During the pandemic, something remarkable happened. Doctors could suddenly treat patients across state lines. Therapy sessions happened from living rooms. Rural patients saw specialists without driving three hours. Then the emergency waivers started expiring, and many of those possibilities began disappearing.

Telehealth showed us what modern healthcare access could look like. But the regulatory framework governing medicine was built for a world where care happened in person, in specific locations, within specific boundaries. Those old rules are now the biggest obstacle to telehealth's transformative potential.

Here's something that surprises most people: if you're a licensed physician in California, you generally can't treat a patient sitting in Nevada. Medical licenses are state-specific. A doctor needs separate licenses for each state where their patients are located—not where the doctor is, but where the patient is at the moment of care.

This made sense when medicine meant examining someone in an office. It makes far less sense when a dermatologist could review a skin lesion photo from anywhere, or a psychiatrist could conduct therapy via video. The licensing system creates artificial scarcity. There might be 50 excellent specialists who could help you, but if none are licensed in your state, you're out of luck.

Some states have joined interstate compacts that make multi-state licensing easier. But participation is voluntary, the process still takes time and money, and not all specialties are covered. The fundamental assumption—that healthcare is inherently local—remains baked into the system. Meanwhile, patients in underserved areas can see the care they need exists, just behind a regulatory wall they can't cross.

Takeaway

Geographic licensing assumes healthcare must be local. But medical expertise isn't constrained by state borders—only the legal permission to use it is.

Licensing determines whether telehealth can happen. Payment determines whether it will happen. And reimbursement rules for telehealth are a patchwork of restrictions that often make virtual care financially impractical for providers.

Many insurers pay less for telehealth visits than in-person ones, even when the clinical work is identical. Some require patients to be in specific locations—like a clinic—to receive telehealth care, which defeats much of the convenience. Others only cover certain types of visits or certain technologies. A phone call might not count. An asynchronous message definitely won't.

Medicare and Medicaid have their own complex rules that vary by service type, patient location, and provider type. During the pandemic, many restrictions were temporarily lifted. But as those waivers expire, providers face a choice: continue offering telehealth at lower reimbursement rates, or shift patients back to in-person visits that pay better. The clinical benefits of telehealth don't matter much if the economics don't work.

Takeaway

Healthcare systems follow financial incentives. When regulations make telehealth pay less than in-person care, convenience loses to economics every time.

Imagine healthcare where specialist expertise flows to patients regardless of geography. Where a rural patient with a rare condition connects with the handful of specialists nationwide who actually understand it. Where mental health care reaches communities that have never had a local therapist. Where follow-up visits happen in minutes from your kitchen instead of half-day clinic trips.

This isn't fantasy—it's what telehealth briefly demonstrated during the pandemic. Patients who had never seen a therapist started treatment. People managing chronic conditions had more frequent check-ins. Emergency rooms saw fewer visits for issues that could be handled virtually. The technology worked. The clinical outcomes were often comparable to in-person care.

The barriers aren't technical. They're structural. Reforming licensing would mean states giving up some control over who practices within their borders. Reforming payment would mean insurers and Medicare rethinking assumptions about what care is worth. These are political and economic challenges, not technological ones. The promise of telehealth sits just on the other side of policy decisions we haven't yet made.

Takeaway

Telehealth's limitations aren't about technology failing—they're about regulations succeeding at preserving a system designed before the technology existed.

Telehealth could be the great equalizer in healthcare access. The specialist shortage in rural areas could matter less if specialists could practice everywhere. The mental health crisis could be addressed by providers licensed to help patients wherever they are.

But regulations built for in-person medicine keep virtual care in a box. Until licensing crosses state lines easily and payment treats telehealth as equally valuable, we'll have technology that could transform access sitting mostly unused. The tools exist. The rules don't match them yet.