The highway from western North Carolina to northeast Georgia is dark at five in the morning. One of my long-time patients grips the wheel and drives two hours for a 15-minute visit with the doctor she trusts. She could have met me by video from her kitchen, but the law forbids it. The moment she crosses that state line, I lose the right to care for her. That’s not medicine. That’s madness. We tell patients to use technology, to stay engaged, and to seek care early. Yet when they do, our laws turn that initiative into a liability. This isn’t a paperwork issue. It’s a national access crisis hiding behind outdated bureaucracy. Millions of Americans live near state borders or travel for work, school, or caregiving. They deserve continuity of care no matter where they are. Instead, we’ve stitched our health care system together with red tape instead of bridges.
Most people assume that if a physician is licensed in the U.S., that license is national. It isn’t. Each of the 50-plus state medical boards controls its own gate. To practice across borders, a doctor must pay multiple fees, repeat identical background checks, and reapply to every state where a patient might sit during a telehealth visit. The Interstate Medical Licensure Compact was meant to simplify this process, but it hasn’t. It is still separate applications, separate fees, and separate approvals; bureaucracy masquerading as progress. Then come the other layers. Medicare dictates where a patient must be located for coverage. The DEA ties prescribing authority to a doctor’s registered address. Private insurers demand separate credentialing in each state. State insurance commissioners set their own telehealth rules. No single entity oversees the system. It is a maze that consumes time, money, and morale. It protects turf, not patients.
And just when progress was within reach, we stepped backward. The rollback of federal telehealth coverage and pandemic-era flexibilities is one of the most shortsighted decisions in modern health policy. During COVID, we proved that cross-state telemedicine works safely, effectively, and efficiently. Patients were treated sooner, chronic conditions stayed stable, and access widened. Now, with those flexibilities gone, we have returned to an antiquated model that punishes innovation and convenience. Medicine must evolve with the times or risk being left behind. Technology has already leapt forward. The law must follow. A physician trusted to prescribe, diagnose, and heal should not become unqualified the moment a patient crosses an invisible border. Every physician already passes the same national exams, completes accredited training, maintains federal DEA registration, and is tracked through the National Practitioner Data Bank. For doctors in border communities, this barrier defies logic. These physicians see cross-state patients daily and should never have to think twice about whether helping them is legally permitted. We have built a licensing regime for a world that no longer exists. It was designed a century ago when medicine was local. Today, technology, mobility, and telehealth have erased those borders. The law just hasn’t noticed.
The cost of inaction is enormous. Delayed visits lead to missed diagnoses and unnecessary hospitalizations. Rural and frontier communities lose access to care that could easily be provided virtually. Doctors spend months waiting for redundant approvals or abandon cross-state practice altogether. Patients are left without the physicians who know them best. Taxpayers lose too. Billions of dollars are wasted maintaining redundant licensure and credentialing systems. Congress funds telehealth expansion while outdated statutes block its use. The left hand of government promotes innovation while the right hand tightens the leash.
Then come the disruptions no one plans for, government shutdowns that halt progress overnight. When the clock strikes midnight, the lights don’t just go out in Washington. They flicker in clinics, hospitals, and telehealth platforms across the country. Approvals stall. Reimbursements freeze. Startups and hospital systems that invested millions in secure telehealth infrastructure are left stranded. Behind every halted program is a team that believed they were building something lasting. Behind them are the patients who depended on it: the elderly man whose remote monitoring data stops transmitting because a CMS server is offline, the rural mother who can’t reach her specialist because coverage has lapsed, and the veteran whose mental health app sits in limbo waiting for renewal. A shutdown doesn’t simply pause care; it fractures it. It exposes a painful truth: Much of American health care depends on decisions made by people who will never meet the patients affected by them. We cannot build a modern system on unstable political ground.
Yes, licensure has traditionally been a state responsibility. But this problem has outgrown the states, and the system that governs it is too fragile to survive endless resets. Congress must create continuity. It can direct CMS to allow any physician licensed and in good standing in one state to provide telemedicine services to Medicare and Medicaid beneficiaries nationwide. It can act under the Commerce Clause to establish a national telehealth license, allowing virtual care across state lines while preserving local authority for in-person practice. It can tie federal funding to a streamlined compact that shares data but eliminates redundancy. This is not a partisan issue. It is common sense. The VA already allows cross-state practice for veterans. The Department of Defense does the same for service members. The FAA licenses pilots nationally. The DEA manages a single federal registry of prescribers. If we can trust one license to keep aircraft in the air and narcotics in safe hands, we can trust physicians to see patients through a screen.
A unified framework would strengthen, not weaken, oversight. It would allow consistent national discipline tracking and background checks instead of the chaos where one board may sanction a doctor while another never learns of it. We don’t need fifty versions of the same bureaucracy. We need one transparent, accountable, interoperable system and a government steady enough to sustain it. This isn’t deregulation. It is modernization. Care today is digital, mobile, and national. Patients already live in a borderless world. Their care should too. When my patient crosses that invisible line back into North Carolina, the system erases our connection not because of training, trust, or technology, but because of geography. The road she drives should not divide care; it should connect it. Patients don’t stop needing care when they cross a border. Our licenses shouldn’t stop either.
Ryan Nadelson is chair of the Department of Internal Medicine at Northside Hospital Diagnostic Clinic in Gainesville, Georgia. Raised in a family of gastroenterologists, he chose to forge his own path in internal medicine—drawn by its complexity and the opportunity to care for the whole patient. A respected leader known for his patient-centered approach, Dr. Nadelson is deeply committed to mentoring the next generation of physicians and fostering a culture of clinical excellence and lifelong learning.
He is an established author and frequent contributor to KevinMD, where he writes about physician identity, the emotional challenges of modern practice, and the evolving role of doctors in today’s health care system.
You can connect with him on Doximity and LinkedIn.
