Evidence in St. Louis drug ring case should be tossed after alleged DEA misconduct, lawyers say

http://www.stltoday.com/news/local/crime-and-courts/lawyers-say-dea-misconduct-in-atlanta-should-void-drug-ring/article_afb1bc5d-724a-5e30-b29f-5f519300f8d6.html

ST. LOUIS • Efforts to nix key evidence against accused members of a violent St. Louis drug ring have revealed a Justice Department investigation of claims that a Georgia DEA official had sexual relationships with paid informers.

The target, a DEA supervisor in Atlanta, allegedly was involved with two confidential informers and paid one of them $212,000 in agency funds, according to court documents obtained by the Post-Dispatch.

Much of the court material is under seal. The woman who received the funds testified for hours Monday in the closed courtroom of U.S. Magistrate Judge Shirley Padmore Mensah in St. Louis. Reporters were kept out, although Mensah promised to make a redacted transcript of the testimony available later.

Defense lawyers say in a pending motion that questionable information from the woman, known as “CS1” for “confidential source 1,” laid the foundation for the investigation of Dionne L. Gatling, Andre Alphonso Rush, Timothy Lamont Rush and Lorenzo Gibbs. The four were subsequently indicted, in 2014, on various federal drug-related charges.

The charges against Gatling and Andre Rush allege they were involved in two murders here.

Based on information provided to them by federal prosecutors, the lawyers said in the documents that the Atlanta-based supervisor’s subordinates admitted helping him justify payments to CS1 by falsely claiming her information was used to advance criminal investigations.

Defense attorneys’ documents say the supervisor had used CS1 to “launder” information agents obtained illegally, or their hunches, by claiming it came from her.

The money was paid starting in 2011, including two DEA bonuses, of $55,000 and $80,750. The woman said she had no idea why she received bonuses, according to court filings. DEA money was at one point used to pay roughly the amount of CS1’s monthly rent after she moved closer to the supervisor, defense lawyers indicated that prosecutors told them.

None of the DEA staffers, who also are based in Atlanta, has been criminally charged, but an internal investigation is underway, the filings say. The supervisor reportedly has denied all the accusations.

James Shroba, head of the St. Louis DEA office, said Monday the agency takes “these allegations extremely seriously” and vowed that they would be “thoroughly investigated.” He declined to comment on other aspects of the case or on the status of the Atlanta supervisor.

The U.S. attorney’s office in Atlanta did not respond to a reporter’s questions about the case.

Practices faulted before

The DEA’s use of informers was faulted in a report released last month by the Justice Department Office of Inspector General.

The report says that management and oversight of the confidential source program needed “significant improvement.” It complains that there is not adequate oversight of payments, “which exposes the DEA to an unacceptably increased potential for fraud, waste, and abuse, particularly given the frequency with which DEA offices utilize and pay confidential sources.”

It also says the DEA had over 18,000 active confidential sources between Oct. 1, 2010, and Sept. 30, 2015, who were paid a total of $237 million.

The agency also has been accused of failing to discipline agents accused of misconduct.

Federal prosecutors allege that Gatling led a drug trafficking organization linked to the “Black Mafia Family,” dealing cocaine, heroin and methamphetamine in the St. Louis area.

A superseding indictment filed in 2015 says that Gatling, then 47, and Rush, then 50, also were involved in two murders.

Prosecutors say Gatling orchestrated the shooting of Theodis Howard, 41, in St. Louis on April 5, 2010, because Howard cooperated in an investigation that led to a prison sentence of more than 17 years for Gatling’s brother, Deron Gatling.

Prosecutors also say the pair then killed Terrance Morgan, 41, in St. Louis on May 2, 2013, because they feared he would cooperate with authorities against them.

CS1 was the original source of information about drug dealing by Gatling and the others, according to DEA agents in Atlanta in 2012, court documents show. They called her a reliable confidential source who had been working with the DEA for at least two years.

She reportedly introduced Gatling to a source of drugs.

In 2012, DEA agents in St. Louis used that information to apply for a series of wiretaps on Gatling that led to his indictment and the others.

But defense lawyers say in court filings that CS1 actually knew Gatling from a prior business relationship and that at the time the DEA sought the wiretaps, she did not have the knowledge agents claimed about drug dealing.

Allegations of misconduct

In 2015, prosecutors disclosed to defense attorneys that an Atlanta supervisor was under investigation by the Justice Department’s Office of Inspector General, and that he and two others were under internal investigation by the DEA.

The supervisor allegedly had personal and sexual relationships with two confidential sources, made improper payments to CS1 and falsified DEA reports to justify the payments, the defense lawyers were told.

Others were under investigation for allegedly falsifying the reports, and reportedly said they did it at the supervisor’s direction, the documents say.

The defense argues that since the entire investigation began with DEA claims about what CS1 knew, and those claims are wholly or partially false, all evidence obtained as a result of the wiretaps should be tossed out.

With many documents under seal, it’s not clear how prosecutors have responded.

Assistant U.S. Attorney Dean Hoag obtained an order closing the courtroom for CS1’s testimony Monday, saying that she, and even her daughter, had been threatened. Prosecutors claim that Gatling had summoned others on social media to watch the testimony, possibly so they can identify her by sight. Gatling has already disclosed CS1’s name, prosecutors said.

The accused supervisor testified in another case that he has been an agent since 1999. His current employment status is unknown.

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These Doctors Want to Abolish the DEA

https://www.civilized.life/articles/doctors-abolish-dea/

Laws that prohibit drugs aren’t meant to keep the public safe, they are meant to silence opposition. And, when making decisions at the ballot box, voters must consider and compare how the candidates would spend taxpayer money. Candidates that support the war on drugs must be voted out and it is time voters push for the closure of the Drug Enforcement Administration (DEA). 

The DEA has its roots in the Federal Bureau of Narcotics (FBN), founded in 1930 under President Herbert Hoover. Noted racist and lead champion of cannabis prohibition, Harry Anslinger, was appointed to be the first commissioner. In 1968, the FBN became the Bureau of Narcotics and Dangerous Drugs (BNDD), the predecessor to the DEA and a massive governmental bureaucracy whose existence relies on drug prohibition.

President Nixon’s top aid, John Ehrlichman, even admitted the war was racist and wasteful, saying Nixon’s war on drugs was really an effort to have a weapon for Nixon to marginalize his two biggest political enemies: people of color and the antiwar left.

“You want to know what this was really all about? The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I am saying? We knew we couldn’t make it illegal to be either against the war or blacks, but by getting the public to associate hippies with marijuana and blacks with heroine and then criminalizing both heavily, we could disrupt these communities.

“We could arrest their leaders, raid their homes, break up their meeting and vilify them night after night on the evening news. Did we know we were lying about drugs? Of course we did,” Erlichman said.

Wasteful expenditure of billions of dollars

This war strategy worked beyond Nixon’s wildest imagination and has led to the wasteful expenditure of hundreds of billions of tax dollars, the destruction of millions of lives, the rise of well-armed gangs, a significant role for the sale of illicit drugs to fund terrorism and the erosion of our Constitutional rights. There has been bipartisan support for the failed war on marginalized people and the massive amounts of government waste it generates. It’s time for voters to say enough is enough.

If the American public pushes their elected officials to rearrange their priorities, existing law enforcement could be employed to investigate terrorism instead. Do we really need the DEA? After all, over 90 percent of the drug war is related to cannabis, and it’s becoming legal state by state. Still, there are over 800,000 cannabis arrests per year, easily dwarfing the arrests for other drugs.

Treating marijuana use as a crime is ‘absurd’

Of course, the whole idea of treating the medical condition of substance abuse criminally, rather than medically, is absurd. The law enforcement approach is compounded by defining drug use as drug abuse.

If we took a harm reduction approach we could dramatically cut the $18-billion currently spent on prioritizing the enforcement of draconian drug laws. Also, if there was no longer an illicit drug market we would take money out of the pocket of terrorists. More importantly, we would have trained law enforcement personnel who could focus on tracking down would-be terrorists and combating terrorism.

Dr. Arnold Leff has come up with a timely idea that I support – abolish the DEA. Leff was President Nixon’s associate deputy director of the Special Action Office on Drug Abuse and has spent his career in public health.

The bulk of DEA agents are almost ideally suited to track down terrorists. We should move the vast majority of current DEA agents to the department of Homeland Security and put them to work where they can do some good: tracking down terrorists and preventing terrorist attacks.

Americans must ask themselves, what is their law enforcement priority?

Dr. David Bearman is a pioneer in medical cannabis, pain management and harm reduction. His work spans decades in California and beyond. His medical practice is located in Santa Barbara, California. 

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The Accepted Medical Use of Marijuana: States Need To Take Action Now To Protect Patient Rights

https://www.medicaljane.com/2016/10/17/the-accepted-medical-use-of-marijuana-states-need-to-take-action-now-to-protect-patient-rights/

After the recent rejection of the Rhode Island-Washington Marijuana Rescheduling Petition, it is easy to point fingers at the Drug Enforcement Administration (DEA) and proclaim how corrupt and inept they must be to uphold the position that marijuana still has no medical use. ^[1][2][3] However, once we see that the DEA and the Food and Drug Administration (FDA) both believe that the only way a drug substance can have medical use is for it to pass through the FDA’s own drug approval process, it’s easy to understand how the DEA is incapable of acknowledging a type of accepted medical use that it has no authority over.

The key to making sense of the DEA’s position regarding the medical use of marijuana is realizing that there are at least three types of accepted medical use.

The first, and most well known form of accepted medical use, results from successful completion of the FDA’s randomized placebo-controlled phase I-III clinical trials new drug approval process, which allows for an approved drug product to be marketed for interstate commercial distribution and carried by pharmacies as a prescription medication.

“[…] in Gonzales v. Oregon (2006), the Supreme Court confirmed the state’s right to accept the medical use of controlled substances by finding that the DEA does not have the authority to deny a standard of medical care that is accepted under state law.”

The second, and less obvious form of accepted medical use – known as “grandfathered” medical use – pertains to drugs that have been in widespread medical use prior to the adoption of the Food, Drug and Cosmetic Act of 1938. ^[4] Aspirin is the most prominent example of grandfathered medical use, as the over-the-counter formulation of this medication has never received FDA approval. ^[5]

The third, and least recognized form of accepted medical use, state-accepted medical use, exists because of the sovereign rights of individuals and our resulting form of government known as federalism, in which certain rights are retained by the states and others transferred by Congress to the federal government. The relevant example here is the authority of the state to accept the medical use of controlled substances, which falls under the state’s authority to regulate the profession of medicine within its own borders.

This authority has never been transferred to the federal government and is why more than half the states in the Union have been able to accept the medical use of marijuana and establish their own state-regulated Medical Use of Marijuana Programs, without legal challenge from the U.S. Department of Justice (DOJ). In fact, in Gonzales v. Oregon (2006), the Supreme Court confirmed the state’s right to accept the medical use of controlled substances by finding that the DEA does not have the authority to deny a standard of medical care that is accepted under state law. ^[6]

This is especially significant when such state-accepted medical use involves a Schedule I controlled substance, as in the case of cannabis, since such accepted medical use has a direct impact upon federal scheduling, a consequence that Congress was well aware of when it created the federal Controlled Substances Act in 1970 and provided a mechanism for states to affect changes in federal scheduling by means of the term “currently accepted medical use in treatment in the United States.” ^[7]

The Rhode Island-Washington Marijuana Rescheduling Petition failed because the governors of those states relinquished their state’s authority to accept the medical use of marijuana. By requesting a specific schedule change based on a scientific argument, they merely gave the DEA another chance to break out the 5-part test of “medical use” (that it solely created in 1994 after two prior attempts at defining such use, and before any state had accepted the medical use of marijuana). ^{[8][9][10][11]}

Think of it this way, a landlord asks a tenant who is in default if he is going to honor the agreement they entered into wherein tenant agreed to pay a set rent each month. Such an approach would most likely be fruitless. The landlord would be better served by giving the tenant notice that rent is due, and then pursuing court action if tenant continues to ignore the agreement. Similarly, those states that have accepted the medical use of marijuana should give the DEA notice that marijuana has accepted medical use and needs to be removed from federal Schedule I.

We need to approach this as a matter of law, not science. Given the DEA’s continued inaction regarding the medical use of marijuana, one solution for the current situation is for those states that have accepted the medical use of this substance to first make sure that marijuana is properly placed in a state schedule that recognizes its state-accepted medical use; and then give notice to the DEA that marijuana has accepted medical use and that its placement in federal Schedule I no longer applies. Such action by the states would demonstrate that they are doing their part to protect their state’s accepted medical use of marijuana, so that ultimately patients can be properly served and no longer placed in jeopardy by the violation of federal law.

To make this happen everyone needs to get involved — contact your state legislators and executive officials to take action.

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North Carolina GOP Office Damaged by Firebomb

http://www.wsj.com/articles/north-carolina-police-say-gop-office-damaged-by-fire-graffiti-1476649527

The Republican headquarters in Orange County, N.C., was firebombed and sprayed with graffiti overnight, local officials in the town of Hillsborough said Sunday.

Flammable material contained in a bottle was thrown through the front window of the GOP headquarters, according to a release from town officials. The graffiti, which was spray painted in black on an adjacent building, included a swastika and the words “Nazi Republicans leave town or else.”

Furniture inside the office was burned by the fire, which also damaged the structure’s interior before going out on its own, town officials said.

Local police and the Bureau of Alcohol, Tobacco, Firearms and Explosives were investigating the incident.

“This highly disturbing act goes far beyond vandalizing property; it willfully threatens our community’s safety via fire, and its hateful message undermines decency, respect and integrity in civic participation,” Hillsborough Mayor Tom Stevens said in a statement.

State Republicans decried the incident, saying they would be calling for additional security at Republican Party offices and events between now and Election Day.

“Whether you are Republican, Democrat, or Independent, all Americans should be outraged by this hate-filled and violent attack against our democracy,” said Dallas Woodhouse, executive director of the North Carolina Republican Party in a statement.

Democratic presidential candidate Hillary Clinton and state Democratic officials also condemned the attack.

“The attack on the Orange County HQ @NCGOP office is horrific and unacceptable,” Mrs. Clinton tweeted. “Very grateful that everyone is safe.”

“We hope the perpetrators of this attack are brought to swift justice, and we are thankful that no one was hurt,” said North Carolina Democratic Party Chairwoman Patsy Keever in statement.

Write to Dan Frosch at dan.frosch@wsj.com

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Another disclosure by WikLeaks revealed that Hillary Clinton’s opinion on legalizing Cannabis. It was revealed that she is firmly against it.

mirrorspectrum.com/info/wikileaks-clinton-told-wall-st-she-is-100-against-legalizing-cannabis#

Imagine this… another ATTORNEY that supports the position of the DEA… along with the 43% of Congress that are attorneys… as is Obama and AG Loretta Lynch.  In the last Presidential election there was 126 million votes cast and FIVE MILLION separated the winner from the loser and there was 106 million eligible voters – THAT DID NOT VOTE..  One can presume that Clinton will also support the rescheduling of Kratom to C-I and we know that she endorses the proposed prescription opiate tax by Senator Manchin of WV… to help fund the treatment of those suffering from addictive personality disorder. Of course, a lot of those people… do not want treatment… do not want to be sober.  Just like the 45 million Nicotine addicts and 35 million alcoholics.  Remember even though the number of legal opiate prescriptions PEAKED in 2012… the bureaucracy is still trying to connect the legal prescribing of opiates with the increasing number of OD’s from illegal drugs being imported from south of our border and China.  They refuse to acknowledge the facts… because it does not support THEIR LARGER AGENDA.  Just like they prohibit research on MJ, Kratom, long term opiate use… so any anecdotal information does not meet their criteria of double blind clinical studies and those clinical studies cannot be done… so benefit to the pts doesn’t exist.  The LACK of a positive is PROOF of a negative ??

WikiLeaks has been the most important thing that has happened to an election in a long time. We’ve been able to catch glimpses of the real nature of politicians and bureaucrats like never before, and see the state of democracy for what it is: a once mighty oak ravaged by white ants.

In Hillary Clinton, we see a figure beholden to Wall St., working diligently to advance the influence of financial corporations over government policy and taxpayer money. Her mega-donor list is a who’s who of megabanks that also happened to benefit from the TARP government bailout.

And in telling the Goldman Sachs banksters to chill out, cannabis won’t be legalized, she was providing music to the ears of the financial fat cats. Big Pharma, so desperate to suppress the truth about the medicinal value of cannabis in order to protect their profits, is a major part of Wall St.

In return for their money, Clinton gave speeches to Wall St. giants behind closed doors between 2013 and 2015. She told Goldman Sachs she was “far removed” from ordinary people and that “you need both a public and a private position.”

Clinton has vacillated terribly on the issue of the Trans-Pacific Partnership (TPP), which is a gift to her donors but very unpopular to Americans who see it for the fleecing it is. She was for TPP before she was against it – a familiar descriptive.

As Bernie Sanders pointed out during the primary – where he was efficiently neutralized by the establishment – the only thing we know about Clinton is that she will be on the side of Wall St.
If Clinton supporters believe she will do anything about government’s war on cannabis, they should think again.

The good people at Marijuana.com have been studying the leaked emails, and during one of those Wall St. speeches, Clinton expressed a clear opposition to cannabis legalization.

“During an on-stage Q & A session with Xerox’s chairman and CEO in March 2014, Clinton used Wall Street terminology to express her opposition to ending cannabis prohibition “in all senses of the word”:

URSULA BURNS: So long means thumbs up, short means thumbs down; or long means I support, short means I don’t. I’m going to start with — I’m going to give you about ten long-shorts.

SECRETARY CLINTON: Even if you could make money on a short, you can’t answer short.

URSULA BURNS: You can answer short, but you got to be careful about letting anybody else know that. They will bet against you. So legalization of pot?

SECRETARY CLINTON: Short in all senses of the word.”

The exchange with Burns is part of an 80-page document containing the emails of John Podesta, her campaign manager. Campaign staffers have been working diligently to try and scrub embarrassing parts of the speeches, and this was one of them.

As Tom Angell points out:

“That the campaign flagged the candidate’s opposition to legalization as a potential problem demonstrates a growing understanding by political operatives that marijuana law reform is now a mainstream issue, one which is supported by a majority of Americans and a supermajority of Democratic primary voters.”

As with so many other issues, it’s hard to tell from Clinton’s public statements exactly where she stands – unlike Sanders, who openly supports legalization and even introduced a bill to end federal prohibition.

Since that exchange with Burns in 2014, Clinton has acknowledged the medical value of cannabis and indicated she would let states do their own thing, and even said cannabis should be rescheduled under the Controlled Substances Act.

However, she adopts a ‘cover your ass’ approach by saying “I don’t think we’ve done enough research yet” and “I want to wait and see” what happens in states with recreational legalization.

This is not in line with the truth becoming exponentially obvious – that denying medical cannabis to suffering patients is a criminal act, and prohibiting a plant that people have used for thousands of years is oppression.

Clinton had no problem making it clear to a Wall St. corporation that she is against legalization, but why?

Perhaps because the pharmaceutical industry is a major part of Wall St., and they are desperately fighting ballot initiatives to legalize cannabis in several states, as it represents a direct threat to their profits.

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Heart Drugs May Affect Mood

http://www.pharmacypracticenews.com/Clinical/Article/10-16/Heart-Drugs-May-Affect-Mood/38254

Those with chronic pain have twice the rate of suicides than the rest of the population… and this study suggests that prescribers that under treat chronic pain that causes elevated blood pressure and elects to treat the hypertension… may be causing a higher probability of suicide by the pt. And the Hippocratic oath states FIRST DO NO HARM…

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Woman sues Memorial Hospital in Colorado Springs, claiming it discriminated against her because of a disability

http://www.denverpost.com/2016/10/14/university-of-colorado-hospital-disability-discrimination-lawsuit/

A physician diagnosed with fibromyalgia has sued Memorial Hospital in Colorado Springs claiming a doctor discriminated against her because of her disability.

The civil rights lawsuit was filed in Denver U.S. District Court on Thursday on behalf of Dr. Elena Sumler by Arvada attorney Ralph Lamar. She is seeking back pay, including lost fringe benefits, compensatory damages, future lost wages and attorneys fees.

“Providing the very best patient care is the top priority at Memorial Hospital and throughout the UCHealth system of hospitals. We cannot comment on potential litigation,” hospital spokesman Dan Weaver said in a statement on Friday.

According to the Mayo Clinic, fibromyalgia is a disorder “characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.”

Sumler filed a discrimination claim with the Equal Employment Opportunity Commission on Dec. 31, 2014, and received a “right to sue” letter on Sept. 29, the lawsuit says.

Sumler was trained as a pediatrician and gastroenterologist in Russia and met her husband when he was stationed in Korea. They married and she became a U.S. citizen in 2005 and moved to Colorado in 2010, according to the lawsuit.

A.S.A.P. Laboratories hired her as an emergency on-call sonographer in 2013. She was laid off in September 2014 when the company lost its contract.

Memorial Hospital offered her a position as an ultrasound technician the following month. The offer was contingent on her answering a health questionnaire.

“(She) did so even though it was clearly unlawful in that it asked questions about her health that were not pertinent to her ability to perform in the position,” the lawsuit says.

She disclosed in the questionnaire that she suffered from fibromyalgia and took prescription medications for the disorder, the lawsuit says.

It was explained to her that she would then need to speak with Dr. Henry Roth. He told her on Oct. 30, 2014 that “because you use narcotics you can’t work in the hospital.” Roth did not examine Sumler or ask her how she moved or felt, the lawsuit says. Roth said he would consult with an attorney.

Sumler explained that she takes medications prescribed by her doctor, had no adverse side effects that would impair her ability to work and that she had worked the past 18 months without any problems, the lawsuit says.

Roth conferred with Sumler’s physician, Dr. Joseph Brooks, who told Roth that Sumler “was in good shape, active and had no physical limitations that would interfere with her ability to perform the job of ultrasound technician,” the lawsuit says.

She was examined and given a drug test by the Occupational Health Clinic on Nov. 5, 2014. The next day, Roth told Sumler once again that she couldn’t work at the hospital because of the narcotics she took.

He refused to answer any further questions, including whether he had consulted with an attorney, the lawsuit says.

“Dr. Roth got angry and said it was not his responsibility to do so and would not continue the conversation,” the lawsuit says.

Sumler then received Roth’s medical report indicating several functional restrictions and range of motion limitations, even though he had never read her medical records and had not done an actual physical examination, the lawsuit argues.

Roth had never told her about the limitations so there had never been any type of “reasonable accommodation” for her disability discussed, the suit says. He conducted no tests to see what she could actually lift or move as a result of a “functional capacity evaluation.”

“Dr. Roth’s ‘visual examination’ of plaintiff and the concomitant physical restrictions he issued was a sham,” the lawsuit says. “Dr. Roth’s contention that he has the ability to note plaintiff’s functional limitations without even asking her to undergo a range of motion exam, or to otherwise physically examine her, is without any scientific support.”

She called an official in the hospital’s human resources office and a week later was told her job offer “had been rescinded,” the lawsuit says. She called the hospital recruiter back and was told her health screen was unsuccessful.

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Cigna Accused Of Cheating Prescription Drug Buyers

http://www.courant.com/news/connecticut/hc-prescription-benefit-class-action-1015-20161014-story.html

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Medicare unveils far-reaching overhaul of doctors’ pay

http://hosted.ap.org/dynamic/stories/U/US_MEDICARE_OVERHAUL?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2016-10-14-09-09-49

WASHINGTON (AP) — Changing the way it does business, Medicare on Friday unveiled a far-reaching overhaul of how it pays doctors and other clinicians.

The goal is to reward quality, penalize poor performance, and avoid paying piecemeal for services. Whether it succeeds or fails, it’s one of the biggest changes in Medicare’s 50-year history.

The complex regulation is nearly 2,400 pages long and will take years to fully implement. It’s meant to carry out bipartisan legislation passed by Congress and signed by President Barack Obama last year.

The concept of paying for quality has broad support, but the details have been a concern for some clinicians, who worry that the new system will force small practices and old-fashioned solo doctors to join big groups. Patients may soon start hearing about the changes from their physicians, but it’s still too early to discern the impacts.

The Obama administration sought to calm concerns Friday. “Transforming something of this size is something we have focused on with great care,” said Andy Slavitt, head of the federal Centers for Medicare and Medicaid Services.

Officials said they considered more than 4,000 formal comments and held meetings around the country attended by more than 100,000 people before issuing the final rule. It eases some timelines the administration initially proposed, and gives doctors more pathways for complying.

The American Medical Association said its first look suggests that the administration “has been responsive” to many concerns that doctors raised.

In Congress, staffers were poring over the details. Rep. Tom Price, R-Ga., who worries that Medicare’s new direction could damage the doctor-patient relationship, said he’s going to give the regulation “careful scrutiny.” Sen. Orrin Hatch, R-Utah, chairman of a panel that oversees Medicare, called it an “important step forward,” but said the administration needs to keep listening to concerns.

MACRA, the Medicare Access and CHIP Reauthorization Act, creates two new payment systems, or tracks, for clinicians. It affects more than 600,000 doctors, nurse practitioners, physician assistants and therapists, a majority of clinicians billing Medicare. Medical practices must decide next year what track they will take.

Starting in 2019, clinicians can earn higher reimbursements if they learn new ways of doing business, joining a leading-edge track that’s called Alternative Payment Models. That involves being willing to accept financial risk and reward for performance, reporting quality measures to the government, and using electronic medical records.

Medicare said some 70,000 to 120,000 clinicians are initially expected to take that more challenging path. Officials are hoping the number will quickly grow.

Most clinical practitioners – an estimated 590,000 to 640,000 – will be in a second track called the Merit-Based Incentive Payment System. It features more modest financial risks and rewards, and accountability for quality, efficiency, use of electronic medical records, and self-improvement.

Finally, about 380,000 clinicians are expected to be exempt from the new systems because they don’t see enough Medicare patients, or their billings do not reach a given threshold.

“Half of the physician practices under 10 (doctors) will not be reporting at all,” said Slavitt. Initially more doctors would have been covered.

Advocates say the new system will improve quality and help check costs. But critics say complicated requirements could prove overwhelming. The administration says some doctors will be pleasantly surprised to find out that reporting requirements have been streamlined to make them easier to meet.

With 57 million elderly and disabled beneficiaries, Medicare is the government’s premier health insurance program. The Obama administration has also been working to overhaul payment for hospitals and private insurance plans that serve Medicare beneficiaries. The unifying theme is rewarding quality over volume.

While some quality improvements have already been noted, it’s likely to take years to see if the new approaches can lead to major savings that help keep Medicare sustainable.

John Feore of the consulting firm Avalare Health said it appears many doctors are still unaware of the magnitude of the changes ahead.

“MACRA is a huge change in how physicians are paid, and there is a wide spectrum on whether they are ready,” said Feore. “By providing some options and a transition over a year or two, the (administration’s) intent is to allow them to get comfortable.”

Medicare also launched a new website with interactive features aimed at educating doctors about the changes.

Medicare’s previous congressionally mandated system for paying doctors proved unworkable. It called for automatic cuts when spending surpassed certain levels, and lawmakers routinely waived those reductions. MACRA was intended by lawmakers as a new beginning.

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More Than 1 Million to Lose Obamacare Plans as Insurers Quit

Sign-ups for Obamacare coverage begin next month. Fallout from the quitting insurers has emerged as the latest threat to the law, which is also a major focal point in the U.S. presidential election. While it’s not clear what all the consequences of the departing insurers will be, interviews with regulators and insurance customers suggest that plans will be fewer and more expensive, and may not include the same doctors and hospitals.

It may also mean that instead of growing in 2017, Obamacare could shrink. As of March 31, the law covered 11.1 million people; an Oct. 13 S&P Global Ratings report predicted that enrollment next year will range from an 8 percent decline to a 4 percent gain.

Vanishing Plan

Last year in Minnesota, Theresa Puffer, 61, used Obamacare to sign up for a BlueCross BlueShield plan after leaving her job following a skin cancer diagnosis. “I would have had a hard time finding any sort of coverage before the ACA,” Puffer said by phone.

Next year, Puffer’s plan is disappearing from Obamacare — making her one of about 20,000 Minnesotans in the same situation. To make matters worse, premiums for other plans in the state will rise by at least 50 percent, though subsidies under the law can help cushion the blow.

“Trying to determine which would be the best plan for my situation is not easy,” Puffer said. Her dermatologist appears to be out of network in other plans, she said. “I’m willing to pay a higher premium to see him, because when you have cancer you want to stay with the same group of doctors,” she said. “I’ve spent so much time trying to figure out what my options are.”

Bloomberg contacted officials in all 50 states and Washington, D.C., and the 1.4 million-person estimate includes 32 states and only plans sold on the individual “exchange” markets. In Texas, Arizona, Georgia and Missouri, insurers have pulled out, but regulators couldn’t or wouldn’t say how many people are affected. Three states didn’t provide sufficient data.

Eleven states said they weren’t affected. In Washington, D.C., because one insurer withdrew some of its offerings, about 7,800 customers will need to choose new plans.

Normal Disruption

The U.S. agency that oversees Obamacare has said that some disruption is normal, and that choosing a new plan can help people get the best deal.

“It’s part of the normal business cycle for insurers to discontinue, change, and replace plans from year to year,” Benjamin Wakana, a spokesman for the Department of Health and Human Services, said by e-mail on Oct. 5. “Such changes don’t prevent people from obtaining coverage. People can shop for new coverage through a transparent market.”

HHS said Thursday that it will contact people losing their coverage and encourage them to sign up with new plans. The law requires all Americans to have insurance or pay a fine.

Nationwide estimates of the number of people losing their current plans are higher. For example, Charles Gaba, who tracks the law at ACASignups.net, estimates that 2 million to 2.5 million people in the U.S. will lose their current plans, compared with 2 million a year ago. Gaba’s estimate is based on insurance company membership data.

Fewer Choices

For the people losing plans, there are fewer and fewer choices. One estimate by the Kaiser Family Foundation predicts that for at least 19 percent of the people in Obamacare’s individual market next year there will be only one insurer to choose from.

In North Carolina, for example, a BlueCross BlueShield insurer will be the only option in 95 of the state’s 100 counties after Aetna and UnitedHealth said this year that they would leave. That will leave 284,000 people looking for a new plan, according to the state.

“Without any significant statutory and regulatory changes on the federal and state levels, we may face the crisis again,” said North Carolina Insurance Commissioner Wayne Goodwin, a Democrat who’s up for election this year. “There needs to be a wholesale re-evaluation by leaders in Washington.”

Losing Access

In Tennessee, UnitedHealth and the state’s BlueCross BlueShield plan are pulling back, and about 117,000 people will lose the plans they have now.

Amanda Page Cornett, a 34-year-old musician and athletic trainer in Nashville, is among them. For 2015, Cornett was careful to pick a BlueCross BlueShield plan that covered specialists at Vanderbilt Health, to treat nerve pain stemming from a 2013 accident. Her condition worsened recently, she said, and she’s worried about losing access to her doctor.

“I’m hopeful that he’s going to be able to help me,” she said of her current physician. “I feel like now I have two and a half months to figure it out before they shut me out.”

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