here the data by time, ken alluded to these two, i've broken things into decades since the '40s. and what you see is you see some variation around that average, but there's usually something happened in those decades that departed a lot from the average. medicare, med cade, managed care introduction in the '90s, the recession in the last decade, but what's remarkable, to me, and the reason i put this up is to give some perspective, that this issue of cost growth is a common across countries and, b, has been going on for a very long time. so what i take from that is that while the u.s. certainly spends a lot more than everybody else, that must be something that u.s. specific. but the growth issue must be something that's common to countries and to decades. i take ken's point that, what's -- things may have changed over time in terms of what's driving this, but i still think it's important to keep in mind that this is not -- whatever is happening here is not necessarily a result of things that are specific to the u.s., which we naturally tend to get wrapped up in. the second point

so that is a real challenge and especially as ken even alluded to, much of the medicaid care coordination through managed care carves out mental health and manages it totally separately, and now much of the drug costs is also carved out in many places, so that you don't have the integration for that disability population that could help. but we are focused increasingly -- i have to make sure i get the right arrow -- increasingly today on the share of medicaid spending that goes for the dual eligible population. and as you see from this slide, there are about 15% of total medicaid enrollment are people who have both medicaid and medicare coverage, but the -- and they account for 38% of overall spending. and a huge part of that is long-term care services. but i'd like to point out really if you're trying to manage that low income, disabled population there's another 10% of the medicaid population that are disabled and a few nonmedicare eligible aged that account for another 28% spending. so i would say within the medicaid program we really need to look at how to really better manage and act

here the data by time, ken alluded to these two, i've broken things into decades since the '40s. and what you see is you see some variation around that average, but there's usually something happened in those decades that departed a lot from the average. medicare, med cade, managed care introduction in the '90s, the recession in the last decade, but what's remarkable, to me, and the reason i put this up is to give some perspective, that this issue of cost growth is a common across countries and, b, has been going on for a very long time. so what i take from that is that while the u.s. certainly spends a lot more than everybody else, that must be something that u.s. specific. but the growth issue must be something that's common to countries and to decades. i take ken's point that, what's -- things may have changed over time in terms of what's driving this, but i still think it's important to keep in mind that this is not -- whatever is happening here is not necessarily a result of things that are specific to the u.s., which we naturally tend to get wrapped up in. the second point