Interstate Compact: Frequently Asked Questions
What is an interstate compact?
Interstate compacts are contracts between two or more states that are working together to create a common agreement on a particular policy issue, adopting a certain standard or cooperating on regional or national matters. Interstate compacts are the most powerful, durable, and adaptive tools for ensuring cooperative action among the states. Unlike federally imposed mandates that often dictate unfunded requirements, interstate compacts provide a state-developed structure for collaborative and dynamic action while building consensus among the states. The very nature of an interstate compact makes it an ideal tool to meet the demand for cooperative state action: developing and enforcing stringent standards while providing an adaptive structure that, under a modern compact framework, can evolve to meet new and increased demands over time.
Why an interstate compact, and why now?
Congress has been taking a comprehensive look at how to expand appropriate use of telehealth services to alleviate current and future provider shortages. Many pieces of legislation have been introduced in the past few years that would fundamentally change the way telehealth services can be provided in the Medicare program. Some of these federal proposals have attempted to address current barriers to telehealth that are associated with state licensure.
Questions related to cost and licensure continue to impede any real progress toward adopting telehealth services for Medicare reimbursement. Congressional leaders have expressed frustration at the lack of common licensure requirements and compacts that would ensure patient protections while at the same time relieving costly administrative burdens on providers. In the most recent version of the 21st Century Cures Act, which is a comprehensive bill to modernize Medicare, the Food and Drug Administration, and many other facets of health care delivery, Congressional leaders expressed their desire for state licensure boards to take the lead in the development of interstate compacts.
Section 3021 of the 21st Century Cures Act [PDF] includes a "Sense of Congress" that encourages states to form and collaborate through interstate compacts to create common licensure requirements for health care providers and allow them to practice via telehealth technologies across state lines.
Although nonbinding, the language does provide the intent of what Congress is thinking. Given this language, we believe that it is in the best interest of the professions to seriously consider creating an interstate compact. It is our belief that if we are not proactive and develop a model for a compact, Congress might take action in the future to develop one for those professions that have not proactively developed their own models or might instruct the Secretary of Health and Human Services to develop one through the Centers for Medicare & Medicaid Services. This "one-size-fits all" approach may not be in the best interests of the professions or those we serve. Conversely, Congress might also choose to work only with provider groups that have national compacts or common licensure agreements and exclude those provider groups that have not considered or created such agreements. Neither option is ideal for audiologists and speech-language pathologists interested in treating patients via telehealth.
Although Congress is focused on the delivery of health care services, other federal agencies—including the U.S. Department of Education—support ASHA’s position that the provision of services should be available in all settings (not just health care).
In addition, although states allow for licensure portability, our members often have difficulties obtaining multiple state licenses to practice. Members who practice in multiple states face additional administrative burdens, including the added cost of licensure. These burdens hinder their ability to provide quality, timely services and restrict consumer access in underserved and rural communities.
Who else is working on interstate compacts?
The following health-related compacts have met their threshold and have gone into effect:
- Enhanced Nurse Licensure Compact – 32 states
- EMS Licensure Compact (REPLICA) – 18 states
- Medical Licensure Compact – 31 states
- Physical Therapy Compact – 25 states
- PsyPact (Psychology) – 8 states
The following compact has not yet met their threshold:
- APRN Compact – 3 states (10 state threshold)
What are the advantages of an interstate compact?
- Interstate compacts provide an effective solution to suprastate problems.
- Compacts enable the states—in their sovereign capacity—to act jointly and collectively, generally outside the confines of the federal legislative or regulatory process.
- Interstate compacts can effectively preempt federal interference into matters that traditionally fall within the purview of the states and yet have regional or national implications.
- Compacts afford states the opportunity to develop dynamic, self-regulatory systems over which the member states can maintain control through a coordinated legislative and administrative process.
- Compacts enable the states to develop adaptive structures that can evolve to meet new and increased challenges that naturally arise over time.
What are the disadvantages of an interstate compact?
- Interstate compacts may often require a great deal of time to both develop and implement.
- The ceding of traditional state sovereignty may be perceived as a disadvantage.
- The requirement of substantive "sameness" prevents party states from passing dissimilar enactments.
What might the interstate compact development process look like?
The development of an interstate compact requires a cooperative arrangement between all stakeholders. Interstate compacts should be administered at the state level. CSG has outlined the key steps (see below) to the development process of a regulatory compact. These should be viewed as examples and can be customized as needed.
Phase 1/Year 1
Advisory Committee: Composed of state officials and other key stakeholders (e.g., the American Speech-Language-Hearing Association, the National Council of State Boards of Examiners of Speech-Language Pathology and Audiology [NCSB], and representatives from individual licensing boards), the Advisory Committee examines the problem, suggests possible solutions, and makes recommendations as to the structure of the interstate compact. Typically, an Advisory Committee is composed of up to 20 individuals.
Phase 2/Year 2
Drafting Committee: Composed of five to eight compact and issue experts, the Drafting Committee pulls the thoughts, ideas, and suggestions of the Advisory Committee into a draft compact that will be circulated to various constituencies for comment. Following the comment period, the compact will be revised as needed and sent back to the Advisory Committee for final review to ensure that it meets the original spirit of the group’s recommendations.
Phase 3/Years 3–4
Education: Once completed, the interstate compact would be available to states for legislative approval. During this phase of the initiative, state-by-state technical assistance and on-site education would be provided by key stakeholders. Education occurs before and during state legislative sessions.
Enactment: Interstate compacts typically activate when triggered by a pre-set number of states joining the compact. For instance, the Interstate Compact for Adult Offender Supervision required 35 state enactments before it could become active. The Physical Therapy compact requires 10 states to enact legislation before that compact may become active. Most interstate compacts take up to 7 years to reach critical mass.
Transition: Following enactment by the required minimum number of states, the new compact becomes operational and, depending on the administrative structure placed in the compact, goes through standard start-up activities such as notifying states, planning for the first commission or state-to-state meetings, and, if authorized by the compact, hiring of staff to oversee the agreement and its requirements. A critical component of the transition will be the development of rules, regulations, forms, standards, and so forth, by which the compact will need to operate. Typically, transition activities run for 12–18 months before the compact body is independently running.
Why is ASHA involved?
ASHA has the organizational capacity and financial resources to support the development and implementation of an interstate compact. Because we have the largest number of affiliates in each profession, we can ensure that all professionals will benefit.
ASHA's role is to underwrite the effort and to facilitate communications between stakeholders and the various committees. ASHA will be the contact point for questions and comments.