In September 2018, I left my home in Washington, D.C., to spend a year in a small Rust Belt town to help with the opioid crisis. Like half of all U.S. counties, Lawrence County, Ohio, lacked a single psychiatrist. As a psychiatrist myself, I wanted to help.
In Ironton, Ohio, population 10,300, I worked at a federally qualified health center run by the Ironton–Lawrence County Community Action Organization. I treated patients addicted to heroin and fentanyl, as well as several with severe mental illness. The experience was rewarding, but the process of acquiring an Ohio medical license was time-consuming and expensive, requiring medical school transcripts, board certification, fingerprinting, and fees—culminating in a $308.50 license that took five months to arrive. I remember wishing for reciprocity agreements between states. Driver’s licenses are honored in every state, I thought. Why can’t medical licenses be? In some domains, they are: clinicians in the Veterans Affairs system or the Indian Health Service can work throughout those networks. But only about 27,000 out of the nation’s 1.2 million doctors work for those agencies.
Belatedly, I found the closest thing to a solution: the Interstate Medical Licensure Compact. First implemented in 2017, the IMLC is an interstate agreement that allows physicians to obtain new licenses more easily across its 40 participating states. As part of the pact, states issue licenses to out-of-state doctors who remain in good standing, recognizing that most of the licensing information resides with the state that issued the doctor’s existing license.
Doctors wanting to work in another state can apply through the IMLC Commission, an administrative clearinghouse of licensing and disciplinary information. Those clinicians pay a onetime application fee, but they don’t have to recertify their educational credentials or undergo a potentially months-long application process. While states remain responsible for issuing licenses, participating states route their applications through the commission, significantly streamlining things.
Licenses are delivered within six weeks; for nearly half of applicants, the process takes under a month. With the new state license in hand, a physician can work in other states, whether in person or via telehealth. “We’re the TSA of medicine,” Marschall Smith, the commission’s executive director, told me with pride. Since its establishment seven years ago, the commission has worked with 26,000 physicians and helped states issue 100,000 licenses.
The IMLC is the next best thing to full reciprocity. It expands the pool of physicians serving rural and underserved areas. It also aids patients who need to see an out-of-state specialist but find themselves stymied by state-specific health-insurance restrictions. And the compact is a godsend for patients who, until now, have had to drive across state lines to see a doctor.
Research demonstrates the agreement’s effectiveness. According to an independent study by San Jose State University, states that joined the IMLC saw an increase in the number of licensed physicians, and “nearly double the practice growth of nonparticipating states.”
Why states like Alaska, Arkansas, California, and Oregon—four of the ten nonparticipants—have refused to join the compact isn’t clear. “Rumor has it that California believes it would be a drain on their license base,” says Smith. But participating states have not experienced such losses, he adds.
That 40 states have elected to join the IMLC is a huge step in the right direction. Given the shortage of medical professionals, particularly psychiatrists, that plagues rural and other underserved counties, the state holdouts owe it to their citizens to sign on, too.
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