Better Is Possible: Interview with Dr. Robert McLean, President, American College of Physicians

The American College of Physicians is a national organization of internists, the largest medical-specialty organization, and second-largest physician group in the United States. Its 159,000 members include internists, internal medicine subspecialists, medical students, residents, and fellows.

The ACP has just released a new call to action for healthcare reform, entitled “Better Is Possible: The American College of Physicians’ Vision for the U.S. Health Care System." To learn more, I spoke with the president of the American College of Physicians, Robert McLean, MD.

Full audio here: Interview with Dr. Robert McLean, President, American College of Physicians

ROBERT MCLEAN, MD: My name is Robert McLean. I'm an internal medicine specialist as well as a rheumatologist. I live and work in New Haven, Connecticut. I have a clinical academic appointment as an associate clinical professor of medicine at the Yale School of Medicine. I practice and I'm medical director with a group called Northeast Medical Group, which is part of the Yale-New Haven Health System, and I happen to also be in my side job the president of the American College of Physicians.

DOUG MCVAY: The ACP has just released a new call to action for healthcare reform, published as a supplement to the journal Annals of Internal Medicine. Entitled “Better Is Possible: The American College of Physicians’ Vision for the U.S. Health Care System," the ACP's call is a bold new prescription for healthcare policy.

Doctor McLean, could you please summarize for us, what is the ACP’s vision for the US healthcare system?

ROBERT MCLEAN, MD: The American College of Physicians has for many years been advocating for universal access to affordable health insurance coverage for all Americans. And we have had multiple policy papers over many years that have talked about that in different ways and with slightly different perspectives.

Starting a year ago, the ACP's leadership gave our policy committee the charge to really kind of do a reboot of sorts and try to help put together a series of issues in a way that was a bit more understandable for the people who need to understand this, which are our legislators and policymakers as well as the public at large.

So we did what we basically usually do, we put out lots of different policy papers, guideline papers, and we did what we do, which is evidence based review. And we looked for what has happened in healthcare systems across the world in different countries, in different parts of our country, what's been tried, what's worked, what's not worked, what happens in the different states, and put all of that stuff together and came to some very basic conclusions, which were that we need to really do a lot of stuff better, and we can do a lot of stuff better.

We need to address social practice in healthcare, we need to address administrative burdens in healthcare, and I think that the key conclusion which people will pay attention to the most is that we are recommending transitioning to a system that achieves universal coverage with essential benefits and lower administrative costs through one of two potential approaches. And we've concluded that those two approaches could be either a single payer financing system or a publicly financed coverage option with regulated private insurance.

We don't think that isolated, market driven solutions work, based upon all the evidence that we see. Healthcare is not a commodity that really is appropriately dealt with in market based approaches, and they have historically not done enough to get enough people affordable insurance.

DOUG MCVAY: If I could get you to unpack a couple of the concepts in this. Now, your call moves way beyond that well-worn catchphrase “Medicare For All” 

ROBERT MCNEAL, MD: That is correct.

DOUG MCVAY: And you're talking about universal coverage. For the benefit of our listeners, could you explain a little bit about the concept of universal health coverage?

ROBERT MCLEAN, MD: Universal health coverage is essentially providing some mechanism that every American is able to obtain health insurance coverage that is affordable. That's kind of the basic idea, you know.

At this point, people who are over the age of 65 or have disability qualify for a government sponsored plan called Medicare, and that has a certain defined premium per month, and certain defined copays and all this kind of stuff, that is in the grand scheme of things quite affordable.

We have now many Americans who are covered by employer sponsored plans, because of the way our system has evolved, and while that gives a lot of people insurance coverage, a lot of those people are in fact relatively speaking underinsured because they have very high copays and deductibles or premiums, and while they may have insurance, it's not affordable and it is one of the leading causes of family bankruptcies in this country, health care bills.

So it's not working. So universal health -- universal coverage is kind of trying to make it affordable for everyone who needs it, and everyone needs healthcare at some point in their life.

DOUG MCVAY: In your call, you say that Universal Health Coverage could be achieved through either a single payer model or the public option. Again, could you explain a little bit about how those two different models would work?

ROBERT MCLEAN, MD: We feel that, I mean, a single payer option does not first of all eliminate -- I mean, the paper gets into a lot of the details of what these really mean. I think that one of the purposes of the paper is to get beyond a lot of the rhetoric that's out there, the news around the election trail, where people talk about, you know, Medicare For All, but many people have analyzed, well, what does that really mean? It may mean a little bit different from one candidate to the other, about - keep talking about it on the news.

We're trying to get through the rhetoric and the labels and say, you know, a single payer option would not be a market driven approach. It would basically look at having a standardized, centralized kind of payer, the government, that taxes would support.

People would be worried, oh my gosh does this mean my taxes are going to go up, and there may well be some small healthcare directed taxes that might increase for some Americans, depending on the situation. However, people need to remember that when in fact a system like this goes into place and all of the evidence reviews show this, premiums go down. Deductibles go down. All those other things that currently are making so many people not go get care because they're afraid of the cost, or get the care and then go bankrupt because of the cost, those things will be much lower or go away.

In aggregate, the cost or expense to individuals should be clearly less, and quite frankly, based upon our analysis, and the analysis of many others, the cost to the system may be less, because you're going to be simplifying a lot of the administrative burden and a lot of the duplication and stuff that happens that's driving our health care system to be so expensive.

That's a large picture view of single payer. There would still potentially be local insurance carriers that are doing the local management of claims and things, and that exists to this day. Now, when one looks at, well, with Medicare, I mean, Medicare has a lot of private insurers that are doing a lot of the administrative work that makes things happen at the state level and local level.

Insurance companies would not go away, which is a concern people might have, but will be potentially playing a more regulated, slightly different role.

With the public option, you would have kind of what was, in a way, designed through the Affordable Care Act, you would in fact still have private insurance type plans but you would also have a public option that would have probably less administrative burden, less overhead, and would essentially help drive the market expenses down to a more competitive way than has actually happened.

DOUG MCVAY: The bottom line is really that people are already writing that check for their insurance, they'd just be writing it to someone different and it would be for a less amount.

ROBERT MCLEAN, MD: Yes. That is our conclusion. And I think that we've looked at market driven approaches, and because healthcare is not a commodity, or should not be treated like a commodity, like other entities within our society, purely market driven approaches simply do not work. There's too large a role for the public good, for public health, and it just doesn't work the way it is now.

We know that patients deserve better. We deserve better. We can get to a better place and all the evidence and research shows that we really can do much better. We're trying to elevate the conversation, get beyond the rhetoric, and have people understand some complex issues.

Unfortunately healthcare is very complex, It cannot be drilled down to a sentence or two on the news or in an election cycle. That's why we have four papers to get into some of this. It's unfortunately complicated but we want people to understand better, and make better decisions on how we move forward.

DOUG MCVAY: It’s inevitable that some people are going to complain about doctors getting involved in politics, while others will point out quite sensibly that you’re doing the right thing by advocating for your patients. So, but I've got to ask: why has the ACP decided to step into the politics of reform?

ROBERT MCLEAN, MD: Well, we've stepped into the politics of reform going back, in the early 1990s, when we first put out a policy paper about the importance of access to care. And yes, we anticipate people will say, you know, doctors and healthcare people shouldn't be getting into politics, and quite frankly, my pushback is, you can't get into trying to enact and improve policy without being in politics.

So we are in politics here, and we have to be in politics. But what we're not doing is being partisan, and that is I think a real significant distinction to make. We are not endorsing any other -- any candidate's plan in this situation. We are not endorsing a party, or a party approach. We have done an evidence based review and come to some conclusions on what evidence shows us works and what doesn't work, and we have put that out there.

It may well be that some of those principles and positions line up with certain candidates, and that's great. But that's not why we did it. We did it because it's the right thing to do, it's what the evidence shows we need to do, and we want to make better policy. So this -- we have to throw it out there into the political realm, to enact better policy.

DOUG MCVAY: Again folks, we’ve been speaking with Doctor Robert McLean, he’s president of the American College of Physicians. Doctor McLean, any closing thoughts for our listeners?

ROBERT MCLEAN, MD: I think it's worth people trying to take a little time to read into some of this. As I say, I think one of the concerns we have on a lot of issues is that sometimes rhetoric runs the day, and these are complicated issues. Everybody is a patient at some point. This affects everyone.

Most people are one illness away from tragedy, which can be financial and bankruptcy as well. And so these are really important issues for everyone and everyone's family. It cannot be dumbed down too much, and we hope to really elevate the dialogue and help people understand where we need to go and why. And we hope that other physician organizations jump on board and endorse that. We anticipate that will happen.

We think that a lot of people, when they actually read some of these policies, will agree with them. We hope even more that the legislators and policymakers read this and realize that so much of this is common sense reform that need to be done. We've been talking around about it for years, and we need to really to in a comprehensive way put all of it together and get to the right place.

DOUG MCVAY: Better Is Possible: The American College of Physicians’ Vision for US Health Care was published on January 21 2020 as a supplement to the Annals of Internal Medicine. Doctor McLean, thank you very much.

ROBERT MCLEAN, MD: Thank you very much, Doug.

Crime & Law Enforcement

According to the FBI’s Uniform Crime Report, in 2017 there were an estimated 10,554,985 arrests by law enforcement nationwide for all criminal offenses, of which 518,617 were for violent offenses and 1,249,757 arrests were for property offenses. Also that year, there were 1,632,921 arrests for drug law violations.

Most arrests for drug law violations are for possession. In 2017, possession offenses accounted for 85.4% of all drug arrests (1,394,515 out of 1,632,921 total arrests). Only 14.6%, or 238,404 arrests, in 2017 were for sale or manufacture of a drug.

US law enforcement in the US made a total of 599,282 arrests for simple possession of marijuana. Researchers in New York City found that each arrest for simple possession of marijuana by officers of the NYPD took up at least 2.5 hours of police time.

It must be noted that this research only applies to New York City. It is also worth noting that the state of New York decriminalized possession of small amounts of marijuana in 1977. More research is needed to be certain whether a possession arrest involving other substances take up more police time than a marijuana possession arrest.

According to the FBI’s Uniform Crime Report, nationwide in 2017 law enforcement could only clear 45.6% of all reported violent crime and 17.6% of all reported property crimes. Those figures are roughly consistent with law enforcement success over the past two decades. (An offense is counted as “cleared” when someone is arrested, charged with an offense, and turned over to the court for prosecution. It does not indicate whether anyone was actually found guilty.)

FBI figures for crime only apply to reported offenses. National crime victimization surveys performed by the US Department of Justice show that people in the US report less than 45% of the violent crimes committed each year. Only about 35% of the property crimes committed each year ever get reported to police.

At yearend 2015, the most recent year for which final data are reported, there were 1,298,159 people serving sentences in state prisons in the US, of whom 197,200 (15.2% of the total) had as their most serious offense a drug charge. Drug possession was the most serious offense for 44,700 of those people, or 3.4% of the entire state prison population.

Fourteen states and the federal Bureau of Prisons operate at over their maximum population capacity.

According to the Bureau of Justice Statistics, about 21% of people in jails or in state prisons convicted of any type of offense committed their crime to get money for drugs or to obtain drugs. People convicted of property crimes were more likely than any others to report they committed their offense to get drug money.

Putting people in prison for drug offenses does not make the community safer. According to the Pew Research Center in 2018: “Pew compared state drug imprisonment rates with three important measures of drug problems — self-reported drug use (excluding marijuana), drug arrest, and overdose death — and found no statistically significant relationship between drug imprisonment and these indicators. In other words, higher rates of drug imprisonment did not translate into lower rates of drug use, arrests, or overdose deaths.”

For more information, check out Drug War Facts: Crime, Arrests, and Law Enforcement.

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Continuously updated and constantly expanding, Drug War Facts is your number one resource for information on drugs, drug policies, and the drug war.

Why the Legal Challenge to Colorado's Adult-Use Marijuana Program Will Fail

A suit has been filed in federal court, by a handful of Colorado sheriffs among others, asking for Colorado's legal adult-use program to be ended. There is one argument of significance: The sheriffs, and some other prohibitionists, are asserting that when the state is put into the position of licensing and regulating activities that violate the CSA, they can be argued to be in violation of federal law. That argument is not original, we've actually been hearing it mentioned in other parts of the country. I'll get back to that in a minute. The counter-argument to the CSA concern has always been that there is a 10th amendment to the US constitution, which is a guarantee of states' rights. Also these are intra-state concerns and not inter-state concerns, so the interstate commerce clause of the US Constitution should prevent Congress from interfering with a state program. The two arguments together are quite powerful. Unfortunately those arguments have been tried, and have failed, in the past. The Raich v Gonzalez case was decided by the Supremes back in 2005. A decade can be a long time in legal terms. We have a new court now, with new judges, and we have new attorneys who have the benefit of all the trial transcripts and motions and appeals histories. There are lawyers out there who have spent the past 10 years learning and studying and devising ways to win on those constitutional arguments. And we've got a lot more than just that. When the Raich case first went to trial, we had very limited experience with regulated state medical marijuana programs. There were no state legal adult use programs. The justices and the attorneys on both sides had no data, no real world experience, on which to draw. They justified over-riding the commerce clause concerns because of the possibility that there might be public health or public safety concerns. And now, 10 years later, we have several states running regulated medical marijuana programs and the states of Washington and Colorado running legal adult-use marijuana programs. We have research and evidence showing that these programs have had a positive impact on public health, and a positive net impact on public safety. This suit being brought against the state of Colorado by the sheriffs, it's not an isolated thing. Prohibitionists around the world and around the nation are networked, they work together, they share information. I said before, I've heard some of these arguments recently. The state of Oregon is working to implement its own legal adult-use marijuana program. That state's legislature is being lobbied by the Association of Oregon Counties and the League of Oregon Cities to give local governments more power and authority to ban marijuana businesses and to impose local taxes. Officials from those organizations have made some not-so-subtle threats that if they don't get their way, some city or county might file suit in federal court, using the same arguments about the CSA that the Colorado suit mentions, to try and stop the Oregon legal adult-use program. Significantly, those Oregon attorneys conceded that it's only the regulation and licensing of sale and commercial production that could be challenged that way, and that personal use possession and cultivation could not be challenged with that argument. But I digress. Doing a little more research, it appears that these arguments were developed in earlier cases, in Michigan and also in Oregon. They've been refining and expanding on these arguments over the years, and they've been learning from their losses. The prohibitionists think that they know what they're doing. They don't seem to understand that our side has also spent the past decade working and learning and sharing information, and learning from our losses as well as our victories. And we've been researching and assessing these programs, and their impacts on public health and public safety, and so have the states running these programs. The prohibitionists want a replay of Raich v Gonzalez. But they must not realize what they're asking for. The justice who wrote that decision, John Paul Stevens, retired in 2010. Federalism is making a resurgence. The evidence on marijuana legalization is finally in and it is clear that legalization is a good thing on several levels, having positive impacts on public safety and public health. The train has left the station, the tracks are clear, and this time around there are no stops until we have reached our final destination: the end of prohibition.

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