Top Five Issues in 2015: Interstate Compacts

When it comes to solving problems, states increasingly are turning to a mechanism that dates back to America’s colonial past—the interstate compact. Compacts are one of the few tools specifically granted to states by the U.S. Constitution. They provide states a sophisticated administrative mechanism, allowing interstate collaboration to resolve complex policy challenges.

Compacts, which are governed by the tenets of contract law, provide states an enforceable, sustainable and durable tool capable of ensuring permanent change without federal intervention.  Each state belongs to an average of 25 of the more than 215 interstate compacts in existence.

Legislatures will have the opportunity to consider several CSG-facilitated projects in the coming months.


Compacts Ready for Legislative Consideration

Medical Licensing Compact

CSG has been worked with the Federation of State Medical Boards, state medical boards, and subject matter experts to develop a medical licensing compact the last two years. Several factors—including changing demographics, the need for better and faster access to medical care in rural and underserved areas, the passage of the Affordable Care Act and the rise of telemedicine—have created unprecedented demand for health care services.

Compact language is now finalized and ready for legislative consideration during the upcoming session. The compact creates a process for expedited licensing for doctors wishing to practice in multiple states and has been endorsed by groups such as the American Medical Association and the Federal Trade Commission. 

To read the final compact language please click here

EMS Licensing Compact

States have had the authority to license emergency medical services personnel since the 1970s and issue licenses based on individual state practices. While licensing requirements in many states are similar, they also vary considerably among the states. It is becoming more common for EMS emergency services personnel to cross state lines to provide services in nondeclared states of emergency, which is making interstate cooperation for EMS licensing more urgent.

An interstate compact is one way to solve this problem; it would allow member states to work cooperatively to address interstate licensing challenges. CSG and the National Association of State EMS Officials have been working with a group of subject matter experts to develop an EMS Licensing Compact. Drafting is now complete and several states have expressed interest in considering and potentially joining the new agreement.

Under the terms of the new agreement, member states would agree to honor other jurisdictions’ licenses as long as the license is issued in another member state in a manner consistent with the new compact. The new compact also allows member states to self-regulate the existing system for licensing emergency medical personnel, while simultaneously promoting license portability.

To read the final compact language please click here


Compacts in Development

Physical Therapy and Telepsychology Licensing Compacts

The Federation of State Boards of Physical Therapy and the Association of State and Provincial Psychology Boards are continuing efforts to draft license portability compacts for their respective organizations. Both groups began exploring compacts in 2014 and are expected to finish drafting in 2015, with the goal of having each compact ready for legislative consideration beginning in 2016. Staff from CSG’s National Center for Interstate Compacts will participate and assist with both projects.

Each effort is being driven by a desire to make affordable health care across a variety of medical professions more accessible. The cost of health care in the United States has grown an average of 2.4 percent faster than the gross domestic product since 1970 and now represents 18 percent of the total GDP, according to the Kaiser Family Foundation. One challenge contributing significantly to these costs is access to health care in hard-to-serve locations.

Problems accessing care is especially common in rural areas. According to the American Academy of Family Physicians, 21 percent of the U.S. population lives in rural areas, but only 11 percent of medical specialists practice in those areas. The group notes that, because of this disparity, patients in these areas are frequently dramatically undeserved. These patients often do not have access to the latest research, scientific breakthroughs and medicine because of where they live. Missed appointments and incomplete care can contribute to escalating health care costs.

Experts expect this problem to worsen as the population grows and ages and the number of insured Americans seeking health services increases as a result of the Patient Protection and Affordable Care Act. Research published by the Annals of Family Medicine estimates the United States will need an additional 52,000 primary care physicians by 2025 to keep up with growing demands on the health care system.

These agreements also are intended to allow practitioners to more easily move to and practice in multiple states in an increasingly mobile society. Finally, the EMS agreement specifically includes a provision for transitioning active duty military personnel and their spouses in an effort to make their transition back into the civilian workforce more seamless. A similar provision is likely to be included in the Physical Therapy Licensing Compact. 


Additional CSG-Supported Agreements

State Authorization Reciprocity Agreement

Many of today’s colleges and universities employ online learning with varied degrees of onsite support for students on a national, and even international, scale. Regulatory requirements and evaluative measures, however, vary considerably from state to state, making interstate reciprocity difficult to achieve. This problem is costing states and institutions significant amounts of money.

CSG, The Presidents’ Forum, existing regional higher education compacts and The Commission on the Regulation of Postsecondary Distance Education have collaborated to advance an effective, practical framework to achieve interstate reciprocity in the regulation of distance education. This voluntary State Authorization Reciprocity Agreement is intended to broaden the availability of and access to accredited online degree programs by reducing state regulatory barriers, while also ensuring strong consumer safeguards.

The agreement allows states and institutions to work together to address an existing patchwork of regulation across states while strengthening the states’ roles in protecting students from unfair or illegal practices. With funding from the Lumina Foundation, a national office has been formed and the regional compacts are working closely with states and institutions that wish to participate in the State Authorization Reciprocity Agreement. To date, nearly 20 states have already joined and that number is expected to continue growing in 2015.  To learn more about the agreement, please click here

To track the progress of these and other compacts, visit CSG’s National Center for Interstate Compacts—the only organization of its kind—at or contact Crady deGolian at