Yes, the system could still be better, but there are improvements, and I think Dr. Northrup is making changes that are favorable to airmen.
There is now a FAST TRACK program that expedites the issuance process. It doesn't appear to be something the AME can process in their office, but if approved by this worksheet, the downtime is reduced waiting for OKC. It would be great if the CACI list continues to expand and reduces the conditions requiring special issuance.
We could get into the minutiae of MedExpress and the language of the form versus "I paid cash, I don't have to report that."