The 51 License Question: Is Practicing Medicine in Every State Worth It?

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, according to Federation of State Medical Boards data, 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, and about the small but growing cohort of physicians who have decided that the bureaucratic pain of maintaining licenses in every jurisdiction is worth the ability to reach patients anywhere in the country.

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 physicians can expect renewal costs approaching $10,000 every cycle. Add FSMB credential verification fees, background checks, fingerprinting, and state specific documentation requirements, and the administrative overhead becomes a second job. The Interstate Medical Licensure Compact has helped somewhat by streamlining the process for participating states, but not every state participates, and you are still managing separate licenses with separate renewal dates, separate boards, and separate requirements.

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 state, child abuse recognition in another, HIV/AIDS education in a third, implicit bias training in a fourth.

The hours add up, but worse, the specificity adds up. You can't just complete 50 hours of CME on topics relevant to your practice and call it done. You need a spreadsheet tracking which state requires what, which courses satisfy multiple state requirements simultaneously, and which deadlines fall when. There are services to help with this such as mocingbird, cebroker, and modio health, but they all come with added costs. For a physician trying to maintain 51 licenses, this becomes a genuine operational challenge that either consumes personal time or requires hiring help to manage.

The Risk Factor Nobody Talks About

There is a con that rarely gets enough attention in these conversations. 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. The more licenses you hold, the more boards have jurisdiction over your practice, and for physicians engaged in telemedicine or cross state consulting work, this multiplied exposure is not trivial. 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 is that the IMLCC has its own rules where if one license is sanctioned you can potentially lose the privilege of being able to participate in the compact thus losing all your compact licensure.

The Case for Impact at Scale

Despite all of that, there is a compelling case for broad licensure, and it begins with a reality that the American healthcare system has never adequately addressed. 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. The DEA has continued to extend telemedicine prescribing flexibilities through 2026, meaning physicians can establish patient relationships and prescribe controlled substances via video visits without a prior in person exam, provided they hold a valid license in the patient's state. For physicians who want to make an outsized public health impact, this combination of broad licensure and regulatory flexibility creates a powerful opportunity.

Prescriptive Authority as a Public Health Tool

Consider what a broadly licensed physician can actually do in practice. Health plans and value based care organizations constantly identify patients who are overdue for medication adjustments, chronic disease management interventions, or preventive care measures. Maybe it is a statin that should have been started six months ago, or an A1C that has been creeping up without a corresponding change in diabetes management, or a patient on an ACE inhibitor who has not had basic metabolic panel monitoring in over a year, or a 50 year old who is two years overdue for colon cancer screening. Traditionally, closing these gaps requires the patient to schedule an appointment, show up, and see their local provider, a process that can take weeks or months and often does not happen at all. A physician with multi state licensure and prescriptive authority can reach these patients directly through telemedicine, review their clinical data, and make evidence based care decisions in real time.

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, and her health plan has flagged her rising A1C and overdue medication review as a care gap. 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. The nearest gastroenterologist with availability is a four month wait, and his health plan has flagged him as overdue for colorectal cancer screening. A broadly licensed physician connects with James via telemedicine, reviews his risk factors, discusses screening options, orders a FIT or Cologuard test as an immediate step, and coordinates a referral pathway to a gastroenterology group that serves his region for follow up colonoscopy. Without that outreach, James likely would have remained in the system as another open care gap, another patient whose cancer risk went unaddressed because geography got in the way.

Scale those interactions across thousands of patients in underserved communities, and the public health potential becomes difficult to ignore.

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 through telemedicine, public health programs, establishing professional corporations, or supervising advanced practice practitioners, 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 and prescribe the medication they need regardless of which side of a state line they live on 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. As telemedicine continues to mature and care models increasingly require national reach, that number will keep climbing. 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. For now, it remains one of medicine's more interesting cost benefit analyses.

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