrictions would have hampered the state’s ability to respond to the surge in health care demand created by COVID-19, and were rightly tossed aside. When this crisis is over, Congress should take action to require mutual recognition of all health practitioner licenses. While some medical boards may lose out on fee revenue, ensuring unimpeded interstate commerce in health care will ultimately be to the benefit of providers and patients alike.
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