The Private Sector vs The Government in Health Care

One of the core Republican Tea Party tropes is that "Government cannot do anything right; the private sector, motivated by profit and competition is always more efficient and effective."

Obamacare's troubled roll out has played into this cant, and Republicans have been frothing and delighted.

The problem is, the profit motive is not always the most functional motive: Consider medicine.

In medical school, nascent doctors are taught relentlessly what constitutes good medicine: Every medical student admits patients to hospital and each new patient begins a series of quality control exercises, as the student presents the case to the ward attending and to each attending who visits the patient from each specialty. So a diabetic admitted for chest pain who is found to have an infection of his big toe will get seen by the ward attending, the attending cardiologist, the attending infectious disease faculty. Every chart note the student writes, every presentation he makes is reviewed by his intern, his resident, his attending, the specialists, the faculty member who hears the case presented at morning report. Feedback is critical, constant, valuable. 

You learn, through this process to judge quality: the infectious disease consult who sees the patient for his toe infection should cut away the dressing from the toe, inspect it daily, to see how it is healing or not.  Some attendings are lazy. They don't remove the bandage, which often takes time to search for the nurse for a kit to use and then to rewrap. Some never fail to examine the toe. That is quality care. The doctor who does not unwrap the toe may miss the fact the antibiotics he has ordered are not working.  He may save time by not unwrapping, and he may be able to see twenty five patients on his rounds, and bill and profit more than the plodding doctor who does it right, but the rapid moving, lazy doctor is not practicing high quality medicine. The doctor who sees fewer patients, unwraps every toe, bills less, but does more good.

Mad Dog has worked for medical care organizations in which the work the physicians do is never reviewed for quality by another doctor. No chart note is ever read, not case is ever required to be presented. No conference to review performance is ever done. The only metric that matters  in such organization is the metric of dollars in and dollars out. When contract renewal negotiations occur, there is never a mention of whether you unwrap toes, examine hearts or lungs because the contracts are negotiated by MBA types, not doctors. And the MBA types don't have any mechanism to check which of the doctors they are negotiating contracts with are practicing low quality medicine and who is high quality. But those MBA's can add up dollars just fine.

There is a big push in medicine now for "quality metrics" which often means some easily quantifiable thing which can be collected easily, with a minimum of effort, by an entry level staff person and plugged into a spread sheet. The glycohemoglobin fits all these criteria.  It is a number which tells how high the blood sugar as been for the past three months.  Want to know if a doctor is good at treating diabetes? Add up all his patients' glycohemoglobin, divide by the number of patients and presto: Quality assessment.

The problem with such easy metrics is they can always be gamed. They invite gaming.  So the organization announces you will be judged by glycohemoglobins: What to do?  Well, first fire all your overweight, non compliant, under performing patients. Or send them to some other doctor, an endocrinologist or a nurse practitioner; let someone else carry these neer do wells. Keep all your thin, compliant diabetics with their good glycohemoglobins and you look great. 

The problem with this good assessment of diabetic control is that it attributes to the physician the entire burden of the outcome. Doctors may find themselves in the same position as  teachers in the South Bronx, the poor  scores of their students do no mean they are bad teachers; these teachers are not working with cooperative subjects. Doctors who work with patients who cannot or will not do the things they need to do to control blood sugar, who are judged by poor results,  know they can do nothing to affect those results. So they will game that system.

All this is happening because the wrong people have been given the task of judging doctors. MBA's can only judge how much money the doctor brings into the coffers.  CPA's and economists might dream up a metric or two which sounds reasonable, but they cannot see where the metric fails and how it can be gamed. 

Health care systems, whether they are for profit corporations, or "voluntary hospitals" are all failing in the same way: They have excluded the very people who can judge the work of the doctors in the system, namely other doctors. 

The emergence of the profit motive as the driving force in medicine, combined with the flight of doctors from being independent shop keepers to hired help has meant the culture of business has, by default, assumed control of the way doctors are evaluated, paid and ultimately what kind of quality they provide their patients. 

Next time some Republican says,  "Keep your government hands off my Medicare, get the private sector control of medicine, let the profit motive prevail,"  just tell them government may not be as efficient as we'd like, but it is still worlds better than profit driven private companies. At least the government has the motive of providing good health care. The company cares only about the bottom line.

Much as doctors love to complain about Medicare, they mostly agree Medicare generally does what is best for the patient.  The private insurance company will deny a diagnostic test for its customer, knowing that two years later the patient may be much sicker because the diagnosis was missed. But, two years later the customer will likely have another insurance company, and paying for his illness will be that company's problem. Medicare knows they are stuck with every patient for life. 

So Medicare will pay for a pair of shoes designed to prevent ulcers on the feet of diabetics. The shoes may cost $100 a year. A single visit to the ER for a foot ulcer is $500. Medicare makes the investment because keeping the patient out of the hospital is cost effective. The private insurer is hoping to keep the patient out of the hospital only for the term of the policy. 

Democracy may be the worst form of government ever devised, as Churchill noted, except for all the other forms of government which have ever been tried. The same may be true of government guided medicine--the worst form of management except for all the other forms which are currently out there.

The Constitution Is Only A Rough Draft

A Well Regulated Militia

This week's New Yorker Jeffrey Toobin notes that the Constitution is America's Holy Book, that both conservatives and liberals avow they are the true defenders of the founding fathers' holy words and their opponents are trying to thwart the intentions of those divinely inspired, bewigged 18th century gentlemen (and they were none of them peasants) who assembled in Philadelphia. 

In fact, as a law  professor named Sanford Levin has pointed out, the document set forth a plan which was a political compromise, with morality often absent, to wit, the enshrinement of slavery (with slaves, referred to as "other Persons").

In many ways, the political compromises which were made in the late 1700's still thwart us today:  A representative democracy, if that's what we are aiming for, should, ideally, represent the people who live in the nation rather than some artificial constructs, which are, after all, what states are. (There is a wonderful book about how states got their boundaries, and if ever you doubt the artificiality of states, read that.)

The notion of states ultimately stood in for real divides among the people of the nation:  In the 1800's states which raised cotton and kept slaves were different from states which did not. Today, there are rural to wilderness states with few people but lots of land and resources, and it is the people who control those resources and that land which get a commanding voice in the U.S. Senate. 

The idea, expressed by Orin Hatch of Utah, that the populous states of California and New York could rule Utah, Wyoming and Montana is horrifying to the people living in those states, who believe only they should control the water, the gold, the silver, the gas and oil on their "property." And that's, in essence, the idea of a state, the people in that geographic area have fenced off the land as "ours" and everyone else is trying to take their rights to use that land as they see fit. 

Toobin notes that in 1787 Virginia, the largest state, had eleven times the population of Delaware, the smallest. Today, California has seventy times more people than Wyoming. And yet, the people of Wyoming get to control resources, get to align themselves with other wilderness states to prevent meaningful gun control. 

If Mad Dog had his way, and if we really decided we need states, he would create a single state out of Montana, Utah, Wyoming, Idaho, Nevada. The Northern Virginia suburbs of Washington, D.C., and a part of Maryland from those suburbs up through Baltimore would form another. Upstate New York would become part of Vermont, and populations which share common concerns and problems would be bound together.  This would likely mean retrenchment every twenty years, but at least we could avoid the absurdity of Albany, New York controlling New York City.

If state boundaries were eliminated tomorrow, if we all became simply "Americans" then we could people in Idaho, they do not have a right to their AK 47 attack rifles and grenades.  

But Delaware, Rhode Island and likely Vermont and New Hampshire might not have joined the union if people in those states, who thought of themselves as being from those states, were told they would be represented according to their numbers rather than according to  their property.

In fact, those hallowed founding fathers did not trust the hoi polloi to govern themselves, so they created a Senate which could be controlled by the landed gentry, the wealthy and the well connected, and which could nullify whatever the rabble in the House of Representatives tried to enact as law.

We are not, and were never intended to be a democracy. "This has never been a democracy. This is a representative republic, with heightened democratic principles," Orin Hatch says. 

Through time, the revered checks and balances have thwarted change: For part of our history it was the Senate, which blocked emancipation of the slaves, then civil rights, then Clinton's health care reform.  Then there was the Supreme Court, which confirmed slavery in the infamous Dred Scott case, and which blocked changes to Jim Crow and recently made stealth political contributions a protected form of free speech. 

The government, as our founding fathers handed it to us was designed to accomplish little. That's what "checks and balances" is all about. 

That is why the Tea Party canonizes the founding fathers. If you believe government is bad, if you believe that government is best which governs least, well then, the Constitution is your Bible and Thomas Jeffferson and his fellow slave holders your apostles. 

All Men Created Equal. Except the Slaves

That may have worked well in the 18th century, when there was really very little which any government could do for its people other than to tax and wage wars against other governments. There were no medical schools to fund, no hope of curing cancer or infectious disease, no way of  doing any meaningful public health. They could build roads, locally, but there were no bulldozers, no bridges which could span large rivers, and no airports, no need for air traffic control. There were no automobiles to power with gas lines, and no internet, no computers, no mass communications beyond newspapers, no telegraph, no railroads, no labor unions (although we may soon join the 18th century in that respect) no hospitals which we would recognize as hospitals, no real pharmaceutical industry, no public education, and the few universities which did exist taught mainly Latin, Greek and theology. 

The men who signed that parchment with quill pens did make a giant leap in thinking: They recognized the idea you needed a king to govern was absurd. But then, they had seen England's Parliament.  They were, for the most part, ordinary men of their times, who found some extraordinary men, like Franklin, Jefferson, Adams, Madison and Hamilton to lead them.  What they cobbled together almost fell apart because they had sewn their fabric with the poisoned threads of slavery, states rights, property, male dominance, class suppression, aristocracy and indentured servitude. 

Lucky for us, Abraham Lincoln found his voice and his chance.

President Obama has been hamstrung by what those dead white men left him. 

So have we all.

Obamacare Takes Root

Norman Rockwell

This morning, NPR aired a story following a thirty-something man as he  tried to work through the Obamacare website. NPR followed him through his first frustrating encounters, then as he gradually wended his way through the web, and finally as he discovered a plan which would work for him. The plan costs about $180 a month, more than $200 a month less expensive than his current plan and it covered his prescriptions, had minimal co-payments and deductibles and was overall way better. In the end he phoned the insurance company, Unity, which would be his new insurer and they confirmed the good news, which he could hardly believe.
"The really funny part, " he said in the end, "Is that it was Unity which rejected me a year ago, because I'm diabetic. Now they are giving me way better coverage at a fraction of the cost."

Family Plan

This, of course, is an anecdote. It's the kind of reporting that is easier because you do not have to fight through statistics and computer screens and try to draw conclusions which are supported by statistics. And, as they always say in journalism, it's got the "human dimension." You can follow the individual. The problem is, how do we know whether or not that individual is representative of a larger trend?

If he is, then the Republican party, and people like Fred Rice and Nancy Stiles should, eventually be in big trouble, if voters remember how they tried so hard to prevent this leap forward in healthcare. 

Of course that's a lot of "if's."  If Obamacare works this well for the millions. If voters remember who tried to prevent it and who made it happen.  If voters go to the polls.

John Singer Sargent 

But, if this sequence occurs, it will be good for a lot of people, and it will be a huge step forward for the nation. 

Fried Rice

"We face a $17 trillion federal deficit and $128 trillion in unfunded liabilities. Continuing to look to Washington as a bottomless pit of money that we can draw on just by complying with increased federal conditions is irresponsible and leads to greater dependence on government for everything in our lives."

--Fred Rice, Republican Delegate House of Representatives, New Hampshire

Whenever people start throwing around big numbers, you can be pretty sure they have no idea what they are talking about. When they talk about thousands, they may have some inkling; millions, they are in a fog; billions, they are listening to someone else; trillions, they haven't the faintest idea.  There is a strong inverse correlation between large numbers and solid evidence.

--Mad Dog, Hampton New Hampshire Democrat

Fred Rice voices the standard Tea Party Republican tripe when he says we cannot afford Medicaid for our New Hampshire citizens, and we cannot afford health care for our nation. The line is so old  and wrong it is like a worn out pair of shoes: leaky, inadequate, but  comfortable.

Here's how it goes:  We are spending more money than we can afford. This will result in catastrophe, not necessarily today, but tomorrow, when the bill comes due.If we agree to this Medicaid thing, then we will be involving ourselves more with the federal government, and that is always bad. The federal government is bad. Government is bad. Someday, when the bill comes due, we will be owned by the Chinese, and our grand children will have to learn Chinese. They will be working for Chinese companies, living in dormitories next to the factories and they will live in a soulless country where there is no free market. Government spending is always bad. If we had only not spent government money during the Great Recession, we'd be oh so much better off. General Motors would have gone bankrupt, but that would have only hurt the unions, so that would have been a good thing.

One advantage of mouthing this line is that it is easy to remember and it never changes and it sounds homey and has the ring of truthiness.

Only problem is, it is total rubbish.

We have the money.  Medicare is not,  and never has been,  and in the foreseeable future will not be in economic trouble. Social Security is not in danger of default, unless the Republicans drive it in that direction. Medicaid will not bankrupt the state of New Hampshire, especially given the federal government's generosity when it comes to this program. (Of course, Mr. Rice knows the federal government is just trying to trick us into taking part in this program so it can control us later.)

What Mr. Rice and his Republican colleagues really fear is not that Medicaid will hurt New Hampshire, but that New Hampshire will come to love Obamacare as much as it loves Medicare, and maybe, just maybe, New Hampshire voters will remember who tried to give them health insurance and who tried to stand in the way.

Remember, expanding Medicaid is not a way to help the few, but the many. The reason we worry about denying Medicaid to fellow citizens is not because we care so much about those who need Medicaid. What we really care about is if we don't insure those Medicaid eligible people, they will go to the Emergency Rooms, where they will run up the bills for all the rest of us. 

As for Mr. Rice, as an example of a specimen of this Republican species, we must always remember that Mr. Rice has (and continues) to insist that building a motorway along the abandoned railroad line between Hampton and Portsmouth would be better for the environment than building a bicycle path.  You see, Mr. Rice informs us, the new two lane road would reduce traffic along Route 1, and with fewer cars, there would be fewer cars idling their motors at traffic signals and that would reduce emissions and seacoast air would be cleaner.  So there you have it: Worried about air pollution? Build roads.  Build roads and the roads will carry fewer cars. (If you build it, they will not come. Roads are good. Roads do not simply fill up with more cars if you build them--they empty out.)

Mr. Rice is probably not, at heart, a bad sort. It is true, he voted for lowering cigarette taxes because his unfailing economic compass told him if we lower taxes we could sell more product and if we sold more product, even at a lower price, we'd make more money. When confronted with the question about why we tax cigarettes, what we hope to accomplish, he looked like a deer in the headlights. Why? To make money, of course. But do we not hope to diminish the use of cigarettes by taxing them? Are we not concerned with the health of the citizens of New Hampshire?  Well, Mr. Rice replied, what we are really going to see is all those Massachusetts residents will drive across the border for the cheap cigarettes. So, Mr. Rice was asked:  "Are we trying to export our lung cancer to Massachusetts?"

Mr. Rice replied, "Well, cigarettes are legal aren't they?"

Fellow citizens of Hampton, do we not have a single human being willing to stand in the next election against Mr. Rice?  Can we not rid our town of this vexatious priest of Republican obtuseness? 

The man, plainly put, is an embarrassment. And he represents Hampton! People up there in Concord must look at him, listen to him and say, "Do they still have lead in the drinking water in Hampton?"

Ms. Liasson, Mr. Obama and Death by A Thousand Cuts

Mara Liasson first grabbed Mad Dog's attention during the 2008 Presidential campaign, when her pieces for NPR got Mad Dog frothing at the mouth and in risk of being taken away by the Humane Society as a rabid canine.

What she would do was subtle, but effective. A piece about Sarah Palin would have several extended clips of Ms. Palin delivering zinger after zinger, invectives against Mr. Obama and, with five seconds left, Ms. Liasson would  squeeze in, dismissively, a  terse summary of what Mr. Obama had said in response. So it would go something like this: 

  Sarah Palin clip:  "Senator Obama has insulted not just every soccer Mom in this great country of ours, but he has betrayed his own sexist attitudes about women when he snidely said you can put lipstick on a pig but it's still a pig. Well, I don't think I resemble a pig, and that's unworthy of a serious candidate for President of this great country of ours."
  Ms. Liasson:  "Mr. Obama replied Governor Palin had used the lipstick imagery first, so it was fair game."

And so on.

Over the past five years, Ms. Liasson's  antipathy toward the President has become increasingly apparent.  Now is a slow news stretch with Congress on recess,  and when dead calm strikes, reporters start interviewing each other.  Ms. Liasson was asked to comment on what the Obamacare website fiasco means for Mr. Obama's Presidency and Ms. Liasson told her NPR listeners:
1. Mr. Obama's "signature" (read that as "only") accomplishment has been the passage of the health care law.
2. The law is now moribund, owing to the catastrophic breakdown of its website.
3. Mr. Obama's Presidency will never recover from this blow.
4. He has nobody but himself to blame because this is simply a matter of incompetence. 

President Obama, one might conclude listening to Ms. Liasson, may as well pack it in.  He has been a thoroughly worthless President and he should resign in disgrace. 

During the last Presidential debates, Mr. Romney informed Jim Lehrer that as President Mr. Romney would defund public television and public radio because it is anti-American for the government to spend money on things the private sector can do. 

Apparently, National Public Radio panicked. We need to appease those conservatives, who think we are a sort of Fox News for the left.  So, we'll put forward a few really rank conservatives and then we can claim we are "balanced."

Mad Dog has no problem with that. Just call a spade a spade. 
Just say:  "And here is NPR's answer to Rush Limbaugh: Mara Liasson." 
 

New Hampshire Medicaid: Chris Muns and Nancy Stiles

So here's the thing about Medicaid: Most people do not want to think about it.

Most people do not want to think about prisons, either.

These are things which happen to other people and we have enough to think about when it comes to things which might happen to our own selves.

So, when Obamacare (now the Affordable Care Act) gets passed, New Hampshire gets offered a lot of dollars if it will only sign on, but Republicans in New Hampshire, particularly Republicans in the Senate, like Nancy Stiles, see treachery in these dollars, and they know those are tainted dollars, dollars likely to lead us down some dark, sinister road to perdition. These are dollars with Democratic fingerprints all over them, and they vote to refuse the money, on principle. On the principle that no money from Democrats, even if it goes to New Hampshire citizens, can be good money.

But, as Mad Dog has said, Medicaid is  not something most people in New Hampshire care about, because Medicaid is for poor people, welfare queens, people who are not willing to work, people who would accept government charity, people who are lazy and undeserving. 

Even if all that were true, there is a problem with the Republican position: When those lazy, undeserving people get sick, they do what?  They go to...you guessed it, THE EMERGENCY ROOM.  And guess who pays for their care?  The deserving, upright, hard working citizens of New Hampshire. 

It's not a direct tax bill you see on April 15th, but that does not make it any less real.

Think on that, Granite staters.

As Chris Muns said, rather forlornly, after Nancy Stiles voted with her Tea Party friends to reject federal Medicaid funds, these Republicans don't care who they hurt, or how crazy their position is, from a public policy or public health viewpoint--they only care about an ideology:  Government is bad. Democrats are bad. Democrats handing out money is doubly bad. Bad. Bad. Bad. 

The question is, do the good folk of New Hampshire really want to be led by fundamentalists?  

Mad Dog and Marijuana

per

Mad Dog must admit, from the outset, he does not smoke marijuana, has never given it a fair try, has never smoked cigarettes, although he once tried and found the experience uninspiring, does not drink caffeinated drinks, cannot tolerate much alcohol, although he has tried to develop a taste for wine and beer, just cannot.

(In fact, Mad Dog married a Jack Mormon, whose entire family can regularly drink Mad Dog and all his relatives under the table.)

Having said all that, Mad Dog may not be qualified to say much about marijuana, but that will not keep him from trying.

Patrick Radden Keefe's article about Mark Kleiman and the legalization of marijuana in the state of Washington, which appears in the Nov 18 New Yorker, triggered a potent memory in Mad Dog.

Sometime in the mid 1990's Mad Dog received a notice to report to  the Rockville, Maryland Courthouse at  the Montgomery County seat for jury duty. Mad Dog's initial reaction was dread and anger: Mad Dog was in the private practice of medicine and if he were taken out of his office for a week he would have trouble meeting his payroll, his rent and his expenses, while most of the members of the jury pool would be getting a free holiday from their government and corporate offices. 

But when Mad Dog was seated for a trial the judge assured everyone this would be a one day trial and Mad Dog quickly became enthralled by the experience:  The defendant was seated at a table in the courtroom and the jurors filed in and took their places in the jury box. Mad Dog was the 13th juror, the alternate juror.

Looking around him at his fellow jurors, and then across the room at the defendant, Mad Dog could see immediately this defendant was marked as clearly "guilty" and stood next to no change of acquittal. The jurors looked much like Mad Dog, white, dressed in the wardrobe of  Ann Taylor, Brooks Brothers, Talbot's, Barney's--white bread through and through. Guido, the defendant hand been cleaned up for the occasion:  clean shaven,  dark slacks and a new, pressed shirt, but the clean up would not help Guido, whose dark, slicked back hair and Hispanic/Mediterranean features marked him as guilty, guilty, guilty.

The judge asked the jury if anyone knew of any reason he or she should not hear this case of the sale of marijuana. Mad Dog raised his hand and the judge told him to approach the bench and they turned on some white noise machine and the prosecutor and the public defender flanked Mad Dog as Mad Dog explained to the judge Mad Dog did not believe selling or using marijuana ought to be illegal.  The judge asked Mad Dog, "But if the state could prove to your satisfaction the defendant did in fact sell marijuana and that selling marijuana in Montgomery County is illegal, could you find the defendant had violated that law?"  Mad Dog had to admit, meekly, he could. That satisfied the prosecutor and Mad Dog was told to go take his seat. 

The only witness for the prosecution was a florid faced Montgomery County detective named O'Shaunessey (or something Irish) and he testified he had been sitting in his car, with a delicatessen sandwich on a waxed paper wrapper in his lap, looking through binoculars at the housing project buildings 150 yards away, across a playground and walkways. He was on a stakeout on a separate case, looking for some felon, when he saw a young man in a red tropical shirt drive up, park and start talking to Guido, who had been working with his brother, under the hood of his car. Guido reached into his pocket pulled something out and slapped the hand of the red shirted guy and Detective O'Shaunessey knew, from years of observation, he had just seen a drug deal go down, and the pass off of a packet of something illegal and the exchange, with another hand slap of cash. 

O'Shaunessey reached for his radio and rained down mayhem upon the playground and environs of this housing project,  as half a dozen Montgomery county police and detectives swarmed over the grassy knoll, guns drawn, brushing aside squalling infants, and young children, and their mothers and nannies, as they raced across the 150 yards, toward Guido, his brother and the unfortunate buyer in the Hawaiian Punch shirt. 

By the time the cops reached the scene of the crime, Guido had disappeared into his apartment building and the cops arrested his brother, who had just lifted his head from under the hood and was bewildered, thrown to the ground, arms pinned behind his back, handcuffed and told he had just sold some drugs to the tropical shirt felon.

Guido then emerged from his apartment and breathless cops realized they had arrested the wrong guy and they arrested Guido. It is not clear how long Guido's brother had his arms pinned behind him. 

Presented to the jury for their viewing pleasure and edification was the roll of cash found in Guido's pocket, the cell phone he carried. Guido had no drugs on his person. Hawaiian Punch had a packet of marijuana in his pocket.

The prosecutor held up the roll of cash and the beeper confiscated from Guido at the scene and said, "This money, this beeper, which is used by drug dealers to set up sales,  is all the evidence, taken with Detective O'Shaunessy's testimony, you need."

Now the beeper as an incriminating article struck Mad Dog as particularly bogus. Mad Dog ran an inner city clinic in Washington, D.C. and every 13 year old carried a beeper. Most of these beepers were not even operational--that would have meant a monthly bill and required a credit card. They were simply status symbols. If you had a beeper, you were cool, a player. The prosecution never even established Guido's beeper was activated. The roll of money, Guido's lawyer explained, was no crime, no indication of venality. Guido, like many project people, had no bank account, no checks and lived on a cash economy and the arrest occurred on a Tuesday afternoon, and Guido had just been paid.

Guido's public defender made one tactical error, by saying Guido had purchased the beeper because his girlfriend was pregnant and he needed to be reached when she went into labor, which suggested to the white, upper class Montgomery County jurors: A/ Guido had fathered a child out of wedlock  B/Guido did not live with the mother of his child and C/ Guido likely did not support the mother. D/ The mother was likely some 13 year old child, living with her parents, who would not allow Guido near her except for the event of the delivery, because they knew Guido was a no good scum bag, a point of view the jurors, at a glance, could readily understand.

To Mad Dog, if the story were true, it suggested at least Guido intended to do the puffing and panting with the mother of his child at the delivery.

Probably none of these assumptions was true.  But the fact all these assumptions were in play suggests an explanation why the vast preponderance of convictions for marijuana sale and possession occur among the underclass in America although the numbers of middle and upper class children and people who use the drug vastly outnumber those in the underclass who do.

After the testimony, the judge instructed the jury which rose to go deliberate in the jury room and Mad Dog prepared his impassioned argument for acquitting poor Guido,  when he heard the judge call his name and summon him to the bench. The judge said, "Those also serve who only watch and wait." And the judge dismissed Mad Dog, who would not be allowed in the jury deliberations with the 12 real jurors.

In the hallway, the prosecutor and the public defender collared Mad Dog to ask how he would have voted. Why these two were so interested escaped Mad Dog. But they were 20 somethings and they had done at least some work on the case, and it was a game to them and they wanted an early signal about who might win. 

"I'd have voted to acquit," Mad Dog told them. "The cops arrested the wrong guy initially which speaks to confusion about who actually saw what when. And no drugs were found on Guido. No packet was actually seen through the binoculars. In fact, the major risk to public safety that day was all the police with their fingers on their triggers, running around among a dozen children on the playground. If anyone should have been charged, it should have been O'Shaunessey for reckless endangerment."

The prosecutor told Mad Dog, the only other juror he had as a choice for  the 13th juror was someone who had been convicted of marijuana possession a decade earlier. So Mad Dog, even after his statement to the judge looked like a better bet. Even in that white bread county, they couldn't find 14 people who had never used or admitted to using marijuana. 
 

So Guido went down, found guilty, found guilty by a jury of his peers, convicted of selling a packet of marijuana, sent off to jail, missed the birth of his son, likely lost his job at Jiffy Lube. 

The whole concept of being tried by a jury of your peers, as Mad Dog understands it, arose in English law and was incorporated by the English colonists who wrote the American constitution. No peasant wanted to be judged by a jury of disdainful aristocrats who would not know about the status symbol value of a beeper (or its 18th century equivalent) among the peasants. But that jury of your peers thing has been perverted by the complexities of class and class resentment and disdain in America today. So the poor get tried in front of a jury of their betters and they get sent to jail more or less ruthlessly and ineluctably. 

Maybe he's moved to Washington State by now, where he would likely be arrested even today, for selling marijuana on the black market.  

As Keefe observed in the New Yorker:  "When legal marijuana goes on sale, sometime next spring, the black market will not simply vanish; over-the-counter pot will have to compete with illicit pot. To support the legal market, Kleinman argued, the state must intensify law-enforcement pressure on people who refuse to play by the new rules."

It's third season of the wire, coming to real life, where Major Howard Colvin's experimental "Hamsterdam" emerges on the streets of Washington state. As David Simon and the Wire ensemble so intricately and clearly showed, the results of drug legalization, even for the most benign drug, marijuana, will likely not be pretty and will create new problems. 

Hopefully, the new problems will be less damaging than the current problems. But watching that third season should be required viewing for legislators from New Hampshire to California.

It's all right there, in the good book called "The Wire," if anyone would actually brave up and watch it.