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As states mobilize to meet the crushing health care demands resulting from the COVID-19 pandemic, policymakers are increasing the flexibility and capacity of their health care systems. One strategy is to address provider shortages that existed even before the pandemic by loosening health care licensing requirements and expanding scope-of-practice rules. 

As states work to address the shortage of providers and to increase the capacity of the health care system, they are changing licensing rules. Under normal circumstances, health care providers must undergo state licensing procedures that can take at least 60 days. These procedures are designed to protect health care consumers by ensuring that providers are competent — but this lengthy vetting system has drawbacks during emergencies when medical reinforcements are urgently needed. In response to the COVID-19 pandemic, nearly every state has made some change to their licensing requirements to increase the pool of available health professionals. 

Relicensing Retired Providers 

Currently, 29 states are encouraging retired providers to return to work by expediting the recertification process and loosening requirements for license reactivation, including waiving re-application fees and continuing education pre-requisites. How recently providers have retired and how long these temporary licenses last vary. In Massachusetts, only physicians who have retired within the past year, effective March 17, can apply for emergency licenses, which stay active until the state of emergency is terminated. In Pennsylvania, physicians can apply to get their license reactivated if they retired within the past four years, while nurses can obtain a new license after being inactive for up to five years. Medical doctors may practice under a temporary license until Dec. 31, 2020, and doctors of osteopathic medicine (DOs) can practice until Oct. 31, 2020. 

Retired medical professionals are eager to help individuals suffering from COVID-19, and state laws that loosen provider re-application requirements make it easier for previously retired physicians and nurses to return to work. However, sending retirees to the front lines also raises the concern of increasing the exposure of an already at-risk population to COVID-19. The American Medical Association recommends that senior and retired physicians avoid direct patient care.

Amending Out-of-State Licensing Laws

Typically, health care providers’ licenses only allow them to practice in a single state. In order to address shortages, many states are relaxing this requirement and allowing providers with existing, active out-of-state licenses to care for patients. As of April 2, 2020, 49 states and Washington, DC, are either allowing physicians to practice using out-of-state licenses, or enabling physicians to acquire expedited, temporary licenses to practice in additional states. Additionally, some states have expanded the provision to include other medical professionals. An executive order in Delaware allows pharmacists, respiratory therapists, physician assistants, paramedics, emergency medical technicians, and nurses to practice with an out-of-state license and Kansas is offering temporary licenses to all health care professionals regulated by its State Board of Healing Arts, which includes physical therapists, radiologic technologists, and occupational therapists, provided they are willing to assist with COVID-19-related care. 

While in some states these provisions are combined with provisions enabling inactive and retired physicians to return to work, other states require physicians to have an active medical license, albeit an out-of-state one, in order to practice. As active providers react to the crisis and move to COVID-19 hot spots, many of which are in cities, this migration may further exacerbate health care shortages in rural areas. 

States’ moves to loosen restrictions and allow providers to practice without a state-specific license are drawing attention to the strict state licensing requirements that exist for physicians. Though state licensing procedures are designed to ensure that qualified and competent providers make up the physician workforce, some have deemed this system outdated and too burdensome. While state licensure is common in many professions, some have agreements that allow individuals to practice in multiple states under one license. For example, 24 states have signed the Nurse Licensure Compact, which allows nurses to practice in any of those states. 

Expanding Scope-of-Practice

Scope-of-practice laws are designed to keep patients safe by ensuring that the tasks that health care providers may complete are matched to their educations and training. In 27 states, these laws dictate limits on aspects of care that nurse practitioners (NPs) provide, while others require them to perform certain functions under supervision of another health care provider. However, due to the current public health emergency, some states are suspending scope-of-practice laws in order to allow more health care providers to practice independently. For example, under a Michigan executive order, a state where nurses typically operate under restricted practice, advanced practice registered nurses and licensed practical nurses are now permitted to provide some medical care without supervision. 

Modifying scope-of-practice laws during a public health emergency is not without precedent. In 2009, some states expanded nurses’ and pharmacists’ scopes of practice by authorizing them to administer vaccinations in response to the H1N1 influenza pandemic. At the time, states’ modification of scope-of-practice laws was deemed more substantial than in any previous public health emergency. Due to the comparatively large scale of the COVID-19 pandemic, scope-of-practice laws may be relaxed more widely and to a larger degree than ever before.

While relaxing these laws increases the number of health care workers able to treat patients during the pandemic, these actions may also raise concerns for patient safety. Scope-of-practice laws protect the health of patients and suspending these laws may authorize providers who have little practical experience to perform tasks under minimal supervision. On the other hand, research suggests that expanding nurses’ scope of practice can also save states money and improve access to care and the quality of care. According to one study, eliminating restrictions on NPs could save the country up to $543 million in emergency room use. Current state actions that loosen the restrictions on nursing practices are only temporary, but allowing nurses to practice at the top of their license may benefit hospitals beyond expanding the workforce to address COVID-19.  

Conclusion

States are continuing to find innovative ways to meet the demands of the COVID-19 pandemic. These critical and creative responses provide needed health care capacity, a priority essential to protect the public in a time of such crisis. After the pandemic abates, states will need to consider the impact of these modifications on their rules and regulations, public health infrastructure, provider requirements, and hospital priorities.

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.