Wisconsin improves while Louisiana backslides as federal Rural Health Transformation Program raises stakes for reform
Boston, Mass – A new report from the Cicero Institute and Pioneer Institute finds that while state legislatures remained active on telehealth policy in 2025, most states made only incremental progress toward modern, patient-centered telehealth systems. With the passage of the One Big Beautiful Bill and its $50 billion Rural Health Transformation Program, states now face growing pressure to modernize outdated telehealth laws or risk falling behind in access, affordability, and federal funding competitiveness.
The report assigns letter grades to all 50 states, revealing that only nine states earned an A+ or A, while nine states received an F. Most states continue to cluster in the middle, signaling that significant barriers to innovation and patient access remain firmly in place. Despite heightened legislative activity, many reforms introduced in 2025 focused narrowly on individual provider types or imposed new mandates, rather than pursuing broad-based telehealth modernization.
Massachusetts received a B, reflecting continued barriers to across-state-line telehealth access and limits on provider flexibility, even as the state performs better than many peers. States were graded across four key policy areas that directly affect a patient’s ability to access telehealth care: modality-neutral telehealth policies, the ability to initiate care by any mode, access to across-state-line telehealth, and independent practice authority for nurse practitioners.
“Telehealth is one of the most efficient and cost-effective tools we have to expand access to care, especially in rural and underserved communities,” said Josh Archambault, author of the report for the Pioneer Institute and Cicero Institute. “But most states are still clinging to outdated laws that limit competition, raise costs, and prevent patients from benefiting fully from modern care delivery. With billions in federal funding now tied to reform readiness, states can no longer afford incrementalism.”
“States that modernize their telehealth laws will be better positioned to improve access to care while making smarter use of taxpayer dollars,” said Jim Stergios, Executive Director of the Pioneer Institute. “This report makes clear that meaningful reform—especially removing barriers to cross-state care and expanding provider flexibility—is essential not only for patients, but for states hoping to compete successfully for new federal rural health funding.”
Key findings from the report include:
- Modality Neutrality & Patient-Provider Relationships: Many states still restrict how telehealth relationships can begin, with laws or regulations favoring real-time video over asynchronous care, remote patient monitoring, or other clinically appropriate modalities.
- Cross-State Telehealth Access: Only four states (AZ, CO, DE, UT) earned the highest rating for allowing patients to access providers across state lines without unnecessary barriers. Most states continue to rely on narrow and costly interstate compacts that limit patient choice.
- Independent Practice for Nurse Practitioners: While Wisconsin improved its grade after enacting legislation expanding nurse practitioner scope of practice, most states continue to impose supervision or collaboration mandates that restrict access to care, particularly in rural areas.
- Policy Setbacks: Louisiana’s overall grade declined after new regulations undermined predictable access to across-state-line telehealth services, highlighting how regulatory actions—not just legislation—can erode patient access.
The report emphasizes that telehealth reform is not merely a healthcare policy issue but a core component of states’ competitiveness for Rural Health Transformation Program funding. Approximately 30 percent of policy-related scoring under the program can be directly or indirectly influenced by telehealth and remote-care reforms, including licensure flexibility, provider scope of practice, and payment policy.
Telehealth is not a magic wand, but it remains one of the most powerful tools available to improve healthcare access, lower costs, and support innovation. States that fail to modernize their telehealth laws risk reinforcing outdated systems and missing a once-in-a-generation opportunity to pair rural investment with forward-looking reform. The report examines state telehealth policies for fully-insured private insurance plans and laws that impact provider practice in each state. It does not consider Medicaid policies on telehealth.
About the Pioneer Institute:
Pioneer empowers Americans with choices and opportunities to live freely and thrive. Working with state policymakers, we use expert research, educational initiatives, legal action and coalition-building to advance human potential in four critical areas: K-12 Education, Health, Economic Opportunity, and American Civic Values.
About the Cicero Institute:
Cicero Institute is a non-partisan 501(c)(3) public policy organization dedicated to advancing constitutional principles and promoting the rule of law. Through rigorous research, advocacy, and legal analysis, Cicero Institute strives to uphold the values enshrined in our nation’s founding documents and ensure that justice prevails for all Americans.
About Josh Archambault:
Josh is a senior fellow on health care at Cicero and Pioneer Institutes. Josh has over fifteen years of experience operating in complex and highly political waters in thirty-five states and in Washington, D.C. He has become a trusted adviser to governors, state legislators, senior White House staff, and executive branch leadership as they navigate the complexity of health care policy.
Josh holds a master’s in public policy from Harvard University’s Kennedy School of Government and a B.A. in political studies and economics from Gordon College. He and his wife enjoy raising four kids—a mix of biological, adopted, and children experiencing foster care.
