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How Cross-State Licensure Reform Can Ease America’s Mental Health Crisis


This post was written by Harry Ritter, a physician-turned-entrepreneur and the founder and CEO of Alma.

Teletherapy has made mental health care more accessible than ever before, making care possible for people who otherwise would never have been able to get it. But the antiquated system of licensure in the United States is creating a huge barrier to realizing the potential for telehealth.

I’ve seen the benefits of teletherapy firsthand. As the founder and CEO of Alma, a mental health company that helps independent mental health providers run their private practice and accept insurance, we saw the transformative impact of virtual care during the early days of the Covid-19 pandemic when teletherapy became the only way to get this care. As society has reopened, we’ve continued to hear countless stories where patients have been able to get much-needed care that was simply not available physically near their home or place of work.

People seeking care for mental health issues are more accepting of telehealth than ever before. Even older Americans, a group that was previously skeptical of telehealth, are growing to embrace online care. Clinicians also value it. My colleagues surveyed more than 200 providers, and 98% reported having positive experiences seeing clients via teletherapy.

Mental health therapists have traditionally been licensed on a state-by-state basis, which means that someone licensed in New York can’t see a client in California — or even in neighboring New Jersey or Connecticut — unless they are also licensed in that state.

State-based licensure laws were written in the 1870s to protect Americans from the flood of post-Civil War quacks and charlatans. In today’s modern health care system, these laws no longer serve the best interests of therapists or their clients.

Standards of care in modern health care are consistent nationally. When I was in medical school, the way I learned to treat a patient with high blood pressure didn’t change depending on the state where the patient lived. The same applies to the ways mental health providers care for their patients.

In our survey, one provider responded, “As a bicultural, bilingual trauma therapist, I would be able to work with folks who may not have the same access to my specialties in their states. And as a brown immigrant woman, I know the importance of having someone who understands you and your background.”

State-by-state licensure rules also force providers to terminate therapeutic relationships, setting clients back in their care journeys. Our survey found that 70% of therapists reported that they had to stop seeing a client who moved to a different state. Forcing clients and providers to stop care is profoundly damaging in a health care category where therapeutic alliance and fit are so critical to outcomes.

For providers who want to get licensed across multiple states, the costs are significant. Our survey found that 54% of respondents with a second license spent between $250 and $500 on getting licensed in another state, while 13% spent between $501 and $1,000. For reference, the median annual wage for therapists (jobs that typically require a master’s degree in counseling, psychology, or social work) is $65,050. These licensing costs can add up quickly and can hurt the financial security of mental health professionals.

And even if a provider is willing to incur the costs of additional state licenses, the process takes months. Twenty-five percent of the therapists we surveyed waited four to six months, and 11% waited seven to 12 months to get a state license. By the time these providers are licensed in a new state, their clients will have likely needed to move on to a new provider. In fact, 75% of the therapists we surveyed revealed time as a top barrier to getting licensed in another state.

These providers are eager for reform: 89% wanted to see reforms in cross-state licensure.

One solution gaining traction is to create standards for states to honor out-of-state licenses by establishing reciprocity agreements. Perhaps the best example is the Psychology Interjurisdictional Compact (PSYPACT), an interstate agreement allowing psychologists in participating jurisdictions to practice across state lines without having to get licensed. This agreement allows for telehealth as well as for temporary in-person practice as well. Similarly, the U.S. Department of Veterans Affairs announced rules that allow its providers to practice teletherapy within the VA system across state lines.

Another option involves using federal funding incentives to pressure states to automatically recognize out-of-state licenses.

During the public health emergency triggered by the Covid-19 pandemic, many states waived licensure requirements. The result? People were able to get the care they needed when they needed it from providers who could’ve been anywhere in the country — and the sky did not fall. But by reinstating licensure barriers, these requirements once again stop teletherapy from saving lives all across the country.

Enough is enough. We need cross-state licensure reform now to address the needs of America’s growing mental health crisis and to ensure accessibility for everyone, regardless of their geographical location or identity.

This op-ed was originally published on

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Alma CEO Harry Ritter leaning up against a windowsill in Alma's photogenic Brooklyn headquarters.
Harry Ritter

About the Author

Dr. Harry Ritter is the Founder and CEO of Alma, a company on a mission to simplify access to high-quality, affordable mental health care. Alma’s software platform makes it easy and financially rewarding for therapists to scale their practice, accept insurance, and offer affordable in-network care to people. People seeking mental health care can use Alma’s free online member directory to find a therapist that fits their budget, schedule, and needs. Prior to founding Alma in 2017, Harry was an early employee at Oscar Health where he built out the company’s flagship primary care and wellness center as well as its telemedicine efforts as the Vice President of Care Delivery. Harry has also worked as a management consultant for McKinsey & Company. A trained doctor, he completed his internal medicine internship at Massachusetts General Hospital and earned his medical degree from the University of Miami Miller School of Medicine. He also has a law degree from New York University School of Law, and was included in Business Insider’s 2022 30 under 40 in Healthcare list.

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