The Great Prescribing Divide: California and Texas's Radically Different Approaches to Telehealth
The digital transformation of healthcare has unlocked unprecedented access to medical providers, yet a stark divide has emerged in how states regulate one of its most critical functions: the ability to prescribe medication remotely. Two of the nation's most populous states, California and Texas, stand as prominent case studies with fundamentally different philosophies on telehealth prescribing. California has championed a flexible, technology-neutral approach, empowering providers to use asynchronous methods like questionnaires to prescribe. In contrast, Texas has historically mandated a more traditional, synchronous video or in-person examination to establish a patient-provider relationship before a prescription can be issued.
This divergence in policy is not accidental but the result of years of distinct legislative histories, stakeholder influence, and differing views on the appropriate balance between innovation, patient access, and safety. An extensive analysis of their legal frameworks, historical context, and available data reveals a complex landscape where the question of "who is getting it right" has no simple answer, but offers crucial lessons for the future of virtual care in the United States.
The Two Paths Taken: How California and Texas Forged Their Models
The policy paths of California and Texas were shaped long before the COVID-19 pandemic made "telehealth" a household term. Their approaches reflect deep-seated philosophies about the role of technology in medicine and the definition of a valid patient-provider relationship.
California: The Pioneer of Asynchronous Care
California's journey has been one of consistent, incremental expansion of telehealth services. The state's landmark Telemedicine Development Act of 1996 laid the groundwork for a flexible regulatory environment. A key piece of legislation, Assembly Bill 415 in 2011, was pivotal, replacing the term "telemedicine" with the broader "telehealth" and, crucially, removing prohibitions on using telephone and email for consultations.
This legislative evolution was driven by a coalition of technology companies centered in Silicon Valley, consumer advocacy groups, and health systems focused on expanding access. The prevailing philosophy, as reflected in the Medical Board of California's guidance, has been "modality-neutral," meaning the standard of care, not the technology used, is the ultimate measure of a consultation's validity. This allowed for the rise of asynchronous "store-and-forward" technologies, where a patient can fill out a medical questionnaire or send images for a physician to review and prescribe from at a later time.
The California Medical Association (CMA) has generally supported this expansion, advocating for policies that enable physicians to use their professional judgment. Their stance has been that as long as the provider can obtain a sufficient medical history to make a sound clinical decision—the same standard as an in-person visit—the modality should not be a barrier.
Texas: A Deliberate Path Toward Parity
Texas, in contrast, has a history of more cautious and proscriptive telehealth regulation. For years, the Texas Medical Board (TMB) maintained that a physician-patient relationship could not be established solely through a questionnaire or a phone call. The board's rules were widely interpreted to require an in-person visit or, at a minimum, a real-time, interactive video examination before most prescriptions could be issued.
This more restrictive stance was heavily influenced by the Texas Medical Association (TMA), which long harbored concerns about patient safety, the potential for fraud, and the erosion of the traditional physical examination. The TMA argued that asynchronous methods could lead to misdiagnoses and inappropriate prescribing, particularly for conditions that benefit from a visual or physical assessment.
The turning point for Texas was the passage of Senate Bill 1107 in 2017. This legislation was the result of a hard-fought compromise between telehealth advocates, who wanted to remove the in-person requirement, and the TMA, which sought to ensure stringent standards. SB 1107 officially defined a valid patient-provider relationship for telehealth, permitting it to be established via synchronous audiovisual interaction. While it was a significant step forward that officially sanctioned direct-to-consumer telehealth without a prior in-person visit, it cemented the state's preference for synchronous modalities over asynchronous methods for establishing care and prescribing.
Analyzing the Models: Access, Quality, and Cost
Determining which model provides the "best, most comprehensive care" requires a nuanced analysis of how each approach impacts access, quality, and cost.
Access to Care: A Clear Win for Asynchronous Models
On the metric of access, California's model demonstrates clear advantages. Asynchronous care significantly lowers barriers for patients who may lack the technology for a video visit, have inconsistent schedules, or face language barriers that are more easily accommodated through written communication. Reports from the California Health Care Foundation (CHCF) highlight that telehealth has been a vital tool for expanding care in underserved and rural communities (California Health Care Foundation, 2025). For simple, low-acuity conditions like urinary tract infections, acne, or birth control, the convenience of an asynchronous consultation can mean the difference between getting timely care and forgoing it altogether.
In Texas, while SB 1107 vastly improved access compared to the pre-2017 environment, the requirement for a synchronous video visit can still pose a challenge for individuals with limited broadband access or digital literacy. Data from Texas has shown that telehealth expansion has been crucial for addressing provider shortages, particularly in its vast rural areas (Texas Health and Human Services, n.d.). However, the reliance on video can inadvertently exclude the most vulnerable populations who may only have access to a phone.
Quality of Care: The Central Debate
Quality and patient safety are at the heart of the debate between the two models. Critics of asynchronous prescribing, echoing the long-held concerns of the TMA, argue that it increases the risk of misdiagnosis by omitting a real-time interaction and physical examination.
However, a growing body of research suggests that for many conditions, asynchronous care is just as safe and effective as traditional care. A study published in the Journal of the American Medical Association (JAMA) found high diagnostic concordance between video telehealth and in-person visits (AMA, 2022). Furthermore, proponents of asynchronous care argue that the structured data collection of a well-designed questionnaire can sometimes lead to more thorough documentation than a brief, in-person visit. The key, they argue, is the appropriate use of the technology, reserving it for conditions where a physical exam is not essential.
Conversely, the synchronous model favored by Texas offers the benefit of direct, real-time patient-provider interaction, which can foster rapport and enable a more dynamic clinical interview. For complex conditions or when prescribing medications with a higher risk profile, the ability to see and speak with a patient is invaluable.
The prescribing of controlled substances represents a particularly contentious area. Both states must adhere to the federal Ryan Haight Act, which generally requires an in-person medical evaluation before prescribing controlled substances. The flexibilities introduced during the COVID-19 Public Health Emergency, which have been extended temporarily, have allowed for remote prescribing under certain conditions. The California Medical Association has been a vocal advocate for making these flexibilities permanent, while Texas has maintained a more cautious approach, emphasizing the need for strict safeguards.
Cost-Effectiveness: Potential Savings on Both Sides
Both models offer significant potential for cost savings. Telehealth, in general, reduces costs associated with patient travel and time off from work. One study noted that a large telehealth provider in Texas demonstrated significant savings by diverting unnecessary emergency department visits (Texas Association of Health Plans, n.d.).
Asynchronous care may offer even greater efficiencies. By allowing physicians to review cases and respond in batches, it can optimize provider workflow and potentially lower the cost per consultation. These savings can then be passed on to patients and payors.
Who is Getting it Right? A Question of Balance
Neither California's highly permissive model nor Texas's more structured approach is unequivocally superior. The optimal model may not be a binary choice but a hybrid that leverages the strengths of both.
California's model excels in maximizing access and convenience, particularly for low-risk conditions. It trusts physicians to use their professional judgment and empowers patients to seek care on their own terms. However, this flexibility places a greater onus on providers to know when an asynchronous consultation is insufficient and to redirect patients to a higher level of care.
Texas's model prioritizes a more traditional standard of care and patient-provider interaction. It provides a clearer, more defensible standard for physicians but at the potential cost of excluding patients who cannot meet the technological requirements for a video visit.
The most effective and comprehensive approach would likely incorporate the following:
Tiered Modality Requirements: Allow for asynchronous prescribing for a defined list of low-risk conditions while requiring synchronous video or in-person visits for more complex issues or the initial prescription of certain medications.
Provider Discretion: Empower physicians with the ultimate discretion to determine the appropriate modality for a given clinical scenario, while providing clear guidelines to support their decisions.
Robust Technology Standards: Ensure that asynchronous platforms utilize evidence-based clinical questionnaires that are designed to effectively rule out red-flag symptoms.
Patient Choice: Whenever clinically appropriate, patients should be offered a choice of modalities to best suit their needs and technological capabilities.
As states continue to navigate the post-pandemic regulatory landscape, the experiences of California and Texas offer invaluable lessons. The future of prescribing is not a battle between asynchronous and synchronous, but a challenge to thoughtfully integrate both into a cohesive system that delivers safe, effective, and accessible care for all.
References
American Medical Association. (2022, October 10). Telehealth, in-person diagnoses match up nearly 90% of the time. Retrieved from https://www.ama-assn.org/practice-management/digital-health/telehealth-person-diagnoses-match-nearly-90-time
California Health Care Foundation. (2025, January 15). Telehealth's Evolution in California: Progress, Challenges, and Opportunities. Retrieved from https://www.chcf.org/resource/telehealths-evolution-in-california-progress-challenges-and-opportunities/
California Legislative Information. (2011). Assembly Bill No. 415. Retrieved from https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201120120AB415
Texas Association of Health Plans. (n.d.). Telemedicine in Texas: Access, Convenience & Cost-Savings. Retrieved from https://www.legis.state.tx.us/tlodocs/84R/handouts/C4102016021009001/c73be392-815e-4c33-b89d-0892107dc8b3.PDF
Texas Legislature Online. (2017). SB 1107, 85th Legislature, Regular Session. Retrieved from https://capitol.texas.gov/BillLookup/History.aspx?LegSess=85R&Bill=SB1107
Texas Health and Human Services. (n.d.). The State of TeleMedicine and TeleHealth in Texas. Retrieved from https://www.dshs.texas.gov/sites/default/files/chs/shcc/SHP/tmreport.pdf