Rob Natelson: The Modern University: Giving Honors to the Dishonorable

If you want an illustration of what is wrong with higher education today, a good one is what I had to sit through when my daughter Deborah graduated a few months ago.

Deborah is a native Montanan, born when my wife and I lived in Missoula. She recently received her masters degree from the University of St Andrews in Scotland. (There’s no period after “St”—in keeping with British writing style.) The school is widely considered the best university in that country and one of the best in Britain. St Andrews also was the principal alma mater of the American Founder James Wilson, who was second only to James Madison in his imprint on the U.S. Constitution.

I was proud that Deborah was at St Andrews, and as a constitutional scholar I’m grateful to the university library for making James Wilson’s library records available to me.

But my view of St Andrews soured when I attended Deborah’s graduation ceremony: It was there that the school granted an honorary degree to Noam Chomsky, of all people.

Chomsky is an ultra-left, anti-American, anti-Israel crank. But his political views matter less than the fact that he’s a smear monger whose political statements bear tenuous, if any, connection to the truth. In case you think I say that only because I’m a conservative and he’s a leftist, then read how respected left-leaning scholars have assessed Chomsky.

For example, here is what Alan Dershowitz, the celebrated Harvard law professor, has to say. And the late Arthur Schlesinger, Jr., a committed liberal—and one of America’s most respected historians—was so disgusted with Chomsky’s misrepresentations that Schlesinger pegged him as an “intellectual crook.” Illustrative of Chomsky’s style is this attempt to smear George W. Bush with Nazism.

“Okay,” you might respond: “Was there anything Chomsky did that might justify the degree?”  Yes—long ago, he did distinguished work in linguistics. But the St Andrews faculty member who introduced him made it clear that he was being honored primarily for his politics.

“Okay,” you might add: “That’s only single example, and not even from an American school—so what?” Here’s so what: As Chomsky’s introducer pointed out, this was the 28th time a college or university gave Chomsky an honorary degree! (Chomsky’s Wikipedia biography lists more.) By comparison, the late Nobel Laureate Milton Friedman, one of the greatest economists of the 20th century, received 19. (And Chomsky is still alive, and probably will get more.) Among the American schools granting him their highest honors are such mainstream American institutions as the University of Maine, Georgetown, Amherst, Swarthmore, and the University of Pennsylvania.

You might well ask: “Why is a political figure whose tactics are so corrupt receiving any honorary degrees?” The answer lies in another kind of corruption: The political corruption that has deeply compromised our system of higher education, and renders it imperative that state legislatures couple any further appropriations with fundamental reforms.

Let Other States Experiment with Medicaid Expansion – Part II

Medicaid expansion is supposedly a no-brainer. It’ll provide insurance for a lot low income people. It’s free federal money. And it’ll create jobs and pump up local economies. So why are the 50 states almost evenly divided on whether to take this gift horse or send it out to pasture?

It’s because a lot of governors and legislatures have decided that at best the jury’s still out on whether expansion is a good idea; and more likely it’s a bad idea that will hurt many of the people it’s supposed to help and turn into an albatross around taxpayers’ necks.

I’m open to being proven wrong, but I agree with those who say that Medicaid expansion as laid out in Obamacare is both bad welfare policy and bad economic policy. It’s bad welfare policy because it shifts primarily young, able and to a large extent childless adults into a system with demonstrably inferior access to care, and then traps them there. Forty four percent of the newly eligible would be adults under the age of 34, and seventy five percent would be childless.[i] In addition, a fourth of all new enrollees would be dumped into Medicaid from private insurance plans that almost always provide better access to care than Medicaid.[ii] The difference is in having health insurance versus getting health care.

I have a fishing license. That gives me the right to stand in a river waving my fly rod around, but it doesn’t guarantee that I’ll catch any fish. Same goes for health insurance versus health care. Medicaid recipients encounter barriers to primary care at nearly twice the rate of those with private insurance.[iii] Because of this lack of access to primary care, they then show up in emergency rooms at rates nearly twice those of the privately insured, but sicker and much more expensive to treat.[iv] Shoveling well over 70,000 new Montanans into this system[v] while also decreasing provider reimbursements under Obamacare won’t make access to quality care any easier for these folks or for anyone else in the state.

Medicaid expansion is also bad economic policy. In fact, it’s pure crony capitalism. You can’t swing a dead cat in Helena right now without hitting a hospital or pharmaceutical lobbyist trying to get their surgical gloves into taxpayers’ wallets. Yes, there’s good evidence that the “free” money coming from Washington may create around twelve thousand jobs in Montana; but will those jobs create health benefits that are commensurate with their costs? If not, the money is better left in the private economy where it can be spent more productively. A recent New England Journal of Medicine article said that “Treating the health care system like a (wildly inefficient) jobs program conflicts directly with the goal of ensuring that all Americans have access to care at an affordable price.”[vi] And anyway, it’d be much cheaper for Montana taxpayers to just put those who are eligible for federal subsidies into the new exchanges and let Washington pay their entire bill. It’s free money, right?

Except that it’s not. It’s taxpayer money whether you write the check to Helena or to Washington. The net cost to Montana taxpayers of Medicaid expansion through 2021 is over $50 million according to one estimate,[vii] and closer to $100 million according to another.[viii] That’s after the “free” money and jobs and tax revenues, and assumes the federal government will keep its promise to cover 100% of expansion costs in the early years and 90% later on, despite the fact that even the President’s own past two budgets included reductions in those commitments.[ix]

In reality nobody knows what it will cost, but there’s precious little precedent for entitlement spending coming in below or even near initial estimates. In 1965 Medicare was estimated to cost $9 billion annually by 1990. The actual cost in 1990 was $67 billion.[x] There’s no reason to think Medicaid expansion estimates will fare any better, and Montana taxpayers would be on the hook for the difference since it’s politically unlikely that these entitlements would be reversed once they’re put in place.

So why not wait a couple of years? Let’s see how things go in California and Illinois and other bastions of state fiscal responsibility, and then take a look at what’s working and what’s not so we can make an informed decision. Or, we could try true reform and turn Medicaid into a system that really does provide quality access to quality care for more people who need it. We’d do that by reconnecting the patient to the provider and the cost to create responsible consumers rather than filtering both the funding and the care through a self-perpetuating bureaucracy. But that’s a topic for another day.


[i] The Urban Institute, “Opting in to the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could gain Health Insurance Coverage,” August 2012,  pp. 8-9.

[ii] University of Montana Bureau of Business and Economic Research, “An Estimate of the Economic Ramifications Attributable to the Potential Medicaid Expansion on the Montana Economy,” January 2013, p. 6.

[iii] 16.3% of Medicaid patients encountered barriers versus 8.9% of those with private insurance. Annals of Emergency Medicine, “National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries,” 2012, p. 4.

[iv] Ibid

[v] Urban Institute, op. cit., p. 18 and BBER, op. cit., p. 7.

[vi] Katherine Baicker, Ph.D. and Amitabh Chandra, Ph.D, The New England Journal of Medicine, “The Health Care Jobs Fallacy, June 28 2012, p. 2435.

[vii] BBER, op. cit., p. 29.

[viii] The Heritage Foundation, “Obamacare and the Medicaid Expansion: How Does Your State Fare?” March 5th 2013,

[ix] Charles Blahous, Mercatus Center, “The Affordable Care Act’s Optional Medicaid Expansion: Considerations Facing State Governments,” 2013, p. 32.

[x] Conn Carroll, The Foundry, “Health Care Reform Cost Estimates: What is the Track Record?” August 4th 2009,

Rob Natelson: On the Medicaid Expansion—Yes, Montana Should Say No

When the Supreme Court’s Obamacare case was pending, I noticed that while there was a lot of attention given to the individual insurance mandate, there was little discussion of the Medicaid expansion.

The Medicaid extension was the part of the law that sought to force states into signing up for an expensive new program by threatening to cut off all Medicaid funds if they did not.

Whether the individual mandate was constitutional was an arguable question under the Supreme Court’s modern jurisprudence.  (As you probably know, the court’s modern law on federal regulation and spending is largely disconnected from the Constitution’s actual meaning.)

But the Medicaid mandate was different. However, I looked at it—under modern law or the Constitution’s actual meaning—that mandate seemed flagrantly unconstitutional to me. But almost no one was addressing it.

As a result, I authored one of the very few Supreme Court briefs to address the issue in detail. The brief was edited and filed by Dave Kopel at the Independence Institute, where I am also a senior fellow.

Against all popular expectations, we won: By a 7-2 margin, the Supreme Court struck down the coercive portion off the Medicaid expansion. This left the states free to make their own decisions.

A recent MPI post explains why Montana should not sign up for the budget-busting, dependency-creating Medicaid expansion. As if any additional reasons were necessary, health care expert Linda Gorman adds this compelling argument. It’s written for Colorado, but applies to Montana as well.

Rob Natelson: The Montana Supreme Court Ballot Issue Jurisprudence: “Liberal, Sí — Conservative, No!”

Many Montanans have complained of the state’s supreme court’s leftward bias. But law is such a specialized area, that this bias can be hard to illustrate in ways non-lawyers can understand.

But everyone can see it in how the Montana justices handle ballot issues.

In Montana, the legislature and citizen petitioners enjoy the right to place initiatives and referenda on the ballot. Opponents also are free to challenge those measures in court.

The state supreme court has heard many ballot-issue cases. Some of the cases involve measures that are truly non-partisan, or can’t be classified as “liberal” or “conservative.” But many others do involve measures that can be classified that way.

 In my MPI study of the court issued late last year, I identified 18 cases in which the ballot measure under attack could be classified as either “conservative” (tending to reduce the power of government) or “liberal” (tending to increase the power of government). In 12 of the 18 cases, the measures challenged were “conservative.” In six, they were “liberal.”

The results, tabulated in a chart on page 18 of the study, show a dramatic difference in how the court treats conservative and liberal ballot issues.  Of the 12 conservative measures, the court upheld only two and struck down 10.  But of the six liberal measures, the court upheld every one! Since 1996, moreover, the pattern was perfect: every challenged conservative measure was struck down, every liberal measure upheld.

There were some particularly striking cases. For example, in one dispute the court voided a proposed conservative measure because it did not have legal force—it was an expression of popular opinion: what the court called a mere “resolution.” Yet in a later case, the court upheld a liberal initiative (I-166, which I discussed in an earlier post), although it, too, was a mere resolution.

Now, what made that pair of cases particularly perverse is that, under the law, they should have been decided precisely the opposite way. This is because the conservative measure was a proposed constitutional amendment, and the state constitution contains no rules against “resolutions” being part of the constitution. (In fact, resolutions or “recitals” are common in state and federal constitutions.) On the other hand, the liberal measure was a statutory initiative, and the state constitution (Article III, Section 4) specifically requires that statutory initiatives be genuine “laws” rather than mere expressions of opinion.

So the court struck down a conservative measure that was stronger on the law, and upheld a liberal measure that was weaker!

You can read the entire study here.

More On Medicaid Expansion

Had a good time on KMMS this morning talking about Medicaid expansion so I thought I’d jot down a few notes from the show.

If you’re on MPI’s website you’re already active and aware on policy issues so I won’t belabor the point with a lot of background, but in a nutshell the Governor is about to roll out his plan to expand Medicaid as our masters in Washington have directed to include people earning up to 138% of the federal poverty level. That’s a bad idea for several reasons, as I argued in an Op Ed back in January. We’ll have a lot more on this soon, but here’s a quick outline:

  1. It’s bad welfare policy: According to an Urban Institute study that pretty much everyone is using, 43% of those added to Medicaid in MT would be under 35 years old and 75% would be childless. Unless they’re disabled, putting young, unfettered individuals on public assistance without some kind of work or payment in kind system is unfair to taxpayers, creates all the wrong incentives, and traps them in an entitlement web that’s tough to get out of.
  2. Will cost taxpayers more than just the expansion: Hospitals claim it will save taxpayers and those who are privately insured money because putting more people on Medicaid will reduce their unreimbursed or charity care costs. Don’t believe it. In states like Maine where they’ve already been down this road, those costs increased as people moved from private insurance to Medicaid and uninsured numbers remained virtually unchanged. Just think about it: how will adding 50,000 people from an at-risk population (lower incomes equate to poorer health) to a program with low and sinking reimbursement rates save money?
  3. Job numbers are probably overstated: We need to do a little more homework on this – and will – but claims of more jobs from “free” federal money have been wildly overstated in the past and probably are now as well. And besides, as argued in a New England Journal of Medicine paper called “The Health Care Jobs Fallacy,” if the same health care outcomes can be achieved with fewer resources that leaves more for schools, transportation, safety, and other public priorities.
  4. And finally, it ain’t free money: Over 30% of the “free” money will be borrowed by the federal government, and the remaining will either paid for by you on April 15th or come out of other spending priorities. Direct costs to Montana taxpayers of expansion range from $50 million to around $150 million depending on whom you believe, and there are few examples of entitlement program cost estimates being understated. President Obama’s last two budget submissions included increasing the states’ share of Medicaid reimbursements, so talk of 100% federal cost share is doubtful in the future, and so-called circuit breakers that would cancel expansion if the feds renege are meaningless. Nobody is going to take away this benefit once it’s been granted, so let’s wait a couple of years, see how they like it in other states, and then make an informed decision.

Rob Natelson: The Misplaced “Philosophy” of I-166

    In the 2012 elections, Montanans overwhelmingly approved I-166—a measure that has no substantive effect, but expresses the “philosophy” (the word used in I-166) that corporations have no First Amendment rights.

When you read I-166 carefully, you have to wonder what the voters were thinking when they passed it. In case your own thoughts on the subject are fuzzy, here are some cool, clarifying fresh breezes:

1.     Corporations are not alien cyborgs from the planet Bloton. They are merely teams of people working for a common purpose.

Some are big and rich, but most (especially in Montana) are small and relatively poor.

People incorporate because the state pushes them to.  The state offers them the right to (1) use the corporation’s name in lawsuits rather than listing all the owners individually and (2) dispense with clumsy liability disclaimers to protect owners’ and members’ personal assets. (Corporate assets are still vulnerable.) But the team choosing incorporation has to pay extra taxes, extra fees, disclose a lot of private information, and abide by numerous state rules.

2.     The “philosophy” of I-166 would destroy freedom of the press.

Because of how state law is structured, nearly all media companies are forced to incorporate. If groups choosing the corporate form have no constitutional rights, then they have no freedom of the press. Some of the greatest victories for freedom of the press were won only because media corporations could defend their rights in court (for example, the Pentagon Papers case).

So if your “philosophy” is that the politicians should be able to bully all the newspapers and broadcasters into silence, then I-166 is for you!

3.     The “philosophy” of I-166 would heavily impair freedom of speech.

State law effectively pushes political associations to incorporate. If the “philosophy” of I-166 were to prevail, those associations would have no free speech rights.

In the 1950s, racist state officials in the South tried to crush pro-civil rights membership corporations like the National Association for the Advancement of Colored People (NAACP).  Those state officials didn’t think corporations had First Amendment rights, either. Fortunately, the Supreme Court disagreed. (NAACP  v. Alabama).

4.    I-166 has nothing to do with “leveling the playing field.”

I-166 says it seeks a “level playing field in campaign spending.” But does it?

The “philosophy” of I-166 restricts corporate spending, but not union spending. Even worse, it says nothing about controlling government political spending, such as lobbying and other government interventions in the political system. Government political spending is a MUCH bigger problem than corporate spending, because government political expenditures are bigger, largely hidden, and financed with money forced from people.

5.    Campaign finance laws are counter-productive.

In the real world, government campaign laws always are politically manipulated, but still yield unintended results. As I pointed out last week, the 1912 Montana initiative that abolished corporate spending may have INCREASED the power of the Anaconda Company over Montana politics.

Montanans need to reconsider what they did when they approved I-166. And make sure that they are more wary in the future.

Rob Natelson: Amendments Convention

Ed. Note: We welcome MPI Senior Fellow for Constitutional Jurisprudence and retired UM Professor Rob Natelson to our blog. Rob is a national expert on constitutional issues and will periodically post insights and information on a variety of topics. You can find his full bio here.

Senator Art Wittich has introduced SJ 5, by which the state legislature would formally apply for an interstate convention to draft and propose the National Debt Relief Amendment. That amendment, if ratified by 3/4 of the states, would require approval from a majority of state legislatures before Congress could add to the national debt.

At the legislative hearing, opponents trotted out the “runaway convention” scenario. This is the discredited claim that a convention to propose such an amendment would be a “constitutional convention” that could do anything it wanted.

I correct the record in an essay that discusses the claim here.

Rob Natelson

* Senior Fellow in Constitutional Jurisprudence, Independence Institute
* Senior Fellow in Constitutional Jurisprudence, Montana Policy Institute
* Senior Fellow, Goldwater Institute
* Professor of Law (ret.), The University of Montana
* biography & bibliography:


Montana’s Lagging Ways

11-12 Tapping Capitalism V5comp slides

Take a look at the link that’s right above this post. It’s a pdf of three state comparison slides that we’ve been using to demonstrate the real problem Montana has with economic development. What it shows is that, while Montana consistently ranks middle of the road in economic and demographic comparisons nationally, we’re at the bottom of the pack when compared to the states around us.
If we want to fund legitimate government needs we need economic growth and jobs. If we want people to be happy and reach their potential we need to give them the opportunity for earned success. We’re lagging our neighbors in virtually all of these measures because of policies that have been put in place that may have been well-meaning at the time but that remove options and retard growth in the long term. We’re now reaping the ‘rewards’ of those policies through low wages and high unemployment compared to our neighbors.
The problems are many and the solutions are difficult. But they just grow and get more difficult the longer we wait. Here are a few things the legislature and governor should do yesterday to return Montana’s competitiveness and allow our citizens to pursue happiness and reach for their potential:

[list type=”check”]

  • Labor Reform: Become a right to work state, become an ‘at will’ state, and bring the minimum wage back to federal levels
  • Budget Reform: Reform our state budgeting process so that we spend based on priorities rather than politics
  • Legal Reform: Reform our liability system to decide based on rule of law rather than preferred outcomes of specific cases. This is the biggest single impediment to businesses and job creators coming into the state. If they can’t estimate their future liability risks they’ll move on to someplace where they can
  • Pension and Pay Reform: Most state employees are not overpaid, but too many have migrated into higher pay bands over the past ten years while lower paid workers have been left behind. Our pension system is $10 billion underfunded. Without true reform we won’t be able to keep the promises we’ve made to our public employees.
  • Land Use: The federal government owns about 30% of Montana’s lands and is increasingly trying to regulate the rest. We should decide what happens in Montana and we are capable of regulating responsible development, whether it’s in agriculture, resources, or recreation.
  • Health Care: Obamacare will raise health care costs and decrease access to quality care. We need to implement consumer-driven reforms that allow patients and doctors to make responsible decisions rather than being dictated to from Washington.
  • Education Reform: Our education funding system is a mess and our rules don’t allow parents, teachers, and students to innovate and ensure each student gets the best possible education. We need choices and new thinking, not just more money thrown at the problem.
  • Government Transparency and Accountability: Taxpayers have a right to know how their dollars are being spent and what’s being done in their names. We need the state to post spending, actual spending not just projected budgets, so that each Montanan can be a citizen watchdog and a responsible part of the process. Senator Taylor Brown has a bill to do just that. Take a look at it and tell your legislators and the governor what you think.


That’s a pretty good start and what MPI will be working on to make Montana competitive again, but mostly to provide each of us the opportunities that free people deserve.


Baseline Budget Better Than Base-Bloated Budget

This is a good development.

The “Present Law” budget that is the normal starting point for building a new biennial budget is basically the previous one plus an inflation factor plus a case load factor, plus any changes that were required during the biennium plus…, well you get the idea. The result is that it guarantees the starting point for a new budget is larger than the old one, and any reductions in that budget are treated as cuts, even though the actual spending amount is probably more than last year’s. That’s just dishonest.

The feds do the same thing. They budget a billion dollars for a program to search for green cheese on the moon and then ‘cut’ that program and claim a billion dollars in savings even though it had never been spent before and nobody ever really intended it to be spent in the future. It’s purely political gamesmanship meant to allow politicians to claim they cut spending when in reality they probably raised it.

So…when someone says they’re making a cut to the budget be sure to ask them if they’re cutting hypothetical spending or if they’re actually cutting spending, i.e. will this year’s spending be less than last year’s. And then watch as they take out their hanky and explain how complicated the whole process is and that you should just take their word at face value.

Even baseline budgeting doesn’t solve the problem of waste, though. It assumes, for example, that every nickel spent last year was both efficiently and effectively expended. That’s not necessarily the case. The real answer is performance-based budgeting, which allocates dollars based on a program’s demonstrated ability to achieve agreed-upon government missions and functions, and then prioritizes available dollars to get the biggest bang for the buck. In short, it’s how you and I allocate our spending every day. You can read a lot more about it, along with a pension system primer and tax analysis in our new Budgeting For Results study.

Now Is Not the Time for Medicaid Expansion

 Bozeman – Governor Bullock has decided to ignore the Schweitzer administration’s budget submitted last November and instead opt into Obamacare’s Medicaid eligibility expansion. This looks to be a patently bad idea; and even if it’s not there’s no reason to rush forcing Montana’s taxpayers into yet more unsustainable entitlement spending and to herd more of our citizens into a system that provides inferior care at great expense.

First let’s get a little background out of the way and then I’ll explain why it’s a bad idea.

Medicaid provides health insurance – not necessarily health care, but more on that later – to families with incomes up to 133 percent of the federal poverty level (FPL). Montana’s taxpayers currently pay about 33 percent of the program’s cost, with the federal government picking up the balance.

Last summer’s Supreme Court ruling let states decide whether to increase Medicaid eligibility to 138 percent of the FPL, which Obamacare tried to mandate. Many people portray this as “free money” since Washington says it will cover almost all the costs until 2017 and then ramp down to 90 percent of the costs after that. But that promise, like so many others that were made during the health care reform debate, simply doesn’t match the facts on the ground.
These facts argue against expanding Medicaid eligibility for two major reasons, one of them financial and the other one moral.

The financial reason is that we already know this expansion isn’t “free money” for the state. And the moral reason is that it will result in thousands of Montanans being dumped into a system that results in inferior access to care, with many of them forced out of much better private insurance plans.

Estimates of Montana’s potential share of expansion costs vary pretty wildly[i] but most come in between $100 million and $200 million,[ii] or the equivalent of between two hundred and four hundred new teachers, for example.[iii] Our costs increase for a lot of reasons, but I’ll just highlight a few obvious ones.

First, with Obamacare scheduled to cut $8 billion from Medicaid and $500 billion from Medicare, you can be sure that Montana’s health care providers will be coming to taxpayers to be made whole when their costs inevitably outpace their reimbursements under these government programs.

Next, the largest single increase will result from people who are eligible for Medicaid at the 133 percent FPL rate, but not currently enrolled, coming out of the woodwork as word gets out that eligibility has been expanded. Many of these people are technically uninsured today but would be enrolled in Medicaid and receive care if they needed it. Many others, though, have their own insurance and would simply shift from private to public coverage. Since they wouldn’t meet the new 138% FPL threshold, about 33% of their insurance costs would be shifted from them or their employers to Montana taxpayers.

And finally, for anyone who believes that the federal government will continue to reimburse states at the 100 or even 90 percent level, well, I’ve got a bridge to sell you. Washington’s budget woes are going to be transferred to the states, and states like Montana that get from Washington much more than we give are going to feel the pain first and most acutely.

Shifting our most vulnerable population to Medicaid is also immoral. Studies consistently show that Medicaid patients have poorer access to care than privately insured patients.[iv] Since Medicaid typically pays physicians 56 percent of the amount private insurers pay, fewer doctors are accepting new patients and they eventually wind up in hospitals with more serious conditions than those who are privately insured. In addition, there’s scant reliable evidence that Medicaid improves health outcomes at all, and zero evidence that it is the best way to improve health outcomes per dollar spent.

Expanding Medicaid will only worsen our health care system’s woes, increasing costs and decreasing access to quality care while adding a new entitlement burden on taxpayers and dumping thousands of low income Montanans into a failing program. There’s no rush to expand. If it works for other states we can always sign on. But this is one case where we shouldn’t lead with our chin.

Carl Graham is CEO of the Montana Policy Institute

[i] MT Department of Public Health and Human Services, “The Impact of Medicaid Eligibility Expansion and health Montana Kids Monitoring,” 12/2/2011,
[ii] For example, Kaiser Commission on Medicaid and the Uninsured, “the Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis,”  11/2012,
[iii] Derived from data at,
[iv] For a synopsis see The Heritage Foundation, Kevin D. Dayaratna, “Studies Show: Medicaid Patients Have Worse Access and Outcomes than the Privately Insured,” 11/9/2011,