State Licensing Boards Are the Real Healthcare Monopoly

Why Your Doctor's Office Keeps You Waiting

State medical boards restrict the supply of clinicians by requiring physician signatures, supervised practice hours, and facility fees that independent providers cannot afford. These rules create artificial scarcity, which leaves patients waiting weeks for routine appointments and forces small practices to merge into hospital systems that charge more for the same care.

Ask anyone in Dallas or Houston how long it takes to see a dermatologist. The national average wait for a new patient appointment reached 26 days in 2022, according to a Merritt Hawkins survey. That is not a shortage of trained professionals. It is a shortage of permission slips.

Occupational licensing covers nearly one in four American workers today. In health care, these rules are especially dense. A nurse practitioner with a graduate degree and thousands of clinical hours must still pay a physician to sign charts in half the country. A mobile ultrasound technician must buy into a hospital's certificate of need before rolling a van into a rural county. The incumbents like it this way. Small competitors do not.

And the result is predictable. Prices rise. Choice shrinks. Patients in the Rio Grande Valley drive two hours for a checkup that a retail clinic could handle in fifteen minutes. The cartel does not advertise itself. It hides behind patient safety rhetoric while protecting market share.

The Cost of Protecting Incumbents

Certificate of Need laws are the most blatant example of this protection racket, because they let existing providers veto new competitors before a single patient is treated. Thirty-five states and the District of Columbia still require government approval before a hospital, imaging center, or nursing home may expand.

The Federal Trade Commission warned in 2023 that these laws raise prices, reduce quality, and limit access without improving safety. The Department of Health and Human Services reached similar conclusions during the first Trump administration.

Americans paid the price. CMS reported that national health spending reached $4.9 trillion in 2023, or 17.6 percent of gross domestic product. Hospital care alone consumed $1.5 trillion. Much of that spending flows to consolidated systems that face less pressure to compete on price or convenience.

Small medical businesses feel the squeeze first. An independent primary care clinic cannot afford the legal fees required to win a CON hearing against a regional hospital chain. A home health startup cannot scale across state lines when each state demands a different supervisory arrangement. The big players absorb these costs as a rounding error. Entrepreneurs absorb them as a death sentence.

But the human cost matters more than the balance sheet. Rural hospitals close. Maternity wards shut down. Patients wait in emergency rooms for conditions that outpatient clinics could treat. None of this happens because regulators are indifferent. It happens because the rules were written by the industries they regulate.

A Better Model Already Exists

Arizona and New Mexico have granted full practice authority to nurse practitioners, which lets them evaluate patients, order tests, and prescribe medications without a physician's direct oversight. The results have not produced a patient safety crisis; instead, rural areas gain access and wait times fall.

Direct primary care offers another escape route. For a flat monthly fee, usually between $50 and $100, patients receive unlimited access to a physician who works outside the insurance bureaucracy. These practices operate as small businesses, not hospital satellites. They compete on service, price, and transparency.

Telehealth broke the geographic monopoly almost overnight. During 2020, federal and state waivers allowed patients to see licensed providers across state lines. The American Medical Association reported that telehealth visits jumped from less than 1 percent of Medicare visits to more than 32 percent in April 2020. Then the waivers expired. Many states slammed the door.

That reversal tells you everything. The boards did not object because remote care was unsafe. They objected because it was popular, affordable, and hard to control. Safety was the excuse. Market share was the motive.

What Legislators Should Do Now

Congress cannot fix every state licensing board, but it can stop subsidizing them by letting federal dollars follow patients instead of incumbents. State lawmakers should repeal Certificate of Need laws, grant full practice authority to nurse practitioners, and allow direct primary care contracts without insurance mandates.

Federal lawmakers should also make telehealth licensing portable for Medicare and Medicaid beneficiaries. Any provider licensed in good standing in one state should be allowed to treat federal beneficiaries in another state through a secure video platform. The federal government has the spending power to make that stick.

Some will scream about patient safety. The evidence does not support them. A 2018 analysis by the Mercatus Center found no increase in adverse outcomes in states that expanded nurse practitioner scope. The Military Health System has operated under relaxed supervision for decades. Safety is not a function of red tape. It is a function of accountability, information, and competition.

Health care is too important to leave to guilds. Texans understand this when they choose a barber, a plumber, or a mechanic. They should demand the same freedom when they choose a doctor. The reform is not radical. It is overdue.