ANALYSISApril 13, 2026
Should telehealth be permanently deregulated across state lines?
Telehealth cross-state licensure deregulation remains a major unresolved policy question in 2025-2026, with Medicare telehealth flexibilities originally granted during COVID-19 repeatedly extended on a temporary basis rather than made permanent. A 43-day government shutdown in fall 2025 caused a roughly 24% drop in traditional Medicare telehealth visits over the first 17 days, highlighting the fragility of the current patchwork system. Congress has multiple competing bills pending — some extending flexibilities temporarily and others making them permanent — while state medical boards, federal agencies, and patient advocates remain divided on the right path forward.
Telehealth exploded during COVID when states waived their licensing borders — now that the emergency is over, should those walls go back up? The fight is really about whether a doctor's license should follow the patient or the state, and who pays the price when it goes wrong.
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Shutdown collapse proves system fragility
C
A 24% drop in Medicare telehealth visits in 17 days — not because doctors retired, not because patients moved, but because Congress missed a budget deadline — is proof that the current patchwork is itself a form of government-imposed disorder. Elderly rural patients losing established care relationships over a continuing resolution failure is not an acceptable status quo for anyone who takes limited government seriously. Permanent reform is not optional; it is overdue.
L
We agree the collapse is damning, but you're using it to argue for compacts when it actually argues against them. Seventeen rounds of temporary extensions happened precisely because the compact pathway was the alternative on offer and Congress kept reaching for the patch instead — which suggests the compact model has not been politically sufficient to close the deal, not just underfunded.
C
Those extensions failed to become permanent because temporary patches are the path of least resistance in a continuing resolution, not because the compact model doesn't work — that's a political failure, not a structural indictment of federalist coordination. PSYPACT expanded access dramatically without federal preemption and without a single expiration crisis.
L
PSYPACT works for one profession. The IMLC still doesn't cover all provider types or all states after years of trying, and rural patients in the gaps don't get credit for the mechanism being theoretically sound.
Interstate compacts versus federal preemption
C
The Interstate Medical Licensure Compact is the correct instrument here — voluntary interstate cooperation is exactly the constitutional mechanism designed for coordination problems that cross state lines. The VA's Anywhere to Anywhere program proves targeted federal carve-outs can expand access dramatically without stripping states of disciplinary authority, and the FSMB's national telehealth registry proposal shows accountability and portability can coexist.
L
You're citing the VA program as evidence for compacts, but Anywhere to Anywhere is a federal override of state licensure for a specific population — it is closer to the federal preemption you're arguing against than to the IMLC model you're defending. If that program's seven-year safety record is your strongest evidence, it cuts toward the CONNECT for Health Act, not away from it.
C
Anywhere to Anywhere is a targeted carve-out for a defined federal beneficiary population — that is categorically different from blanket preemption that would make the least rigorous state's standards de facto national ones. Scope matters when you're talking about accountability infrastructure.
L
The 'least rigorous state' race-to-the-bottom concern is real, but it's an argument for robust federal enforcement conditions on reimbursement — not for geographic licensure walls that have never been the primary tool for catching bad actors anyway.
Solo practitioners locked out by IMLC costs
C
The compact model is not perfect for every provider type, and the solo-practitioner burden is a legitimate gap — but the answer is closing provider-type gaps and funding compact expansion aggressively, not federalizing licensure and hoping uniform national standards don't collapse to the lowest common denominator. The Johns Hopkins continuity-of-care model, grounding cross-state rights in three-year patient relationships, uses clinical logic as the limiting principle rather than bureaucratic uniformity.
L
You're describing the IMLC as a gap-closing problem, but the College Students Continuation of Mental Health Care Act had to be introduced as a separate bill because the compact couldn't handle a basic use case — students crossing state lines for school. That's not a gap; that's a structural mismatch between a licensure model built around geography and a care delivery model that isn't.
C
The student mental health case is precisely where the continuity-of-care model applies — a documented ongoing clinical relationship is the limiting principle, which is more defensible than treating all cross-state practice as equivalent regardless of whether an established relationship exists.
L
Requiring proof of a three-year relationship to maintain care continuity is a workable principle for established patients and a complete non-answer for first-time access in underserved areas, which is the harder problem.
Telehealth fraud and safety under deregulation
C
Fraud and overprescribing during COVID waivers are real — but those harms occurred in the absence of enforcement, not in spite of geographic licensure. DEA scheduling authority and CMS reimbursement conditions are the federal tools actually capable of targeting bad actors, and using licensure walls as a blunt substitute for real enforcement punishes rural patients for a problem their geography didn't create.
L
Agreeing that geographic licensure wasn't the primary anti-fraud tool doesn't mean removing it is costless — it means we're running a natural experiment where the remaining enforcement infrastructure has to actually perform. The COVID waiver period showed CMS and DEA were not fully up to that task at scale, which is an argument for building that infrastructure before deregulating, not after.
C
Every temporary extension that lapses is itself a natural experiment that produces documented patient harm — we are already paying the cost of inaction in disrupted care relationships while waiting for enforcement infrastructure to be deemed sufficient by people who haven't specified what sufficient looks like.
L
That's a fair pressure point, but 'we can't wait' is how you get telehealth pill mills operating at scale for two years before CMS notices. The sequencing question — build enforcement, then deregulate — is not bureaucratic foot-dragging; it's the difference between reform and a second waiver-era fraud cycle.
Political will versus structural failure
C
The IMLC has never actually received the CMS leverage and funding it would need to pressure holdout states and close provider gaps — concluding the compact model is insufficient before giving it those tools is like grounding a plane for never flying when it hasn't been fueled. Federal preemption should be the last resort after the federalist mechanism has actually been resourced, not the first move because the mechanism is inconvenient.
L
You're asking patients to wait for Congress to fund a mechanism that Congress has had years to fund and has instead replaced with seventeen temporary patches. At some point 'the compact just needs more resources' becomes the telehealth equivalent of 'the market just needs more time' — a principled position that is functionally indistinguishable from no reform at all.
C
There is a difference between 'no reform' and 'wrong reform.' Federal preemption that creates a national licensure floor is not reversible once states lose the jurisdictional layer that makes physician discipline enforceable — the compact is recoverable if it underperforms; preemption is not.
L
The irreversibility argument works if state disciplinary authority is actually doing the work you're crediting it with, but the documented bad actors in the COVID telehealth period weren't caught by state boards — they were caught, when they were caught at all, by DEA and CMS. The accountability layer you're protecting has already been outpaced by the delivery model.
Conservative's hardest question
The most difficult challenge to this argument is that the IMLC, despite years of expansion, still does not cover all provider types, does not include all states, and still imposes administrative burdens that telehealth advocates credibly argue prevent the kind of seamless access that rural and underserved patients actually need. If the compact pathway were truly sufficient, seventeen rounds of temporary federal extensions would not have been necessary — and that pattern of congressional improvisation is genuinely hard to explain away.
Liberal's hardest question
The claim that permanent deregulation would not produce patient safety regressions is genuinely uncertain: evidence for comparable telehealth outcomes is strong in mental health and chronic disease management but uneven across specialties, and documented telehealth fraud and controlled-substance overprescribing cases during the COVID waiver period cannot be fully explained away by existing enforcement mechanisms. A liberal case for reform must honestly reckon with the possibility that scaling cross-state telehealth without robust federal enforcement infrastructure could create real harm, not just theoretical risk.
Both sides agree: Both sides accept that the current temporary-extension system is indefensible and that rural and elderly Medicare patients bear the direct cost of congressional inaction.
The real conflict: A genuine factual-predictive conflict: the conservative argues telehealth fraud and overprescribing during COVID waivers is addressable through DEA and CMS enforcement tools, while the liberal acknowledges those mechanisms were insufficient during the waiver period — this is a real unresolved empirical dispute about whether federal enforcement capacity can substitute for licensure geography.
What nobody has answered: If the VA's Anywhere to Anywhere program is the closest thing to a controlled experiment both sides accept, why has no one conducted a rigorous specialty-by-specialty safety audit of its seven-year record — and what would it mean for this debate if that audit found meaningful outcome differences across patient populations that don't resemble the VA's enrolled demographic?
Sources
- American Telemedicine Association EDGE 2025 Conference reporting and Dr. Helen Hughes remarks (December 10, 2025)
- Johns Hopkins telehealth policy summit summary, Washington D.C. (May 2025)
- Continuing Appropriations Act of 2026, passed November 12, 2025
- CONNECT for Health Act — Sen. Schatz (D-HI) and 59 bipartisan cosponsors
- Telehealth Modernization Act of 2025 — Reps. Carter (R-GA) and Dingell (D-MI)
- Permanent Telehealth from Home Act — Reps. Buchanan (R-FL) and Thompson (D-CA)
- College Students Continuation of Mental Health Care Act — Reps. Flood, Bacon, and Nunn
- American Medical Association statement on IMLC and federal telehealth license proposals
- VA Anywhere to Anywhere program data (2018)
- CMS Medicare telehealth utilization data during 2025 government shutdown
- Federation of State Medical Boards — national telehealth registry proposal
- PSYPACT and IMLC compact documentation