Association of Licensure and Relationship Requirement Waivers with Out-of-State Tele-Mental Healthcare, 2019-2021

During the COVID-19 public health emergency, states waived in-state licensure and pre-existing patient-physician relationship requirements to increase access to care. We exploit this state telehealth policy variation to estimate the association of in-state licensure requirement waivers and pre-existing patient-physician relationship requirement waivers with out-of-state tele-mental healthcare utilization of patients diagnosed with COVID-19. Using claims from January 2019 till December 2021 of 2,037,977 commercially insured individuals in 3 metropolitan statistical areas (MSA) straddling Midwestern state borders, we find increased out-of-state telehealth utilization as a share of out-of-state mental healthcare by 0.1411 and 0.0575 visits per month or 1,679.76% and 467.48% after licensure and relationship waivers, respectively. Within-MSA analyses illustrate an urban-rural digital divide in out-of-state utilization as a share of total or telehealth mental healthcare. Our findings indicate waivers primarily enhance access to care of established patients by enabling the transition of in-person out-of-state healthcare online. Interstate medical licensure compact participation may provide broader access to out-of-state tele-mental healthcare than emergency waivers.