In 2016, just nine physicians in the entire United States held active medical licenses in all 50 states plus the District of Columbia. By 2018, that number had inched up to 14. Then telehealth exploded during the pandemic, and by 2024, 172 physicians had collected the full set, with another 356 holding at least 45 licenses. That growth from single digits to triple digits in under a decade tells you something important about where medicine is heading.

The question of whether broad licensure is worth pursuing has no single answer. It depends entirely on what a physician is trying to accomplish, how much administrative complexity they can tolerate, and whether their clinical mission genuinely requires national reach. What follows is an honest look at both sides of that equation.

The Cost Is Real and It Compounds

The financial burden is staggering. Initial application fees range from $35 in Pennsylvania to over $1,400 in Nevada, with the national average around $500 per state, putting the total cost to get in the door at roughly $25,000 across all 51 jurisdictions. But the upfront cost is the easy part. Renewal fees average about $200 per year per license, with states like California charging over $1,200 alone, meaning renewal costs can approach $10,000 every cycle.

Most physicians already take continuing medical education seriously. But when you hold licenses in dozens of states, CME stops being about professional development and starts being about compliance tracking. Many states require specific topics for renewal: opioid prescribing in one, child abuse recognition in another, HIV/AIDS education in a third. There are services to help with this — Mocingbird, CE Broker, and Modio Health — but they all come with added costs.

The Risk Factor Nobody Talks About

Every active license represents additional surface area for regulatory risk, because each state medical board has independent authority to investigate, discipline, and sanction. A complaint filed in one state can trigger reporting obligations and investigations in others, and a malpractice claim in Montana becomes a question on renewal applications in Maine, Maryland, and every other jurisdiction where a physician holds a license. One adverse action can cascade across every active license, creating a domino effect that takes years and significant legal expense to resolve.

Another thing to keep in mind: the Interstate Medical Licensure Compact has its own rules where if one license is sanctioned you can potentially lose the privilege of participating in the compact — and thus lose all your compact licensure simultaneously.

The Case for Impact at Scale

Despite all of that, there is a compelling case for broad licensure. Patients do not get sick according to state lines, and a physician licensed in all 51 jurisdictions can reach any patient in the country via telemedicine. In a healthcare system where over 80 million Americans live in primary care shortage areas, that reach matters enormously.

Take Maria, a 58-year-old in rural Mississippi with poorly controlled type 2 diabetes whose primary care physician retired eight months ago. The nearest accepting provider is a 90-minute drive. A broadly licensed telemedicine physician connects with Maria by video, reviews her labs and medication history, adjusts her metformin dose, adds an SGLT2 inhibitor given her cardiovascular risk profile, and orders follow-up labs at her local Quest Diagnostics. That interaction took 20 minutes and closed a gap that might have remained open for another six months or longer. Or consider James, a 52-year-old in rural West Virginia who has never had a colonoscopy despite a family history that includes a father diagnosed with colon cancer at 60. A broadly licensed physician connects with James via telemedicine, reviews his risk factors, orders a Cologuard test as an immediate step, and coordinates a referral pathway to gastroenterology for follow-up colonoscopy. Without that outreach, James likely would have remained another patient whose cancer risk went unaddressed because geography got in the way.

The Calculus

For a physician in private practice seeing patients in one state, maintaining 51 licenses is unnecessary overhead with no clear return. But for physicians whose mission is expanding access at a national scale, broad licensure is the infrastructure that makes the mission possible. The costs are real, the administrative burden is significant, and the regulatory risk is multiplied. Yet for the right physician with the right mission, the ability to reach a patient in any zip code in the country is a capability worth investing in.

The 172 physicians who now hold all 51 licenses — up from just nine in 2016 — have decided the juice is worth the squeeze. The question is whether the licensing system will evolve to match the pace of how medicine is actually being practiced, or whether it will continue to force physicians to choose between the scope of their impact and their sanity.

Dr. Josh Emdur is Chief Medical Officer and co-founder of Automate Clinic, where he leads a physician community focused on healthcare AI evaluation and safety. He has practiced telemedicine since 2017 and holds medical licenses in all 50 states and D.C.