Last March, a report from the Association of American Medical Colleges (AAMC) projected a shortage of up to 86,000 physicians, including as many as 40,000 primary care physicians. The report noted that, as of 2021, as many as 17 percent of active physicians were over age 65, with an additional 25 percent of the physician workforce between age 55 and 64, concluding, “it is very likely that more than a third of currently active physicians will retire within the next decade.”

According to a study of 15 major metropolitan areas by Merritt Hawkins, the average wait for a first-time appointment with a primary care physician (PCP) is now 26 days. The wait is 31.4 days for an Ob-Gyn appointment, 26.6 days for a cardiology appointment, and 16.4 days for an orthopedics appointment.

Most state licensing boards require physicians to graduate from an accredited medical school and complete at least one year in an accredited residency program before they are licensed to practice medicine. State licensing boards grant the Accreditation Council on Graduate Medical Education (ACGME) a monopoly on accrediting residency programs. In 1981, the American Medical Association (AMA), AAMC, American Hospital Association, and a few other medical specialty societies created the ACGME.

I have argued for expanding the scope of practice of other health professionals, from nurse practitioners to pharmacists to doctorate-level clinical psychologists, to the full extent of their training to expand patients’ access to health care services.

Now Jay Greene, an education policy analyst at the Heritage Foundation, has weighed in on the issue by bringing attention to the critical fact that, for decades, the allopathic and osteopathic medical professions have kept a tight lid on the production of new MDs and DOs through the government-granted monopoly they wield on medical school accreditation. For decades, the Liaison Committee on Medical Education (LCME), created by the AMA and the AAMC, and the American Osteopathic Association Commission on Osteopathic College Accreditation (COCA) have restricted the number of medical schools they accredit.

Greene correctly points out that this artificially reduces the number of domestic medical school graduates and suggests that, over the years, it has led to a growing proportion of doctors entering residency programs who have graduated from foreign medical schools. However, after reading Greene’s “Backgrounder,” I can’t help but conclude that he is more concerned about the number of doctors who are immigrants and graduated from foreign medical schools than he is about increasing patients’ access to health care services.

Graduates of foreign medical schools accredited by the Educational Commission for Foreign Medical Graduates (ECFMG) may apply to ACGME-accredited residency programs in the United States, providing they obtain a J‑1 immigration visa. These graduates comprise most international medical graduates (IMGs) who seek residency slots in this country. American nationals who attended ECFMG-accredited medical schools overseas don’t need a visa. The ECFMG was created in partnership with the National Board of Medical Examiners (NBME). States granted the NBME a monopoly on administering the standardized US Medical Licensing Exam (USMLE). Can you see a pattern emerging?

Upon completing their residency, international medical graduates who obtain H1B visas or permanent legal resident status (green card) may enter practice providing medical care to Americans.

State licensing boards require that fully trained foreign doctors who are licensed, working, and experienced in other countries repeat the residency training they already received in the foreign country in an ACGME-accredited program in the US, which increases the number of med school grads competing for the scarce number of residency slots.

The Residency Bottleneck

Greene contends that medical school graduates have a surplus of residency programs to choose from. Yet, every year, roughly 8 percent of MD and DO med school graduates are left without a residency position during Match Week in the National Residency Matching Program. These graduates are left in a state of limbo: they can’t get the required residency experience they need for a medical license, and they can’t work in medicine. At the same time, while they must wait another year for Match Week, they owe hundreds of thousands of dollars in student loans. Several states have created a position called “Assistant Physician,” which enables these graduates to work as apprentices to doctors and gain experience taking care of patients while earning some money and waiting for the next Match Week.

Greene proposes that lawmakers rescind the monopoly they have granted medical school accreditors. This would open the accreditation market, make it more competitive, and likely result in a greater number and diversity of medical schools. This, in turn, should produce a greater number of American doctors. Stimulating free markets and consumer choice is always a good idea, and medical education is no exception.

Greene argues that if there were more American medical school graduates, fewer residency slots would be available for foreigners because graduates of American medical schools would gobble them up. There’s a good chance he’s correct.

To ensure he’s correct, Greene proposes that the government require residency programs to offer positions based on nationality rather than merit. He wants residency programs to accept Americans first and immigrants only after they have run out of American applicants—sort of DEI in reverse.

Greene argues for increasing the number of domestic med schools but dismisses the notion that there aren’t enough residency positions to accept all the new graduates, contending there are plenty of slots available for all the American med school grads.

However, unless states rescind the monopoly they grant the ACGME on accrediting residency programs, the doctor production bottleneck will persist, no matter how many more students graduate from US med schools.

If lawmakers adopt Greene’s proposal, the only change will be the increase in the number of IMGs driving Ubers relative to the number of American grads practicing medicine. People will still have to wait an average of 26 days for a first-time appointment with a PCP. However, it will be more likely that the PCP will be an American rather than an immigrant. Perhaps, over several years, as more medical schools open to produce more doctors, the number of residency programs will increase to accommodate them, and the total ratio of doctors to patients will improve. But that won’t happen quickly.

If Greene is interested in creating access to a free, growing, and dynamic market for health care services, he should also call on states to rescind the ACGME residency accreditation monopoly. This would make opening more residency slots in response to demand easier.

Greene should also support granting provisional licenses to fully trained, licensed, and experienced foreign doctors who migrate to the US, sparing them from repeating their residency (and needlessly competing with recent med school grads for residency positions) and adding to the pool of physicians who offer services to Americans. Tennessee became the first state to enact such a reform in 2023. This year, several more state legislatures have enacted provisional licensing for IMGs. These foreign doctors receive full medical licenses after two or three years of practicing under a licensed physician’s supervision.

Let Markets Work, Let Patients Choose

The best way to increase access to health care would be to not only adopt Greene’s proposal to rescind the medical school accreditor monopoly but to add to it by rescinding the ACGME residency accrediting monopoly, granting provisional licenses to experienced foreign doctors already practicing in other countries, and removing government-imposed scope of practice limits on the various other health professions so they can practice to the full extent of their training.

We would welcome more American medical school graduates. We should welcome international medical school graduates able and eager to provide health care services. And we should also welcome non-physician health professionals trained to competently provide health care services. As with other goods and services, more choices and competition benefit consumers—in this case, health care consumers. 

Instead, Greene makes a nativist/​protectionist argument (“These foreigners are taking our medical jobs!”) for increasing the proportion of doctors who are domestically born and trained. Yet he does not address the problem of not having enough doctors to meet the growing demand of an aging American population while an aging physician population retires more quickly than it gets replaced. 

Rena Conti, Richard Frank, and David Cutler recently published a very useful piece in the New England Journal of Medicine under the title, “The Myth of the Free Market for Pharmaceuticals.” Conti, Frank, and Cutler shatter the common myths that the United States has “largely unregulated prices” for medical care (Los Angeles Times) or is “one of the only developed countries where health care is left mostly to the free market” (The Economist).

The authors detail multiple ways that government intervenes in and distorts the pharmaceutical market and conclude, “The net effect of these deviations from the free-market ideal is that prices are high.” When drug manufacturers like Merck claim, “Congress has long been committed to a free-market approach based on market-driven prices,” these producers are merely trying to protect the government interventions that let them charge higher prices than would prevail in a free market.

This problem is not unique to the pharmaceutical industry but pervades the entire US health sector. In the new Cato Institute book The War on Prices (release date May 14), I contribute a chapter with the title, “Government Price Fixing Is the Rule in U.S. Health Care.” I explain that—contrary to industry propaganda that holds government price controls only result in inefficiently low prices—US medical prices are often high because government controls them. For example, “studies conducted in the USA generally conclude that price setting by a regulator…improved hospital financial stability.”

Remember that the next time the hospital lobby comes calling.

Still, it’s hard not to quibble with what Conti, Frank, and Cutler describe as some of the features of free markets.

When they write, “In free markets, consumers are assumed to be fully informed,” the passive voice betrays that they are conflating the concept of real-world free markets with the theoretical concept of perfectly competitive markets. Free markets can and do exist. In contrast, there are few markets, if any, that satisfy all the requirements for perfect competition. To conflate the two deprives the term free market of utility.

It is likewise imprecise to enumerate that drug ads “are often misleading,” that “most consumers are insured,” or that “doctors may be financially rewarded for using more expensive drugs even when less expensive drugs are equally effective” as among the pharmaceutical market’s “deviations from the free-market ideal.” As much as I like the authors’ main conclusion, misleading advertising, health insurance, and conflicts of interest would all exist in a free market. Indeed, misleading advertisements might indicate the market is too free because government is not doing its job of preventing producers from using fraud to overcome the will of consumers.

On May 1, Florida Governor Ron DeSantis (R) signed SB 1084 into law, which prohibits Floridians from buying or selling lab-grown meat. In a press release, the governor’s office stated, “Florida is increasing meat production” and urged Floridians to “continue to consume and enjoy 100 percent Florida beef.”

To his credit, unlike his culture war opponents who oppose genetically modified foods, the governor did not engage in hysterical junk science arguments about the safety of eating lab-grown meat.

Medical researchers and clinicians have been culturing and growing human tissue in laboratories for decades. In some cases, clinical researchers and oncologists cultivate tissue samples obtained from individuals’ tumors to study their unique biology and the effects that various therapeutic agents have on them.

It was only a matter of time before entrepreneurs applied the same technology to growing animal tissue, which enabled humans to consume meat without raising and slaughtering animals.

Historically, many early opponents of genetically modified foods were associated with left-wing politics, who claimed these foods were “an unnatural plot by evil capitalists to enslave food eaters.” Activists claimed genetically modified foods, which they often dubbed “Frankenfood,” were unhealthful. However, there is solid evidence that genetically modified foods are safe.

This time, opposition to lab-grown meat seems to be coming from right-wing culture warriors, the agriculture lobby, and politicians who pander to them. Lab-grown meat critics don’t challenge evidence that it is safe to eat. Rather they oppose lab-grown meat mainly because environmentalists and animal rights activists generally like the idea. Though recent studies suggest they may be wrong, many environmentalists have believed that growing meat will decrease the need for raising methane-producing cattle, thus helping to ease global warming. Animal rights activists promote lab-grown meat as an alternative to slaughtering animals.

But the culture war is not all that animates those opposing lab-grown meat. Another factor is good old-fashioned protectionism. Just as the taxi cartels united to oppose Uber and Lyft, many in the beef and poultry industries fear competition from lab-grown meat. The Florida governor’s press release was quite transparent on this in stating:

We must protect our incredible farmers and the integrity of American agriculture. Lab-grown meat is a disgraceful attempt to undermine our proud traditions and prosperity, and is in direct opposition to authentic agriculture.

Protectionism makes for strange political bedfellows. Commenting on Florida’s new lab-grown meat prohibition, Senator John Fetterman (D‑PA) posted on X:

Pains me deeply to agree with Crash-and-Burn Ron, but I co-sign this. As a member of @SenateAgDems.and as some dude who would never serve that slop to my kids, I stand with our American ranchers and farmers.

I can’t criticize opponents of lab-grown meat for making unscientific claims about its safety, but I can certainly point out the hypocrisy of their claim to be pro-freedom.

Yesterday, the Vermont Senate passed H.72, which permits an overdose prevention center (OPC) to operate in one municipality in the state, provided the municipality approves. The mayor and city council of Burlington, Vermont’s largest city, have already signaled that they support this proven harm reduction strategy.

In a Cato briefing paper last year, I reported that OPCs have been preventing overdose deaths and the spread of infections for more than 40 years. In 2023, there were 147 OPCs operating in 91 communities and 16 countries. Two have been saving lives in New York City since December 2021 and had reversed more than 1,000 overdoses by the summer of 2023.

Rhode Island lawmakers approved OPCs in 2022; its first one is about to open in Providence.

A 1986 federal law, 21 U.S.C. Section 856, also referred to as the “crackhouse statute,” makes it illegal to “knowingly open, lease, rent, use, or maintain any place, whether permanently or temporarily, for the purpose of manufacturing, distributing, or using any controlled substance.” Thus, New York City and Rhode Island are defying federal law.

Last year, Minnesota’s governor signed a law authorizing its Department of Health Services to establish OPCs, but the agency has hesitated to open them, stating that “federal law has been interpreted as prohibiting safer use spaces.”

As more state and local governments defy federal law and embrace OPCs, it might move Congress to repeal or amend the “crackhouse statute.”

Vermont Governor Phil Scott (R) has opposed OPCs in the past. He vetoed a 2022 bill that sought to create one in the state. However, Dr. Mark Levine, Vermont’s health commissioner, recently voiced support for OPCs.

H. 72 passed the Senate with a veto-proof majority of 21–8, and supporters believe it has enough support in the Vermont House to override a veto. Perhaps the governor’s opinion of OPCs has changed as overdose deaths continue to mount and he will sign the bill.

The Drug Enforcement Administration announced today that it intends to reschedule cannabis as Schedule III on its schedule of controlled substances. For the past half-century, the DEA classified cannabis as Schedule I: “No currently accepted medical use and high potential for abuse.”

Of course, no serious person would argue that cannabis has “no currently accepted medical use.” As far back as 1916, Sir William Osler, the so-called “father of modern medicine,” recommended cannabis as the “drug of choice” for treating migraines. But cannabis’s history of “accepted medical use” dates back to at least 2800 B.C.

President Biden had asked the Department of Health and Human Services to review cannabis classification in 2022, and last summer HHS recommended that the DEA reclassify cannabis to Schedule III: “Drugs with a moderate to low potential for physical and psychological dependence.” 

The good news is that the federal cops practicing medicine—the DEA—finally recognize that cannabis has medicinal uses. Rescheduling should make it easier for patients to obtain the drug with a prescription in the states that have not yet legalized medicinal cannabis. To date, 38 states and the District of Columbia have legalized medicinal cannabis. It will also make it easier for researchers to perform high-quality studies on the plant’s medicinal uses. And it will make it easier for cannabis retailers to take federal tax deductions from which the law has barred them. 

The bad news is that it is still federally illegal for people to use cannabis recreationally. With rescheduling, the only way people will be federally permitted to purchase and consume cannabis will be if a health care practitioner prescribes it to them. This should be welcome news to recreational cannabis purveyors in the unregulated black market in the 26 states where recreational cannabis remains illegal.

The medical profession has long recognized that alcohol has medicinal uses. There is evidence that consuming moderate amounts of alcohol may be good for you. Alcohol can also be addictive and cause serious health problems, including cirrhosis, gastrointestinal cancers, cardiomyopathy, and encephalopathy. Yet, after their disastrous experience with alcohol prohibition, federal regulators have never sought to list alcohol as a controlled substance. People don’t need a doctor’s prescription to purchase a product from their local liquor store.

Tobacco has no currently known medicinal use but many known harmful effects. And, while relatively harmless, the nicotine in tobacco smoke can addict smokers and expose them to tobacco smoke’s harmful components. Yet the DEA has never listed cigars or cigarettes on its schedule of controlled substances, even though one can argue that they have “no currently accepted medical use and a high potential for abuse.”

I am not arguing for the DEA to add alcohol and tobacco to its list of controlled substances. On the contrary, I am calling for the DEA to remove a much less harmful—and more medicinally useful—product from that list.

Rescheduling cannabis is nice. It’s a small step in the right direction. But it doesn’t go far enough. The DEA should de-schedule cannabis.

In April 2022, the Food and Drug Administration announced plans to ban all menthol cigarettes and cigars. In December 2023, after several civil rights groups, including the American Civil Liberties Union, expressed concerns about a blanket nationwide menthol ban exacerbating racial law enforcement disparities, the Biden administration announced a delay in finalizing rules to ban menthol tobacco until March 2024.

In a press release on April 26, Secretary of Health and Human Services Xavier Becerra stated his department needed “significantly more time” to consider public comments and concerns about a menthol tobacco ban. The secretary did not mention when it would make its final decision.

According to the National Survey on Drug Use and Health, in 2020, 81 percent of Black smokers preferred menthol-flavored cigarettes. Research indicates genetics may play a role. The cynic in me wonders if the delay is based primarily on concerns about the upcoming election and how African-American voters might react to a ban. However, I will give the Biden administration the benefit of the doubt and not assume ulterior motives. Secretary Becerra made the right call. Perhaps he understands that prohibition doesn’t work and can cause many unintended harms.

The European Union (EU) banned menthol cigarettes in 2020. A recent EU survey finds 40 percent of menthol smokers switched to non-menthol, and only 8 percent quit smoking. Menthol smokers have come up with workarounds, such as “mentholizing” recessed cigarette filters and menthol flavor inserts, or have added menthol to their tobacco.

However, 13 percent reported getting menthol cigarettes from “other sources.” A black market for smuggled menthol cigarettes has emerged. A significant source is Belarus, where menthol brands such as Minsk, Fest, and Queen find their way into EU countries. The UK press reported that gangs smuggle such “illicit whites” into the country, and people can buy them “under the counter” from British tobacconists for the right price.

Worst of all, menthol bans might exacerbate racial and ethnic disparities in law enforcement and within the criminal justice system. In public comments that I submitted to the FDA on its proposed menthol ban, I wrote the following:

Prohibition fuels an underground market where peaceful, voluntary transactions become crimes. It gives law enforcement another reason to interact with non-violent people who commit these victimless crimes. Like everyone else, police respond to incentives. They are rewarded by arrests and convictions. Low-level street dealers in illegal substances are “low-hanging fruit.” They are much easier to find in dense inner cities and less dangerous to confront than violent felons. Law enforcement tends to scour racial or ethnic minority communities for victimless crimes because they are “easy pickings.” That’s how we wind up with African Americans arrested for marijuana violations four times as often as whites, even though both groups use marijuana roughly equally.

And never forget Eric Garner. New York City’s exorbitant taxes on cigarette packages generated an underground market in untaxed individual cigarettes, called “loosies.” In 2014, police infamously encountered 43-year-old Eric Garner selling loosies on a street corner, and a policeman’s chokehold led to his death as he repeated, “I can’t breathe.” This happened without a menthol ban. With menthol cigarettes more popular among Blacks and Hispanics, expect police to focus their attention on minority communities.

The last thing this country needs is yet another reason for law enforcement to engage with minorities they suspect are committing the victimless crime of selling menthol cigarettes in the black market.

Aside from criminal justice concerns, singling out menthol tobacco for a ban lacks a basis in scientific evidence. A 2022 research paper in the Journal of the National Cancer Institute found menthol smokers had no greater difficulty quitting smoking than non-menthol smokers. Furthermore, according to FDA research reported in the Journal of Nicotine and Tobacco Research, there is “evidence of lower lung cancer mortality risk among menthol smokers compared with non-menthol smokers among smokers at ages 50 and over in the U.S. population.” Perhaps that’s because menthol smokers tend to smoke fewer cigarettes per day, according to a Vanderbilt University study that also found “menthol cigarettes are no more, and perhaps less harmful than non-menthol cigarettes.”

Policymakers also cannot justify a menthol ban based on concerns that menthol tobacco might lead to greater teen smoking. Only 1 in 250 teens smoked cigarettes within the past 30 days as of 2020. According to the Centers for Disease Control and Prevention, 60 percent of the vanishingly small number of teens who smoke choose non-menthol cigarettes. A Reason Foundation study found states with the highest menthol consumption had the lowest youth smoking rates.

The wording of Secretary Becerra’s press release left the question of when the federal government will finalize plans to implement a menthol tobacco ban unanswered. Let’s hope it never does.

In a March 22 opinion column in the New York Times entitled “The DEA Needs to Stay Out of Medicine,” Vanderbilt University Medical Center associate professor of anesthesiology and pain management Shravani Durbhakula, MD, documents powerfully how patients suffering from severe pain—many of them terminal cancer patients—have become collateral casualties in the government’s war on drugs.

Decrying the Drug Enforcement Administration’s progressive tightening of opioid manufacturing quotas, Dr. Durbhakula writes:

In theory, fewer opioids sold means fewer inappropriate scripts filled, which should curb the diversion of prescription opioids for illicit purposes and decrease overdose deaths — right?

I can tell you from the front lines that that’s not quite right. Prescription opioids once drove the opioid crisis. But in recent years opioid prescriptions have significantly fallen, while overdose deaths have been at a record high. America’s new wave of fatalities is largely a result of the illicit market, specifically illicit fentanyl. And as production cuts contribute to the reduction of the already strained supply of legal, regulated prescription opioids, drug shortages stand to affect the more than 50 million people suffering from chronic pain in more ways than at the pharmacy counter.

Dr. Durbhakula provides stories of patients having to travel long distances to see their doctors in person due to DEA requirements about opioid prescriptions. However, despite their efforts, they find that many of the pharmacies do not have the opioids they require because of quotas. She writes:

Health care professionals and pharmacies in this country are chained by the Drug Enforcement Administration. Our patients’ stress is the result not of an orchestrated set of practice guidelines or a comprehensive clinical policy but rather of one government agency’s crude, broad-stroke technique to mitigate a public health crisis through manufacturing limits — the gradual and repeated rationing of how much opioids can be produced by legitimate entities. 

In the essay, Dr.Durbhakula does not question or challenge the false narrative that the overdose crisis originated with doctors “overprescribing” opioids to their pain patients.

Unfortunately, Dr. Durbhakula’s proposed policy recommendations would do little to advance patient and physician autonomy. She would merely transfer control over doctors treating pain from the cops to federal health bureaucracies and let those agencies set opioid production quotas. For instance, she claims, “It’s incumbent on us [doctors] to hand the reins of authority over to public health institutions better suited to the task.”

No. The “reins of authority” belong in the hands of patients and doctors.

Dr. Durbhakula suggests that “instead of defining medical aptness, the DEA should pass the baton to our nation’s public health agencies” and proposes that the Centers for Disease Control and Prevention and the Food and Drug Administration “collaborate” to “place controls on individual prescribing and respond to inappropriate prescribing.” She elides the fact that these public health agencies will “respond” to doctors or patients who don’t comply with their regulations by calling the cops.

To be sure, Dr. Durbhakula has good intentions. But replacing actual cops—the DEA—with federal health agencies that can order those cops to arrest non-compliant doctors and patients is like rearranging the deck chairs on the Titanic. True, her proposed new pain management overlords would have greater medical expertise, but they would still reign over doctors and patients and assault their autonomy. And, as we learned during the COVID-19 pandemic, they will not be immune to political pressures and groupthink.

While her policy prescriptions may be flawed, Dr. Durbhakula deserves praise for having the courage to point out that the war on drugs is also a war on pain patients. Alas, courageous doctors are in short supply these days. Most doctors keep their heads down and follow the cops’ instructions.

After I read her essay, I wrote the following (unpublished) letter to the editor of the New York Times:

Dear Editor—

Kudos to Dr. Durhakula for speaking out against the Drug Enforcement Administration’s intruding on doctors’ pain treatment (“The DEA Needs to Stay Out of Medicine,” March 22, 2024). As my colleague and I explained in our 2022 Cato Institute white paper, “Cops Practicing Medicine,” for more than 100 years, law enforcement has been increasingly surveilling and regulating pain management. 

The DEA maintains a schedule of substances it controls, and it categorizes them based on what the agency determines to be their safety and addictive potential. The DEA even presumes to know how many and what kind of controlled substances—from stimulants like Adderall to narcotics like oxycodone—the entire US population will need in future years, setting quotas on how many each pharmaceutical manufacturer may annually produce.

The DEA restricts pain management based on the flawed assumption that what they consider to be “overtreatment” caused the overdose crisis. However, as my colleagues and I showed, there is no correlation between the opioid prescription rate and the rate of non-medical opioid use or opioid addiction. And, of course, as fear of DEA reprisal has caused the prescription rate to drop precipitously in the last dozen years, overdose deaths have soared as the black market provided non-medical users of “diverted” prescription pain pills first with more dangerous heroin and later with fentanyl. 

Researchers at the University of Pittsburgh School of Public Health found that overdose fatalities have been rising exponentially since at least the late 1970s, with different drugs predominating during various periods. Complex sociocultural, psychosocial, and socioeconomic forces are at the root of the overdose crisis, requiring serious investigation. Yet policymakers have chosen the lazy answer by blaming the overdose crisis on doctors treating pain. 

When cops practice medicine, overdoses increase, drug cartels get richer, and patients suffer.

Sincerely, 

Jeffrey A. Singer, MD, FACS

Senior Fellow, Cato Institute

When cops practice medicine, overdoses increase, drug cartels get richer, and patients suffer.