your opinions if i were to offer an amendment as mr. markey talks about giving encouragement, what about if i were to offer an amendment that has a penalty clause so that if a government department or agency does not deliver the relocation at the timeline that is specified whether it is classified or unclassified, then that department or agency is to pay interest on the moneys relative to where that spectrum is located? you can figure out what the economic impact would be. .

saying, but having said that, i applaud the way you're thinking, because i think would have to the effect of incentivizing more interest in specktrum options if they knew it was a two-way street and they would be treated fairly. >> well, thank you. i'd like to explore this idea not only with my colleagues but with you on how we could build this into this next piece of legislation. thank you. i yield back. >> 50eud have to put a second-degree amendment on your amendment and we'd have to punish all the members of congress who spend that

specktrum money five times over. >> and with that i think we'll close this happy hearing. thank you to all the witnesses and have a happy holiday and thank you for being here. >> you're watching public affairs programming on c-span. up next, a new report on u.s. health care spending. topics on this morning's "washington journal" includes unemployment compensation, al qaeda and national security. washington journal begins at the top of the next hour. and later in the morning, the carnegie endowment for national peace hosts a forum on the world economy in 2010.

>> on c-span 2 this morning long-term care services. who provides long-term services, who gets them and who pays for the services? and whether or not congress will include long-term insurance in their final health care bill. that's live at 8:30 eastern. and later in the morning on c-span three, a forum on energy efficiency. those from government industry, and academia will discuss smart technology. that's live from the national press club at 10:00 eastern. the federal government reported a slowing in the growth of health care spending in 2008. but it levels it's still outpacing the overall any. more on the report from the centers of medicare and medicaid services. susan host this isçó 55-minute event.

>> i'm susan denser, happy new year and welcome to our briefing on health care numbers. that is ritual as the medicare and medicaid services as well as health affairs to bring out these spending numbers every year, and we're delighted to be able to do that once more. this year we have historic numbers to help act twares and others unveil. and as you will hear and perhaps already read we had an historic slowdown in the rate of health care spending as well as rate of growth in 50 years.ç] of course the other side of the story is health care spending still grew faster than the overall economy so we're not out of our long-term projectry with the health differing to pay for the health 06 our folks.ñi and i will turn it over to our

folks from cms to present the data. you'll be hearing from micah hartman. with the office of the act tware at the centers for medicare medicaid services or cms. he works primarily on historical and age-basedçó national health care spending benefits and fromtousened university. and we'll hear from anne maten who is an economist with the office of the act twares from the offices of medicare medicaid services. she earned her b.a. from the university of baltimore, maryland county. two other panelists will be available to answer questions, olivia nucio with the office of the actuary and earned her b.a. from the economics of baltimore, maryland and erin

from the office of the actuary earned his ba and msn from the maryland college. >> and the actuary will be available to answer questions and there are many questions emerging not just looking back to the historical numbers but projecting forward spot coming decade. particularly in an environment of potential national health reform and as we say we have many folks available to deal with those questions this morning. so with that let me turn this over to you micah hart marian. >> thanks a lot, susan. >> mm-hmm. >> everybody hear me ok?

ok. good morning. my name is micah hartman and i'm happy to be with you today eto present our overall findings frs 2008. i'm here with the rest of the national health accounts team and the information that we are going to review today is going to be published in the journal of health affairs set for publication tomorrow as susan has already mentioned. tall information we're presenting is embargoed until that date. so let's get into our summary of findings for 2008. as we cançó see national health care spending slowed to a rate of growth of 4.4%. $7,681 per person and the current recession has had a more immediate and profound impact on our health care trend as broadly based as health care and services flowed in 2008 yet

we see an increase in the economy devoted to health care spending from 16.9% to 16.27 in 2008. this first exhibit displays our health care spending trend back to 1980 through 2008 compared to the growth and in the gross domestic product. as you can see health care spending outpaces the depross domestic product. we had slower spending due to cost control and utelyization control. follow that period we see a peak in growth in 2002 as there was a backlash against that managed care and follow that we see slower growth at deaccelerating trend leading into the 2008 recession. the recession that began in

2007. on this exhibit we can see national health care expenditures as a share of the gross domestic product. this is one of the most widely known related to spending. as you can see health care spending did reach 6.2% of the economy. what we've noticed is during recession narrow periods and following them we see larger share increases in the economy devoted to health care spending and follow that we see a period of relative stability for an extended period of time. so let's go ahead and talk about the impacts of the recession for 2008. there were three areas we saw that the recession had an impact on our 2008 trend. and it's often thought health care spending is somewhat insulated from the impact of the downturn in the economy,

however, the recession that began in 2007 had a more i mean immediate yacht and profound impact due to the fact that it's probably going to be the longest around most severe recession since the recession in 1933. we can see three areas where this recession had an impact. first in the ara in the recovery act pass indeed 2009. what that did was provide a retro active adjustment beginning in 2008 for the medicaid program and enhance that had rate, shifting more responsibility to the federal government away from the state and local government and we stipulateed the government the impact and we see a slowdown in private spending growth and all 3com opponents of health care spending slowed including private spending. the slowdown in other private spending was mainly driven by a

slowdown in other private revenues which for hospitals actually declined due to investment-related losses related to the recession. and also we see ran impact in eninsurance enrollment and they accelerateed from 0.7% to in 2007 to.0 -- in 2008. and we had a negative 0.5% growth. so taking a look at the role of public and private health care spending over the last 18 years or so. we can see if we focus in on the more recent period 2004 forward public health care spending has been outpaceing the growth in private health care spending over that period of time. the share of public health care spending has actually increased

sinceçó 2004 up from 45% to 47% in 2008. and there's a few reasons why public health care spending has been outpaceing the growth in private spending due to medicare and medicaid programs growing at stronger rates as well as expanding medical coverage. you can see in 2006 the accelerated there for public health care spending trend. for private health care we see it's been growing at a slower rate of growth mainly due to this stag nation in private health insurance enrollment hovering to 159-196 enrollees since 2004. taking a look at even greater detail at the public health care spending trend, we beak it apart in paras. and i really wanted to focus on 2006, 2007 and 2008 for the

three years, you can see the impact of two pieces of legislation and some changes in our health care spending trent. 2006 you see the history? responsibility for the funding for the dualy eligible beneficiaries that were getting their retail prescription drugs through the medicaid program and in addition you see the impact of stronger growth due to the medicare part d program. you see a convergens of growth in 2007 where these two payers returned to more than normal rates of growth and in 2008 mainly due to the impacts of the arra where federal spending accelerates and state and local spending slows again. and that was mainly again due to the arra. didn't necessarily come out very well. so first of all, health care spending growth can be put into

two broad factors. we can look at price and non-price. non-price would look at population, use and revenues from non-patient and non-operating costs as well as all their factors. examining health care spending in this way could drive what's helping the aggregate. it was do to the slowing and non-price factors, indicated or displayed in the red portion of this exhibit. display a slowdown after the recession where you don't see the red portion get smaller until a couple of years following those recessions, in 2008 we see a more immediate impact in the downturn similar to the 1981 and 1982 recession which was longer and potentially more severe. so this may be an indication that recession that is are a more immediate impact on the recession of health care

spending which appearingçó ever to happen during relatively more severe recessions. >> another way we can add is by looking at sponsors. what we have here are different sponsors of spending, private businesses, private funds and federal government and local government. it's looked at by taking all health care spending less investment. and then what we do is we move the responsibility of health care spending to the underlying sponsors that make those payments or are responsible for those payments, doing something like moving -- moving your share of your insurance premiums to the household sector. >> so between 2007 and 2008 we see that the federal government

share of health services and supplies grease from 23%-25% while state and local government share decline%. to 18%. businesses decline around household shares remain relatively steady at 31% and it has been doing that since 2005. sponsors also allowstous take a look at the burden of health care spending from 1987 through 2008. what we can do is take a look at health care spending in our pneumonia rarte divided by health care spending in the demominator. for most sponsors there was not much change in 2008 in the burden. however, for the federal government we did see dramatic increase in the health care burden increasing from 28% to almost 36%.

it can be explained by a drop in tax revenue and change in code from the stimulus act in 2008 and due to the arra. additionally it's fortunate note that for state and local we saw that the 3wurden did not increase, and that was mainly due to the non-impact of arra as we had that shift of responsibility to the federal government. and with that i'd like to turn the rest of the presentation over to anne martin. thank you. >> thanks micah. my portion of the presentation is going to focus on the services and paras of health care goods and services in 2008. so let's start by looking at ñ trillion was spent in 2008. hospitals accounted for 1/3 of total health care spending at 31%. followed by physicians and

clinicical services at 21% and prescription drugs accounted for 10%. and was the single largest category of health care spendings, and i say single because other accounts were 25% of total health care spending but includes smaller categories such as dental services, other professional services, hole health care and other non-durables. ok. so looking at growth and personal health care spending among depoods and services for 2008 compared to 2007 at the top we can see that total national health spending deaccelerated from 6% in 2007 to 4.4% in 2008. and can also see that among the various goods and services that there was an across the board deacceleration. most of these services grew within the 3%-6% range in 2008 with two exceptions.

first, home health care grew 9% in 2008. however, this wasñi stale deacceleration in 2007 and other personal health care deaccelerated rapidly from 5.8% in 2007 to 2.6% in 2008. we're going to take a closer look at some of the services and start by looking at hospital spending. hospital spending increased by 4.5% in 2008. this was a deacceleration from 5.9% in 2007. and the slowest rate of growth since 1998. growth peaked in 2001 and 2002 following the end of the managed care era and then gradually began to deaccelerate in 2006. then deaccelerated more rapidly in 2007 and 2008. by 2008, deacceleration was

driven by a slowdown in hospital prices, slower medicaid hospital spending growth as the state's budget cutbacks and a decline in non-operating revenue due to investment offers likely due to the recession. ok, next we're going to look at the category of physician around clinicical services combined. physician and clinicical services grew by a combined rate from 5 nt 8% growth in 2007 and the slowest rate of growth since 1996. physician services alone account for 80%. this combined category. and physician services accelerated to 4.7%. this was driven by deacceleration in prices andçó also slower growth in private funding. for both private health insurance and out of pocket.

and that slower tpwhrothe private funding likely impactsñ funding as insurance coverage was lost, tighter credit markets may have restricted access to care and as patients may have postponed elective procedures. in addition other reports have indicated that since the recession began patient volume and position physician offices have declined. growth outpaced that of physician services and therefore continues to grow as a share of this combined cat entire. -- category. ok, now looking at retail prescription drug expend sures. it increased 2.3% in 2008. this was a deacceleration from 4.5% growth in 2007. and is a continuation of a

slowing trend that began in 2000. i should mention that obviously part d caused expend suretures to accelerate in 2006. so in 2008 the deacceleration was driven by a decline in prescription drug use per person, which was likely influenced by the recession. reports have indicate that had people were not filling their prescription and cutting nils half or skipping doses. also there was a decline in out of pocket spending in prescription drugs also likely due to the recession and in addition there was a low number of product introduction ins 2008 and also continued safety concerns. finely the switch of from prescription status to over the counterstatus contributed to the deacceleration. we're now going to look at who

pays for health care depoods and service ins 2008. and the single largest pair is private health insurance at 1/3 total health care spending the largest is medicare at 20%. total public pairs which are medicare, medicaid and other public accounted for a 47% share in 2008. this is a slight increase from 46% share in 2007. total private spending, which is private health insurance, out of pocket and other private accounted for 53% share down 1 per crept g point in 2007. so if 2008 there was a slight shift toward public payers paying for more of the health care bill. in a graphic similar to the one we looked at in services showing the comparison of growth rates in 2007-2008. this is among the different payers and at the top again is total national health spending,

so public payers actually remained unchanged. a gross flat at 6.5% in 2007 and 2008. we can see that medicare growth outpace that of medicate medicaid and other payers. medicaid deaccelerated to 4.7% and other public payers deaccelerated to 6.5%. total private spending deaccelerated rapidly from 5.6% to 2.6%. and as you can see all 3com opponents of private payers show the deacceleration. private health insurance slows due to premiums and benefits. out of pocket spending showed a large deacceleration from 6% to 2.8%. and that was primarily driven by a decline in out of pocket

spending for prescription drugs as well as a deacceleration in out of pocket spending for most depoods and services. a very obvious deacceleration occurred in other private spending from 10.8% in 2007 to 10.1% in 2008. primarily due to the investment income losses experienced by hospitals, which was due to the recession. ok, so now zooming in on med careful spending, this graph shows medicare spending and its two components, service and managed care. so in total medicare spending accelerated to 8 .6%. in 2008. fee for service spending accounts for 77% of total medicare expendtures and fee for service expendtures

accelerated occurring as hospital spending accelerated and that was due primarily to an spreas in patient hospital admissions after two years of delipe organize flat growth. managed care or medicare advantage expenditures for medicare increased 21.3% in 2008. although this is a higher growth rate than fee for service, it accounts for a much smaller service of fee for spending. most was due to enrollment. enrollment in medicare grew 6.7%. when you look at per enrollee expenditures medicare increases 6.8% compared to 5.8% of overall medicare spending per enrollee. looking at medicaid

expenditures now you can also see that it deaccelerated from 6 .1% in 2007 to 4.1% in 2008. this was the slowest rate of growth since 1997 with the exception of 2006 when part d was implemented. the 2008 deacceleration was driven by a deacceleration in hospital spending and also due to budgetary challenges that were faced by several states that reduced medicare and -- payments to providers. also a temporary change in s map percentages caused a deacceleration in medicaid while the -- also medicaid enrollment increased 2.6% in 2008 following a 2.7% growth in 2007 as more people qualified for benefits in part due to the resefplgts and finally because

the majority of job losses occurred in the latter part of 2008, there may be a lag in the enrollment and spending figures presented here. ok so now looking at private health insurance, private health insurance premiums and benefits both deaccelerate indeed 2008. premiums drew slower than the growth in benefits at 237b99% and growth grew at their slowest rate since 1997. it was driven by a decline in private health insurance enrollment which was 5.5% delipe or by 1 million people. this was due in part to income and job losses influenced by the recession. also there was slower spending growth for customer-response period private growth premiums and individually purchased private health insurance.

ok, so to conclude i'd like to summarize some of the major findings from the 2008 national health expenditure accounts. national health spending slothe slowed in 2008 at the slowest rate of growth in the national expendtures accounts but reached $27.3 trillion. as a percentage of the overall economy, health spending represented the 16.2% share as compared to a 16.9% share in 2007. health care spending growth was faster than overall economic growth which contributes to the higher share of broad-based gdp, and in 2008 a slowdown similar to what was heap? past recessions slower growth in hospital spending was a major factor in overall trend as hospitals account for 21% of

total health care spending. in addition sperneding for state and local sources of funding slowed while federal spending slowed at a faster rate than in 2007. so thank you, very much for your time, and at this point we'd be happy to take any questions you have. >> we will open it up for questions now. i would ask those of you who do have questions to wait until microphone comes to you and spruse yourself by name and affiliation as you would. let me toss out the first one if i might. micah, the interpretation of the data clearly wound that the recession, which we know was very severe, hammered health care particularly hard also. not so much perhaps the rest of the economy but to a very serious degree, i guess the

question we could ask is is there anything to suggest that the effects of this will be lasting, or is this in effect a cyclical set of pressures on the health care sector we imagine will disappear as the economy improves? >> well, as we've seen throughout most of the -- sorry. as we've seen throughout the history of national health care expendtures, there's always been in most years an spreas in the share of the economy devoted to health care spending, so that's something made relatively conscious since 1960. the fact that the recession lad a more immediate impact was something we hadn't seen in recent history so that's something we thought was note worthy and worth discuss because it had such a huge

impact in the 2008 trend. >> to the degree health care spending held up, we know largely as a function of the federal government stepping in as you mentioned through aura and the changes on the s map under medicaid, what do we read into that going hard? >> well, i guess we could say that may have been just the beginning for 2008. it was just the fourth quarter that was intacted and it was a retro active impact, the spending already happened. it was just matching the funding from the state to the government level. so it was something to maybe look out for in our future reports coming out next year and our projections article coming out soon. 12k3w4 let's open it up to questions from those of you in the audience. >> yes. over here, please? again please spruse yourself by

name and affiliation. >> peter from the "wall street journal." how do we explain the relatively small grease in private insurance premiums when whenever we talk to small business people my premiums went up 20%, 307 last year and they have continued to do so for the last several years, how do we square that with the overall increase being something like 2%-37? >> well, i guess the only way to aps that question is what our premium number is we're showing -- when you mix the two things together. i've talked about the stag nation in private health care enrollment -- so as you have that stag nation in private health care insurance enrollment, that would impact the actual growth you'd see in

that premium figure. >> did you have a follow-up? ok. great. >> let's move over here. i think we have a question in the rear. >> judy, from national public radio. i just want you to clarify these are obviously the 2008 numbers and yet you're talking about aeroo that was tested in 2009. is that because of the amount of money that would switch from the state government to the federal government now shows up in 2008 because the federal government went back and rei mean bursed states for that medicare funding? >> yes. that'sñi what happened for the first-quarter of 2008.ñi >> now also in error, there was that -- there was a look pack forñi getting cobra rei mean bursed starting with people who

lost their job in september, did any of that show up in the numbers? >> it's a look back at our time frame but the actual kickin for the enhancement for cobra didn't happen until twape. until 2009. so you were eligible based on the loss of insurance but the spending didn't impact until twipe. >> ok. take a question right here in the front, please. >> hi. ericka warner with a.p. a couple things. what is the reason for the stag nation over since 2004 in private health insurance enrollments? >> it's you have to tease out of our data. we go to a bunch of different sources for private health care enrollment services, we looked at the kiezer family foundation report showed a stag nation in

even a decline in smaller -- compleeze that work at smaller forms taking up health insurance.çó there hasn't been much ip take in the largerer firms that we've seen in that data. but it was more of the aggregate pieces and this is specifically coming from our data that can relate or pin point that address or stand that. >> is there anythingñi at all that you saw in that in that data that seems to suggest any reaction to health care reform potentially hanning this year? >> um, wilt i guess maybe we had our answer with everything that was going on with the recession and everything. i'm not sure, you know, with -- i don't know, rick, if you wanted to. >> let's get a mike over to

rick foster here if we could. >> if you think back toñi 2008, what was the news? the news was all about the campaign. the election. and both candidates of course were promoting health care reform. but i don't think, at least even anecdotally, i don't remember much in the way of discussing people anticipating translating that in any significant way to action. particularly what we saw as we talked about was much more to do with the start of the >> i guess to add on. typically contracts and other prices and things like that toñ negotiate for health care are typically done on an annual basis, so añrxd lot of that was already set, leading up to the emphasis for health care reform.ñi

>> sorry. this should be obvious, but why it is medicare expenditures increased more where as everything else increased less? >> do you want to. >> ok. well, like i had mentioned the medicare increase was driven primarily by two things, one was increased hospital spending for fee for service, which was due to increase in admissions and the second biggest factor was an increase in managed care enrollment. so those were two of the biggest driving factors in the acceleration. and the reason why we're not seeing a deacceleration in medicare like we're seeing in a lot of the other payers and services is because medicare recipients are somewhat insulated from the effects of the recession because they are not usually actively participating in the job

market. um, well, there was an unexplained drop in admissions in 2006 and in 2007. so there isn't really an explanation other than to say that it's returned to its normal growth rates. >> in medicare. >> in medicare. >> question over here? >> hi, i'm julia appleby with news. on the medicare spending, you mentioned that one of the drivers was the increased enrollment on medicare advantage. is that because it costs more for enrollment and traditional fee for service or was there another reason why that was part of the original fee or increase. >> well, enrollment increase it costs more.

particularly the increase in cost is driven by depeas in enroll bheant and many people have been switching to managed care because packages may offer some dibble benefits for the same prices. but we don't have specific information that teases out what kind of packages beneficiaries are buying, and a good comparison for similar types of beneficiaries and fee for service for managed care but a at the aggregate level usually health spending is driven by the increases in enrollment. >> so it was just a population change? >> the population, if you take the effects of enrollment out, like i said before growth was 6.8% on a per enrollee basis. so that was a combination of cost and price growth at 6.8%. >> and that compares.

>> yes. and just to tee it up the overall slowdown was it mostly that we were spending less or using less or is it that prices have come down, if you had to pick one, prices, is there any way to quantify which is the main reason for the slowdown? >> overinstall >> overall. >> do you want to take that? >> sure. can you hear me? i would direct you back. i know in the article we have a price versus non-price chart. and i'm not sure what slide number it is here. ok. so when we look at prices for two larminger services which are hospitals and figures those both declined. and then as anne mentioned, with physicians there's recent

surveys indicated since the recession bedepan that there's a slowdown in utelyization. with hospitals we didn't see that. we saw a slightly faster growth in hospital utelyization a but you can see as we look that the chart where we have the price and non-price factors, as micah mentioned, the slowdown we see by this current recession marked by the one line since we don't know what the end period is yet, it's included with the use sbeansdty as well as other things like issue with the income losses for hospitals, that type of thing would show up in the non-price factors as well. so you can see that in this particular recession it's more like 1980-1981 recession in that we saw much less of the growthñi accounted for by non-growth factorsñi like price and intensity, but we did see the slowdown in prices as well

as nursing home and home health. the growth rate was 2.5% which is an acceleration but historically it's really 2if6ly vote. -- relatively slow. ? question here? >> medical news with a question about the slide breaking down drug and health. spending by sources of fund 2007-2008. and i guess the dimpt categories at the bottom it's "other private" which was 10.8% and then in 2008 was 0.1%, wondering what that covers, exactly? >> let me find it. ok. >> yes. sure the majority of long-term.

>> the majority of that category is going to be these non-patient, other operating ref news as well as philanthropy. so these are just other private revenue source that is different areas of the medical sector rely on to help offset the cost of providing care. >> it might be things like hospital endowments are invested in securities, which obviously took a huge hit. 12k34r that was the major drive. although, it's not majority of the category, but for the hospital they relyçó on calf feara -- cafeteria sales and parking lot because the majority are non-profit-operating endties so they need some other type of revenue to help offset the expenses. >> thank you. >> sure.xd >> micah i want to come back

for a moment with the notion that this is the slowest growth rate of health care spending in 50 years. we have two deep recessions as you mentioned 1980-1981 to 1990-1992. he's are lower than what occur indeed those two sessions and as you all established, it's lower than any rate of growth than we've experienced in this country in 50 years. what would we say is the major difference now as between 1980-1981 and 1991-1992, is it in fact the stag nation of private insurance that -- and how we see this reflected in the declines of private spending that is probably the single biggest difference between those earlier periods. >> yes. esee that just in general we're coming off the sixth year in

2008, so that's one main difference leading up to the recession we saw an accelerated growth before and following it we saw lag impact. back in the early 1980's we did have strong inflation growth in generally in medical price, and i think those would be factors, you know, probably the main factors. i guess the private slowing being the slowest rate of growth since the mid 1990's during managed care. it's definitely setting this period apart from those other two that you mentioned. >> and again, very closely to private health insurance or other factor ins particular? >> well, one of the major the the other so we can't sayñi eve to majority in the private slowdown has come from private health insurance but just talking in general over the period, you're correct. the period before we had the stag nation for that has been,

you know, contributor to the slowdown during that time period. >> but for 2008 in the more immediacy of it, it's out of pocket slowing dramatically as it did, and also seen a slowdown in other private revenues. >> so one other possibly interpretation is that the economy was really coming to grips with the rapid rate of growth of health spending, and slowing that as we steered into this recession, and then the recession pushed them as forces more strongly? >> i guess that would be a fair characterize characterization -- and there's been a change especially for hospitals an other non-profits on this relines on this income which was something we were just surprised by that it had such a tremendous impact on the coverage for 2008. i don't think that wasçó the ca leading back where you had these other non-profits and you

could rely on them unless there was -- >> great. merrill, let's get the microphone over to you. >> merrill, free lance. i'm trying to find out some of the numbers. one chart showed household spending and out of pocket, what does the household number refer to?ñr >> the house shold our sponsor category going to include employee and out of pocket payments that you would make as an insured individual through co-pays and deticketibles or unpaid paying for your health care. those are the two major categories. for now you paid premium frs part d, those premium would be included in that category. >> there are two different

looks at the nha. we are standing with the definition of sources of funds is the final bill pair like medicare, medicaid. the slight you mentioned on the spopser basis was where we take some of the spending and shift it into who is ultimately responsible for funding the health care so as micah referred our out of pocket isn't going to include committee premiums. the employees share a premeditate yum! but move it back to the households. so it's a different cat >> and this is a related question. so premiums are taken out of people's pay checks, that's in the household number but not in the out of pocket? >> no. and it would never be in our out of pocket number. our out of pocket number is just going to be the deduct

blets and -- >> i realize this question doesn't fit into health care reform but -- is that money taxable or after taxes? taken out of your paycheck? >> um -- you mean the money that we are accounting for in the national health -- pretax? >> deducted from your paycheck as your share of premiums? that's in the household number but not in the out of pocket. >> right. >> and i'm asking you is that taxed or not taxed? >> pretax. >> also pretax money? >> yes.ñi but your out of pocket spending would be post tax. exclusive of, like, hsa's and other flexible saving accounts, arrangements, things like that. >> thank you. >> sure. >> question here? >> could i just -- since we've continued to see health

spending outpace overfeoff has there been any change in those relative growth rates over time, as well as how much faster health spending has grown compared to the overall economy? >> i think if you look back overall, it's -- it was a wider gap than it is currently, but in 2008 that gap did widen. so the gross domestic product slowed relatively faster than the growth in the national health expenditures. >> i think if you look at the -- i think it was the second slide that had the growth rate, you can see at least in 1984 your question was about the differential, you can see in the managed care era they converged and as micah mentioned before, spending peak indeed 2002 and then helped converge again with the growth in gdp, i know host of you

probably follow our annual report so you'll notice the  health care spending roll is largely due to the gdp being revised. they went through a benchmark revision so their numbers were up so in 2007 we have a will lower sharkse thatñi explains t difference. >> you'lly appleby. let's get a mike over to her. >> so give us a snapshot of what's happened since then. are we going to see a similar slowdown, accelerating? what are we going to see? >> we would like to ask you to stay tuned. we are going to have an article coming outñ@oot our team but short run projections team in february in health affairs, so i'll leave it at that. [laughter]

>> i have a quick question. do you look at jobs in the health care sectors at all in calculating this? because i'm curious what the situation in 2008ñiñixd was in jobs compared to 2007 because in 2009ñi health care jobs adde weçó didn't know until this friday butçó every month health care sector has been adding jobs and we're curious what the jobs creation sect of was. >> it's a get a question. it's not something we did for this analysis and we would have the num!s right near in front of usxd and didn'tñr include it the report but it is a great question. >> so keep asking it. >> we may have it this afternoon on the conference call. might be able to look that number up. >> sort of related tq!q9ñ in the slowdown in pending in

hospitals, for example, have you looked at what the number has been on closing? any other factors you can talk about? >> just from information that i've read related to the hospital sector, definitely profit was down for 2008. but other than that, you know, i don't have anything further to add on that. >> and again, these are aggregate numbers, so we do get data for the hospital sector from a number of sources but we tend to look at it in total and then dig into the data for reasons, why that total increased or decreased. >> anymore questions? if not, let me ask a final one. as you all have sorted through these data to come up with these numbers, what are the biggest anomalies you've discovered, if any?

what are the things left unexplained that you are continuing to do more work on. are there any or is all this now pretty much straight forward? >> i think some of the things that we found interesting when we looked at the data this year. mention ad couple of times the intact of investment income in 2008 on the non-profit providers like on hospitals and nurring homes was interesting because in preevet recessions we didn't see the same effect. there was still some slowing that went on, and beyond that, i think it's a very interesting time for health spending, and with the profession of the detail in the article looks a little more like 1980-1981 as opposed to the recent recessions where holte spending didn't slow until several years after the fact.

>> it was thought there was a flagged intact. that was interesting to us. >> yes. i'd like to just keep track of the impact on the inflation so i'll be reading the article coming out in another month. >> and among other things clearly we'll see is the projected spending will be off a lower base because the recession dampened down spending -- >> just through past history we've seen growth in the program and private health insurance stag nate and sometimes decline. so i guess we've already seen a hint of that in 2008 so we're looking for it in 2009 going forward. >> so we would expect ongoing increases in the overall -- >> i don't know if i could go that far. what the the trends will bring

in 2009. >> all the more reason for eb to come back in february when we unveil that article. all right. thank you all of you very much for a terrific presentation and great article and thank you, all of you for attending this morning. thank you. [captions copyright national cable satellite corp. 2009] .