By Justin Leventhal, American Consumer Institute
Crossing a state line does not erase a medical degree, invalidate a nursing license, or make a pharmacy unsafe. Yet state law often treats it that way. Qualified medical professionals and pharmacies which can serve patients on one side of a border, often face a new maze of licenses, fees, and approvals on the other. Not because the care changed, but because the patient’s location did. States should remove these artificial barriers by joining interstate licensure compacts, or better yet universally recognize qualified practitioners and pharmacies licensed in other states.
Licensing can serve an important purpose in protecting patients. But once a clinician has met those standards, forcing them to repeat substantially the same process in every state adds little protection. It instead shields incumbent providers from competition and reduces patients’ healthcare options.
That problem has become more consequential as healthcare moves online. Primary-care consultations, prescription renewals, chronic-disease monitoring, mental-health visits, medication reviews, and many other services can often be delivered remotely. Telehealth and direct-to-consumer pharmacy services should make access less dependent on geography and allow patients to compare providers on price, quality, availability, and convenience.
However, state licensing rules frequently prevent a cross border market from forming. Providers generally need a license or recognized practice privilege in the state where the patient is located. Without an interstate compact or another exception, obtaining permission to serve even one additional state can require another application, additional fees, and compliance with duplicative administrative requirements.
Existing portability programs demonstrate both the demand for interstate practice and the limitations of partial reform.
The Interstate Medical Licensure Compact has attracted substantial participation. As of June 2026, it included 44 states, the District of Columbia, and Guam. More than 60,000 physicianswere members, and participating boards issued more than 200,000 licenses. But the compact only accelerates the application process. It does not create a single portable license. Physicians must still obtain and maintain a separate license in every state and pay a $700 compact application fee plus each state’s licensing charges.
The Nurse Licensure Compact shows what stronger portability can look like. It allows qualifying registered nurses (RNs) and licensed practical nurses to practice in participating states under one multistate license while remaining subject to the laws of the state where the patient receives care. Forty-three jurisdictions participate. Nurse practitioners (NPs) and other advanced practice registered nurses (APRNs) lack a comparable option. A proposed APRN compact has not attracted enough states to become operational and faces opposition from nursing organizations because it would require 2,080 hours of practice before an APRN could qualify for a multistate license.
Pharmacy regulation remains similarly fragmented. The National Association of Boards of Pharmacy reports processing more than 175,000 pharmacist license transfers over the past decade. Yet pharmacists must still obtain full licenses in each additional state, navigate state-specific rules, and often take another examination.
The barriers are even broader for pharmacies themselves. Online, mail-order, specialty, and direct-to-consumer pharmacies generally must obtain separate out-of-state pharmacy licenses, submit duplicate records, undergo additional inspections, and comply with state-specific personnel requirements. California, for example, requires an out-of-state pharmacy serving California patients to employ a California-licensed pharmacist at that facility to oversee its California operations. Such requirements add costs without addressing medicine safety or the qualifications of the pharmacy.
Compacts can reduce these burdens by creating common rules and coordinating oversight. States outside the existing physician and nursing compacts should join them, and policymakers should develop workable portability systems for APRNs and pharmacists.
But states do not need to wait for consensus to cooperate. They can unilaterally recognize qualified practitioners and pharmacies licensed in other states.
Under unilateral reciprocity, a practitioner with an active, unrestricted license in another state could serve patients after their credentials and disciplinary history have been verified. The practitioner would remain subject to the patient’s state laws, standards of care, prescribing rules, disciplinary authority, and appropriate liability requirements.
Pharmacies could operate under similar rules. They would need to maintain an unrestricted license in their home state, provide verified inspection and disciplinary records, and comply with the patient’s state dispensing and consumer-protection laws.
Reciprocity is not immunity from regulation. It removes redundant permission slips while preserving the receiving state’s authority to investigate misconduct, enforce its laws, and prohibit unsafe practitioners from serving its residents. Patient protection comes from competency standards, information sharing, monitoring, and enforcement. It does not come from making a qualified professional pay another fee.
The benefits would extend across the healthcare system. Physicians could provide remote specialty consultations to patients in underserved communities. RNs could respond more quickly to staffing shortages and emergencies. NPs could offer primary care and chronic-disease management across wider markets. Pharmacists could provide remote medication services, while online and mail-order pharmacies could compete without rebuilding their licensing operations state by state.
Patients need qualified providers competing for their business. State licensing laws currently take technologies capable of creating broader healthcare markets and force them back into fifty separate regulatory territories.
State legislatures should join effective compacts and improve those that impose unnecessary restrictions. But unilateral reciprocity is the stronger reform. A professional license should demonstrate that someone is qualified to practice. It should not function as a border wall protecting local providers from competition.
Justin Leventhal is a senior policy analyst for the American Consumer Institute, a nonprofit education and research organization. For more information about the Institute, visitwww.TheAmericanConsumer.Org or follow on X @ConsumerPal.
