Economic Impacts of the Arkansas Private Option. Chris Brown, John Bennett Regional Economic Models, Inc.

Transcription

1 Economic Impacts of the Arkansas Private Option Chris Brown, John Bennett Regional Economic Models, Inc. August

2 Executive Summary Arkansas increased access to health care by enacting Act 1498, The Health Care Independence Act of 2-13, commonly known as the Arkansas Private Option. Rather than adopting the standard ACA Medicaid expansion, Arkansas successfully applied for a waiver from the Center for Medicare and Medicaid Services to create its own variation. It expanded eligibility by using the available federal funds as premium assistance to allow the newly eligible individuals to purchase health insurance through the online marketplace. Under the guidelines of the ACA, new enrollees are covered 100% by the federal government for the first three years. The share falls gradually each year to 90% by As a result of expanding Medicaid, over 230,000 individuals enrolled in the first year. This expansion in coverage brought in just over $990,000,000 dollars to the state of Arkansas. This report examines the economic impacts of those dollars in the state of Arkansas in 2014 and the potential impact in each following year through The federal expenditures that go into insurance companies to provide insurance coverage cover all of the costs of the Arkansas Private Option. The dollar amounts represented in the study are of payouts to services rendered to the healthcare and insurance fields. Whether through inpatient care, outpatient care, physicians or access to pharmaceuticals, these services are provided by industries that exist throughout the entire state. We used our economic policy model, PI+, to evaluate the impact of these additional health care dollars on the economy of Arkansas and seven sub-state regions. The analysis accounted for the flow of federal dollars directly to private health practitioners, hospitals, ambulatory services, and other health care providers. As a result, we captured the second-order effects of intermediate demand for goods and services, and local consumption demand and investment, stimulated by the inflow of the new dollars. Intermediate demand increased by $230 million in 2014 and largely going to local professional services and real estate. Local consumption demand impacts retail primarily and any manufacturing of consumer-facing goods. Through a combination of these effects, those federal funds contributed nearly $511 million to GDP, or 0.41% growth, in Real disposable personal income grew by approximately $245 million. Total Dollars and Percentage Change in Arkansas GDP $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000, % 0.50% 0.40% 0.30% 0.20% 0.10% Total Spending Percent Growth of GDP $0 0.00% 2

3 Understanding the Results The Affordable Care Act is a complex law with many changes that impact our health care system and our regional economies. Through this report, we examine the Arkansas Private Option in isolation. Given that all the other changes in the ACA continue to happen regardless of the states decision to expand, it is appropriate to understand this issue by itself. The economic impacts presented here should be interpreted as occurring as a result of the decision to implement the new option. The non-expansion baseline includes changes in taxes and federal funding under the ACA that could separately impact the state economy. However, they are occurring regardless of whether the Arkansas Private Option is offered. The decision to expand Medicaid in Arkansas has grown the state economy more that it would have without expansion, and will continue to do so in the future. Once the state begins to cover a share of the cost - up to 10% by 2020 and beyond- it will have to determine how best to pay. When REMI conducted an earlier analysis with George Washington University on the potential impact of Medicaid expansion in Arkansas, we found that there is also large potential for savings on state health care costs and revenue gains from economic growth. Based on our earlier research, we found potential net savings through 2020 if the state adopted a standard Medicaid expansion. Those same savings apply to the Arkansas Private Option. However the state chooses to fund the state s share beginning in 2017, the state will still see positive economic growth. The graph below shows the potential economic impacts from cutting government spending across the board by the growing cost share. The economic impact is still positive into the future. However, it does decline as the reductions in state spending impact public sector employment and industries that supply it directly. Total Dollars and Percentage Change in Arkansas GDP When Accounting For State Costs Offsetting Other Spending 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 State Spending Federal Spending Percent Growth of GDP 0.00% $0 3

4 Economic Modeling REMI is a firm that specializes in the development of economic models that quantify the impact of development, natural disasters and policy changes on a regional economy. Our tools are used across the country at the state and local level by agencies such as departments of revenue, departments of economic development, and regional transportation and land-use planning organizations. Our model has been used to evaluate the impact of Medicaid expansion in over a dozen other states, including Mississippi, Arizona, Kansas, North Carolina, and Ohio. PI+ is a structural economic and demographic forecasting model. A full description of the model itself and the equations can be found in the appendix. Through a complex system of equations, PI+ incorporates the linkages within a regional economy using an integrated methodology. These linkages allow the user to introduce direct changes, such as external dollars going to health care industries, and simulate how they flow through the economy. The model is dynamic, capturing changes over time. Below is an image of the PI+ model structure. It is meant to represent the distinct linkages in a regional economy, as well as serve as a visual representation for how the model solves. 4

5 Methodology Our PI+ model for Arkansas served as a regional macroeconomic tool, allowing us to conduct a full dynamic assessment of the economic impacts from changes in health care spending. As a model, PI+ still requires an analyst to introduce outside shocks that are entered through distinct variables in order to generate results. These variables are described as policy variables. Referring back to the model structure diagram, each aspect of the model linkages contains policy variables that can be exogenously changed by the analyst. Through the process of selecting policy variables within PI+, the analyst can create a scenario that represents the policy question being evaluated. In this case, we chose several policy variables in order to account for the economic impacts of expanding Medicaid. PI+ then simulated the impact of the policy change across the seven regions within the state and generated results at each region. For the purpose of this study, we developed a seven-region, 70-sector, PI+ model of the Arkansas state economy. The seven regions are: Central, Northeast, Northwest, South Central, Southeast, Southwest and West Central. Central Northeast Northwest South Central Southeast Southwest West Central Of the money disbursed under the Arkansas Private Option, we assume 20% is used to cover administrative costs, with the remaining 80% goes directly into covering healthcare services. This follows the state s current legal medical loss ratio. The exact split is subject to differ but likely not by much. Our approach to developing the needed input data on expenditures across healthcare sectors followed several steps. First, a major Arkansas insurance firm provided payment data by five service types for 2014: Inpatient services Outpatient services Physician services 5

6 Pharmaceuticals Other Second, we took the 80% of total new expenditures by region, and allocated them proportionally among the service types above. Then we shared out the dollars for services across the healthcare industries in our model that provide these services: Ambulatory health care services Hospitals Nursing and residential care facilities In addition, 100% of the pharmaceutical expenditures were entered into the model as an exogenous increase in consumer spending on pharmaceuticals and other medical products. The sharing-out of the other four expenditure categories were approximations, based upon a brief literature review and consultations with the Arkansas Hospital Association. While these are imperfect, they can confidently be assumed to roughly represent the actual sharing-out of Medicaid expenditures (links to select sources are included in the footnotes): Service Categories NAICS Healthcare industries in REMI model Ambulatory Health Care Services Hospitals Inpatient 100% Outpatient 50% 50% Physicians 80% 20% Nursing and Residential Care Facilities Consumer Spending Categories in REMI Pharmaceutical and other medical products Pharmacy 100% Other 90% 10% The 20% of expenditures assumed to cover insurance administrative costs was entered into the model under insurance carriers and related activities. From the expenditure data by insurance company we know that roughly 68% of dollars goes to insurance companies located in the state. Therefore we modeled the local portion as new sales and excluded any impact from dollars going to out-of-state insurers. The approach for modeling the insurance administrative expenditures was different from the healthcare expenditures because we knew the portion that was spent directly within state boundaries. With the money going to healthcare industries we used an exogenous demand variable which allowed for leakage on direct impact. For future projections, this study used the baseline population forecast in the model to generate an annual percentage increase in the population by insurance region. Increases in Medicaid expenditures were assumed to be equivalent to annual increases in the overall population (with an aging population across much of the US, in addition to future realizations of the woodwork effect 1, this is a conservative estimate). The share-outs from 1 For our purposes, the woodwork effect is the phenomenon in which the public awareness generated by the drive to expand Medicaid enrolment among newly qualified individuals will make people who qualified for Medicaid before the 6

7 service categories to industries, and the ratio of expenditures between different service categories, were assumed to remain constant throughout the duration of the study period. Results were generated annually from In REMI s 70-sector model, pharmaceutical manufacturing statistics are captured as a part of chemical manufacturing. An exogenous increase in demand for pharmaceutical products would therefore be a stimulus to the chemical manufacturing industry in the 70-sector model, while in reality the benefits would be limited to the sub-industry of pharmaceutical manufacturing. To correct for this, REMI determined pharmaceutical manufacturing s share of total chemical manufacturing, and subtracted the difference from the simulation to avoid over-estimating the effects. In addition, REMI calculated the regional purchase coefficient of pharmaceutical manufacturing and took care to count the local demand for intermediate inputs into the pharmaceutical manufacturing industry. broadening of coverage more aware of their social assistance opportunities. Consequently, this group of people who were previously uninsured (despite qualifying for Medicaid) will come out of the woodwork to enroll for the first time. 7

8 Statewide and Regional Economic Impact Results In this section, region-by-region input factors and key macroeconomic results will be shown. All monetary values figures are denominated in nominal dollars. Regional totals may not add to state totals due to rounding. Statewide Region The results and input figures presented here are for the state of Arkansas as a whole, comprised of its seven service regions. Dollar amounts are denominated in nominal dollar units. Total Expenditures (2014): $991,754,871 Total New Enrollees (2014): 238,382 New Expenditures by Industry Ambulatory health care $340,259,808 $342,138,144 $344,404,513 $346,702,697 $348,933,507 $351,089,332 $351,684,066 services Hospitals $301,811,169 $303,612,521 $305,607,974 $307,630,739 $309,593,756 $311,490,433 $311,968,666 Nursing and residential care $9,070,508 $9,125,001 $9,186,103 $9,247,944 $9,307,905 $9,365,780 $9,380,265 facilities Pharmaceutical and other medical $142,365,571 $143,142,152 $144,079,943 $145,030,711 $145,953,392 $146,844,863 $147,056,759 products Insurance carriers and related $198,247,815 $199,355,029 $200,676,769 $202,025,133 $203,331,178 $204,592,509 $205,792,627 activities Total new expenditures $991,754,871 $997,372,847 $1,003,955,302 $1,010,637,224 $1,017,119,738 $1,023,382,917 $1,025,882,383 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 8

9 Regional Growth Above Baseline Total Employment 7,010 7,247 7,191 6,989 6,726 6,436 6,159 Real Disposable Personal Income (millions) Gross Domestic Product (GDP) (millions) $245.2 $273.5 $293.4 $306.8 $315.4 $320.5 $323.7 $511.1 $540.8 $553.7 $557.4 $556.2 $552.5 $548.0 Top Ten Employment Growth Sectors Ambulatory health care services 2,140 2,114 2,068 2,019 1,971 1,925 1,885 Insurance carriers and related activities 1,109 1,098 1,073 1,046 1, Retail trade Construction Hospitals Administrative and support services Professional, scientific, and technical services Food services and drinking places Personal and laundry services Wholesale trade

10 Central Region The results and input figures presented here are for the Central region, comprised of Cleburne, Conway, Faulkner, Grant, Lonoke, Perry, Pope, Prairie, Pulaski, Saline, Van Buren, White and Yell counties. Total Expenditures (2014): $302,600,989 Estimated New Enrollees (2014): 72,772 New Expenditures by Industry Ambulatory health care services $105,459,500 $106,178,470 $107,069,449 $107,976,445 $108,857,551 $109,713,646 $110,540,451 Hospitals $89,806,316 $90,418,570 $91,177,303 $91,949,675 $92,700,000 $93,429,026 $94,133,110 Nursing and residential care facilities $2,799,066 $2,818,149 $2,841,797 $2,865,870 $2,889,256 $2,911,978 $2,933,923 Pharmaceutical and other medical products $44,015,909 $44,315,987 $44,687,858 $45,066,413 $45,434,162 $45,791,473 $46,136,559 Total insurance dollars paid $60,520,198 $60,932,794 $61,444,102 $61,964,601 $62,470,242 $62,961,531 $63,436,011 Total new expenditures $302,600,989 $304,663,970 $307,220,509 $309,823,004 $312,351,211 $314,807,654 $317,180,054 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 10

11 Regional Growth Above Baseline Total Employment 2,790 2,914 2,911 2,839 2,738 2,622 2,511 Real Disposable Personal Income (millions) Gross Domestic Product (GDP) (millions) $112.9 $126.8 $136.6 $143.2 $147.4 $149.8 $151.4 $221.7 $238.0 $246.1 $249.4 $249.9 $248.9 $247.4 Top Ten Employment Growth Sectors Ambulatory health care services Retail trade Hospitals Construction Insurance carriers and related activities Administrative and support services Professional, scientific, and technical services Food services and drinking places Personal and laundry services Wholesale trade

12 Northeast Region The results and input figures presented here are for the Northeast region, comprised of Clay, Craighead, Crittenden, Cross, Fulton, Greene, Independence, Izard, Jackson, Lawrence, Mississippi, Poinsett, Randolph, Sharp, St. Francis, Stone and Woodruff counties. Total Expenditures (2014): $185,127,403 Estimated New Enrollees (2014): 44,521 New Expenditures by Industry Ambulatory health care services $63,700,582 $64,438,480 $65,223,514 $65,988,109 $66,710,887 $67,390,075 $68,024,213 Hospitals $57,106,101 $57,767,610 $58,471,375 $59,156,816 $59,804,770 $60,413,646 $60,982,136 Nursing and residential care facilities $1,763,814 $1,784,246 $1,805,983 $1,827,154 $1,847,167 $1,865,973 $1,883,532 Pharmaceutical and other medical products $25,531,426 $25,827,178 $26,141,823 $26,448,275 $26,737,967 $27,010,188 $27,264,353 Total insurance dollars paid $37,025,481 $37,454,379 $37,910,674 $38,355,089 $38,775,198 $39,169,971 $39,538,558 Total new expenditures $185,127,404 $187,271,893 $189,553,369 $191,775,443 $193,875,989 $195,849,853 $197,692,792 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 12

13 Regional Growth Above Baseline Total Employment 1,028 1,055 1,048 1, Real Disposable Personal Income (millions) $31.9 $35.5 $38.3 $40.5 $42.1 $43.3 $44.4 Gross Domestic Product (GDP) (millions) $68.3 $71.2 $72.5 $73.2 $73.4 $73.5 $73.5 Top Ten Employment Growth Sectors Ambulatory health care services Insurance carriers and related activities Retail trade Construction Hospitals Administrative and support services Food services and drinking places Professional, scientific, and technical services Personal and laundry services Monetary authorities - central bank; Credit intermediation and related activities; Funds, trusts, & other financial vehicles

14 Northwest Region The results and input figures presented here are for the Northwest region, comprised of Baxter, Benton, Boone, Carroll, Madison, Marion, Newton, Searcy and Washington counties. Total Expenditures (2014): $158,686,085 Estimated New Enrollees (2014): 38,162 New Expenditures by Industry Ambulatory health care services $53,678,458 $53,930,165 $54,170,822 $54,386,252 $54,581,590 $54,758,622 $53,461,242 Hospitals $48,846,177 $49,075,224 $49,294,216 $49,490,253 $49,668,006 $49,829,101 $48,648,515 Nursing and residential care facilities $1,494,623 $1,501,632 $1,508,333 $1,514,331 $1,519,770 $1,524,699 $1,488,575 Pharmaceutical and other medical products $23,445,409 $23,555,349 $23,660,462 $23,754,556 $23,839,875 $23,917,198 $23,350,535 Total insurance dollars paid $31,737,217 $31,866,167 $32,015,593 $32,158,458 $32,286,348 $32,402,310 $32,507,405 Total new expenditures $159,201,884 $159,928,537 $160,649,426 $161,303,850 $161,895,589 $162,431,930 $159,456,272 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 14

15 Regional Growth Above Baseline Total Employment 1,300 1,331 1,309 1,261 1,203 1,141 1,084 Real Disposable Personal Income (millions) $40.4 $44.3 $46.8 $48.2 $48.8 $48.8 $48.6 Gross Domestic Product (GDP) (millions) $88.4 $92.6 $93.8 $93.5 $92.3 $90.9 $89.4 Top Ten Employment Growth Sectors Ambulatory health care services Insurance carriers and related activities Retail trade Construction Administrative and support services Professional, scientific, and technical services Food services and drinking places Hospitals Personal and laundry services Real estate

16 South Central Region The results and input figures presented here are for the South Central region, comprised of Clark, Garland, Hot Spring, Montgomery and Pike counties. Total Expenditures (2014): $65,947,965 Estimated New Enrollees (2014): 15,860 New Expenditures by Industry Ambulatory health care services $22,937,311 $22,987,800 $23,079,364 $23,185,930 $23,298,186 $23,411,891 $23,524,457 Hospitals $19,074,737 $19,116,724 $19,192,869 $19,281,490 $19,374,842 $19,469,399 $19,563,010 Nursing and residential care facilities $651,633 $653,067 $655,668 $658,696 $661,885 $665,115 $668,313 Pharmaceutical and other medical products $10,094,692 $10,116,912 $10,157,210 $10,204,109 $10,253,513 $10,303,554 $10,353,095 Total insurance dollars paid $13,189,593 $13,218,626 $13,271,278 $13,332,556 $13,397,107 $13,462,490 $13,527,219 Total new expenditures $65,947,966 $66,093,129 $66,356,389 $66,662,781 $66,985,533 $67,312,449 $67,636,094 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 16

17 Regional Growth Above Baseline Total Employment Real Disposable Personal Income (millions) $17.3 $19.4 $20.9 $22.0 $22.9 $23.4 $23.9 Gross Domestic Product (GDP) (millions) $36.1 $38.0 $38.9 $39.2 $39.3 $39.2 $39.0 Top Ten Employment Growth Sectors Ambulatory health care services Insurance carriers and related activities Retail trade Construction Hospitals Administrative and support services Professional, scientific, and technical services Food services and drinking places Personal and laundry services Real estate

18 Southeast Region The results and input figures presented here are for the Southeast region, comprised of Arkansas, Ashley, Bradley, Chicot, Cleveland, Dallas, Desha, Drew, Jefferson, Lee, Lincoln, Monroe and Phillips counties. Total Expenditures (2014): $107,607,853 Estimated New Enrollees (2014): 25,878 New Expenditures by Industry Ambulatory health care services $37,538,329 $37,603,487 $37,733,154 $37,890,095 $38,060,675 $38,241,429 $38,421,100 Hospitals $32,879,619 $32,936,690 $33,050,264 $33,187,729 $33,337,138 $33,495,460 $33,652,833 Nursing and residential care facilities $951,863 $953,515 $956,803 $960,783 $965,108 $969,691 $974,247 Pharmaceutical and other medical products $14,716,472 $14,742,017 $14,792,851 $14,854,378 $14,921,252 $14,992,114 $15,062,552 Total insurance dollars paid $21,521,571 $21,558,927 $21,633,268 $21,723,246 $21,821,043 $21,924,674 $22,027,683 Total new expenditures $107,607,854 $107,794,636 $108,166,340 $108,616,231 $109,105,216 $109,623,368 $110,138,415 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal parameter that determines the total amount of demand that is supplied locally by each region. 18

19 Regional Growth Above Baseline Total Employment Real Disposable Personal Income (millions) $15.6 $17.5 $18.8 $19.7 $20.3 $20.7 $21.0 Gross Domestic Product (GDP) (millions) $36.0 $37.3 $37.7 $37.7 $37.5 $37.3 $37.0 Top Ten Employment Growth Sectors Ambulatory health care services Insurance carriers and related activities Retail trade Construction Hospitals Administrative and support services Food services and drinking places Monetary authorities - central bank; Credit intermediation and related activities; Funds, trusts, & other financial vehicles Professional, scientific, and technical services Personal and laundry services

20 Southwest Region The results and input figures presented here are for the Southwest region, comprised of Calhoun, Columbia, Hempstead, Howard, Lafayette, Little River, Miller, Nevada, Ouachita, Sevier and Union counties. Total Expenditures (2014): $79,886,743 Estimated New Enrollees (2014): 19,212 New Expenditures by Industry Ambulatory health care services $26,779,043 $26,778,255 $26,804,613 $26,834,351 $26,858,231 $26,876,930 $26,889,096 Hospitals $24,730,869 $24,730,141 $24,754,484 $24,781,947 $24,804,001 $24,821,270 $24,832,505 Nursing and residential care facilities $690,239 $690,218 $690,898 $691,664 $692,280 $692,762 $693,075 Pharmaceutical and other medical products $11,709,243 $11,708,898 $11,720,424 $11,733,427 $11,743,868 $11,752,045 $11,757,364 Total insurance dollars paid $15,977,349 $15,976,878 $15,992,605 $16,010,347 $16,024,595 $16,035,752 $16,043,010 Total new expenditures $79,886,743 $79,884,390 $79,963,024 $80,051,736 $80,122,975 $80,178,759 $80,215,050 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 20

21 Regional Growth Above Baseline Total Employment Real Disposable Personal Income (millions) $9.5 $10.7 $11.5 $12.0 $12.2 $12.2 $12.1 Gross Domestic Product (GDP) (millions) $24.1 $25.3 $25.6 $25.4 $24.9 $24.3 $23.6 Top Ten Employment Growth Sectors Insurance carriers and related activities Ambulatory health care services Retail trade Construction Hospitals Administrative and support services Food services and drinking places Professional, scientific, and technical services Monetary authorities - central bank; Credit intermediation and related activities; Funds, trusts, & other financial vehicles Management of companies and enterprises

22 West Central Region The results and input figures presented here are for the West Central Region, comprised of Crawford, Franklin, Johnson, Logan, Polk, Scott and Sebastian counties. Total Expenditures (2014): $91,382,032 Estimated New Enrollees (2014): 21,976 New Expenditures by Industry Ambulatory health care services $30,166,585 $30,221,487 $30,323,597 $30,441,515 $30,566,387 $30,696,739 $30,823,507 Hospitals $29,367,350 $29,567,562 $29,667,463 $29,782,829 $29,904,999 $30,032,531 $30,156,557 Nursing and residential care facilities $719,270 $724,174 $726,621 $729,446 $732,439 $735,562 $738,600 Pharmaceutical and other medical products $12,852,420 $12,875,811 $12,919,315 $12,969,553 $13,022,755 $13,078,291 $13,132,301 Total insurance dollars paid $18,276,406 $18,347,258 $18,409,249 $18,480,836 $18,556,645 $18,635,781 $18,712,741 Total new expenditures $91,382,031 $91,736,292 $92,046,245 $92,404,179 $92,783,225 $93,178,904 $93,563,706 The above dollars were used as direct inputs for the model simulation however not every dollar was spent directly in Arkansas. 32% of insurance costs were assumed to go out of state and therefore excluded from inputs. For each of the other four industries, the REMI model develops an internal ratio that determines the total amount of demand that is supplied locally by each region. 22

23 Regional Growth Above Baseline Total Employment Real Disposable Personal Income (millions) $17.7 $19.3 $20.5 $21.3 $21.8 $22.1 $22.3 Gross Domestic Product (GDP) (millions) $36.6 $38.4 $39.1 $39.1 $38.9 $38.5 $38.1 Top Ten Employment Growth Sectors Insurance carriers and related activities Retail trade Ambulatory health care services Hospitals Construction Administrative and support services Food services and drinking places Professional, scientific, and technical services Nursing and residential care facilities Wholesale trade