Can you hear me now? Yes. Can you hear me better? I cannot hear anybody else though. Oh, okay. Bruce, can you hear me? I can hear you. Yes. Yeah, I can hear you all. I can hear him. Okay. Tracy, are you there? Yeah, I'm here. My coming. Hello. We have a quorum. There's one person in the audience too. Just so you know. Oh, okay. There might be like Tater. Sure. We can let them in, I guess, right? Come on. Have we started a recording yet? Yes. Yes. So let me open this meeting by saying pursuant to governor Baker's March 12, 2020 order. Suspending certain provisions. The open meeting law. The meeting of the attack is being conducted via remote participation. So this is the call to order from. For the. October 20th meeting of the attack. And it looks like we have is our guests here. Yeah. Ben. Yes, great. So we have a special guest. Who will be presenting and discussing trains in the valley. And here, could we just ask the attendee if he just wants to come in too? Okay, thank you. Hello. Hi. Hi. I'm so sorry to. I'm sorry. I'm so sorry to interrupt, I suppose. So I'm a UMass student. We had an assignment to attend a public meeting. And I saw this one on the community schedule. And I was like, I thought, you know, a presentation on trains in the valley. It sounded quite interesting. And I noticed there was a public comment period. So I will say, I don't have a public comment to make. Okay. But I was hoping to see it. I hope that's all right. No, absolutely. I mean, the meetings are open to the public. So you're welcome. And I mean, we can put you back in the audience if you want. So. Audience would probably be better. I would hate to. That's fine. Can you, can you put it back out? Guilford. Do you have the power? I'm glad you're attending. Yeah. Welcome. You're welcome. Yeah. Thank you. My pleasure. I think I just moved him out. Okay. Great. So we do have another person in here. So it's up to you. Yeah, I guess we let them in and we just see like if it's Chris. I'm Lynn Strum or somebody else. The number is 7, 8, 1, 5, 2, 8, 7, 2, 5, 7. You can talk. Yeah, it's Marcus. Sorry. Oh, great. Technical difficulties. Oh, thanks for calling us. So. Still in the car. I hate to be home by now. All right. I'm going to turn you off and put you in the panel, Marcus. Thanks, Gilbert. Okay. Great. And. Yeah, so let's get started. So, um, I will just mention to, um, I'm Ben is going to be presenting for the bulk of the meeting, but that there is a TSO meeting at 6 30. And I know that Andy Steinberg needs to go to that and go for moreing. So I don't know, Andy, if you had any really quick updates for us or anything, otherwise we'll just turn the floor over to Ben to give his presentation. I don't have any updates. We appreciate you coming even though you have these meetings back to back. So. Thank you. Glad to be here. Okay, Ben. So take it away. Okay. I'm going to share my screen. Hopefully. Hopefully you can see the first screen, first slide that I put together. Is that correct? Yes. Okay. So I'm going to spend about 20 to 25 minutes running through a slide deck that I put together. Which, um, Which we'll give an overview of our organization. A little bit of overview of a rail service in the region. But the bulk of the presentation will be. Uh, mostly on East West rail. Sort of what's happened a little bit in the past because it's pretty difficult to summarize. Uh, probably 10 years of work. In, uh, 15 minutes. And then talk about sort of what's happening next and then what's going on in the region. And then talk about. Uh, Amherst could get involved with. So as I said, I'm going to do an overview here. I'm going to talk about, uh, also potential new rail service coming into the region. Uh, shortly. Hopefully in a few years. Um, so this just sort of a summary of the topics that I'm going to address. I should have flipped the screen before I started talking. So trains in the valley was, uh, founded by myself and a member of the community in North Hampton back in 2016. Uh, we sort of modeled our group on a similar group that exists up in Vermont. Called the Vermont rail action network. Uh, it's a community advocacy organization. We focus on improved and expanded pasture and freight service freight rail service. In the three counties that make up the pioneer valley. We really focus primarily on pasture rail. But we also spend time on freight rail infrastructure, safety and transparency. Uh, cause there's a lot. And one of the reasons we started the group was, uh, when I moved to this region about eight years ago with my wife, who grew up in North Hampton, it was very, very difficult to sort of find out what was going on with. Changes to the rail network here and new pasture service coming. And I mean, there was information in the newspaper, but very little information was available from mass dot at that time. And even today, there's still very little information available, which is, you know, again, one of the reasons that we created the group. A train to the valley is also one of the four founding members of a group called the restroom mass rail coalition. Uh, which I really will go into in this meeting, but if you want to discuss some more, we could talk about it in the Q and A. Um, just to give you a little bit of a flavor of the kind of thing we get, we get involved with, we often like to say, we do what others can't do, won't do, we don't want to do. And, uh, as you know, Amherst used to have rail service until late 2014 when the service, the remontor service was transitioned over to the north south line that runs north of Springfield. But somehow someone at Amtrak never got the memo that the signage should be taken down at the station. And that signage there hung around for a couple of years. And we started trying to figure out how to get the signage removed because it didn't make any sense to have signage for a station that didn't exist. Well, anyone who's dealt with Amtrak knows it's exceedingly difficult to work with Amtrak. Um, in the end, to make a long story short, we approached congressman McGovern's office. We gave him a draft of a letter. He sent it through channels. And we did it in about three weeks. All the signage was finally removed. But that's sort of a little bit of a flavor of sort of the really dozens or hundreds of things we've gotten involved with over the last six, seven years. So just a quick sort of overview of why we think rail service is important to our region. You know, obviously it lets people travel longer distances without the use of a passenger, sorry. A personal vehicle. It's easier access to New York City, large metro areas like Montreal, New York, Boston. Obviously environmentally friendly. And it gives us a public transit option to Bradley airport for many of us in the rally that there is no public transport option today to get to Bradley. The only option is basically if to drive. And we also think that it increases the attractiveness of our region as a place to live, to visit and work just as our proximity to the mass bike interstate 91 and Bradley airport is. There are, there is existing service in the region. The Hartford line, which runs from Springfield down to New Haven and onto New York and point south. There's approximately a dozen trains a day in each direction. There's the Vermont service, which is one train a day, which runs up starts in northern Vermont, runs through the valley down to New York City into Washington. There's the newer Valley flyer service, which is a morning service southbound and an evening service or late evening service northbound, which is sort of an add on to the Vermont, which has been picking up a fair amount of ridership now. And there's the Lakeshore limited service, which is in many sense east west ramp, because it's been operating for a couple of decades now between Boston and Albany with extended service that goes on Chicago. The timing isn't great, but as we always like to say, one train is always better than no trains. So we're happy to have one train and that actually makes it easier in the long term to enhance the service running east west in the Colorado. So the potential for new service in our region includes expanded service for extension of the Vermont, up to Montreal that services in design now and waiting for some funding, which should come probably next year. Obviously east west rail where there's a lot of work going on and I'm going to talk about that later in the presentation. And you're probably aware that there's a study also going on to look at the potential for service from between North Adams, Greenfield and Boston North Station. This is the so-called Northern Tier Pass through rail study. This opportunity is still at sort of the study phase. As you know, with transportation, big projects like this, everything has to go through a study really within MassDOT before you go ahead and do something. I mean, MassDOT doesn't add an exit on the mass pipe without a study. So they're not going to add rail service without a study. So we've had two studies for the east west rail service. We're in our first study for the Northern Tier Pass through rail potential service. And you have to say there's a lot going on with Pass through rail right now in Western Mass and all sorts of levels, like did not exist 10 years ago. Excuse me for a moment. So just quickly to summarize what's happening with the Vermont are going to Montreal. This has been under discussion really since 1995 when Amtrak withdrew its overnight service, which was some of you may know what's called the Montrealer. That was a nice service to have, but it really didn't help us in the valley because it went through in the middle of the night. If you wanted to get on at 2.30 in the morning in North Hampton, it was great, but most people don't want to do that. So the effort is underway to extend the existing Vermont service past its northern terminus in St. Albans up to Vermont. Since 9.11, it's very, very difficult and complicated to do that kind of stuff to get over the border. But there are real steps happening now. There's efforts underway to build a pre-clearance facility Montreal Central Station. If you've flown into Montreal before any Canadian city from the United States, you know, you go through customs and immigration for either country in Canada before you come to the United States. The same thing applied to the train when it crosses the border. And there's a need for some upgrades to the track between the international border and Montreal. Ball goes well. This will happen in a couple of years. But if you'd asked me a couple of years ago, when it was going to happen, I would have said in a couple of years. So we're still waiting at this point. Now I'm going to transition over to East West Rail. I'm going to talk a little bit very briefly about the history of this. Talk about the political sport that's there, the funding that's there, sort of what the next steps are, and sort of what Amherst can do about this. As one person said to me a couple of years ago, to make services like this happen, you really need two things. You need political will and you need money. And we didn't have that five, six, seven, 10 years ago. But the political will is there to do this now. And clearly the money is there to do this now. So now it's a matter of how do you get all the sort of technical things you have to do to design such a service, to implement such a service, you know, and to build such a service to make it happen. But now to quickly go through the brief history. In between 2013 and 16, there was a very extensive study that was done called the Northern New England inner city rail initiative. It looked at expanded service between New Haven, Springfield and Boston, and also Montreal, Springfield and Boston. The study was completed. They had 1300 pages of output. They finally decided that there should be one new train from Boston to Montreal, and eight new round trip trains between Boston, Springfield and New Haven, with connections onto New York. And no further action was taken after that study was done. Then a lot of things happened between 2016 and 18 that I really won't go into, but the governor made a decision. Governor Baker to initiate a second study of East West rail service. This study really looked at the potential for expanded service between Pittsfield, Springfield and South Station. And the outcome of that was, you know, basically a three to $5 billion project, which would add somewhere between eight and 10 trains on this corridor in some number of years, whenever they could get around to building it. But there was not a decision made at the time the study was completed to move forward. They wanted basically effectively to consider, sorry, continue with what they call the conceptual planning for East West rail. So now move forward to May 2021. Amtrak stepped up and said and issued a nationwide sort of conceptual plan for how they wanted to build out their network to 2035. And included within that plan was additional service between Albany, Springfield and Boston. They wanted to add two additional trains as a start on this quarter. So they basically that was sort of the third version of East West rail, if you will, that has come out in the last eight years. So now I come to this map or this chart, if you will, that we've created, which sort of summarizes that sort of whole picture. The red line shows the existing service today that's operated by Amtrak, the so-called Lakeshore Limited, which is this historic name of a service that runs on to Chicago, one train in each direction. You've got New Haven, Springfield, Boston, which is what the Neary study said they should work, move forward with. You've got Pittsfield, Springfield, Boston, which the second East West rail study said, looked interesting. And then you've got Amtrak, which runs Albany, Springfield, Boston. At the moment, it's not totally clear what NASDAQ is going to move forward with. It's just these are the options that are on the table. All of them potentially are interesting. All of them have different ridership patterns. All of them have pluses and minuses, but we're still waiting for sort of the word to come from Boston. What is this going to look like as far as moving forward? Now, talking about the political support, the big breakthrough, I would say, came in April of this year when Governor Baker announced that he'd agreed with Congressman Neal, Congressman McGovern, and other politicians in a so-called path forward for East West Rail. Governor Baker for many years has been, I would say, hesitant to move forward with this project for lots of different reasons. I think he would say that he needed more information. But eight years went by, two studies were done, and I think sort of from my take, there's a lot of federal money now on the table that makes this really something possible that could happen. And he sees that as sort of the reason why we should now move forward with this. So you've got all of the key players here at the table. This is a Springfield Union Station. Obviously, they're smiling. There was a picture. And so the political will, for Governor Baker to be behind this project now, is a really transformational step for East West Rail, because going back the last eight years, there was really no green light for this project. They were happy to study it. They were hesitant to talk about it, but they weren't ready to move forward with it. The missing piece in this, which you can't really see in the picture is, you've got a lot of legislators in the Eastern part of the state that have, you know, maybe different priorities. The MBTA clearly has a lot of issues. It needs a lot of money. But the key here right now is that there is an incredible amount of money available now, state money and federal money in 2021. The state passed a transportation bond bill with $50 million put in there for potentially for East West Rail. In November 2021, the federal government passed the Infrastructure Investment and Jobs Act with $66 billion, $66 billion with a B for enhancing inner city pass through rail across the country. I mean, that's a lot of money for inner city pass through rail. We're never going to see probably that kind of money ever passed by the federal government again. So that's the kind of federal money that's there to make this happen. Granted, there's going to be a lot of states and of course Amtrak looking to use that money. But these are the kinds of funds that can make East West Rail happen. And then in August this year, the legislature again passed the infrastructure, a new bill called the infrastructure bond bill, which included $275 billion of state bonding authorization that could be matched with federal funds for moving East West Rail forward. The federal funds that will become available will be on a 80 to 20% match. So $275 million plus 50 will probably give you somewhere around just north of $2.5 billion of money towards this project. To put that in perspective, the Neary study said this project would only take about half a billion dollars. So how much is this is really going to cost? We don't know really yet, but the money looks like it is there. So what are the next steps? When the legislature passed the infrastructure bond bill, they included wording in there to create a temporary East West Rail commission, which is mostly made up of legislators and the head of the planning authorities in our region. And they're going to get together very shortly to begin to discuss what the governance structure looks like for East West Rail. Who's going to basically run this? Is it going to be MASTOP? Or is it going to be run by a separate Western MAST Rail Authority, which is what MASTOP has recommended? There's pluses and minuses each way of doing it. I can't get into that here because they wrote a 30-page white paper on it. It's too complicated. But neither is to say this commission is going to meet. Things are going to happen and this is another step forward in making this potentially happen. There's a grant program called Christie that's first round is coming out, one and a half billion dollars. And it's my understanding that MASTOP will have an application in there for some level of funding to move some of the early design and engineering work, I think. I mean, they haven't said anything, but I think that's going to be included. They're going to apply for some money to move forward with this as far as the next step. And clearly we're going to have a new governor in January. And that new governor is going to come in probably with a new mandate for how this is going to move forward. I think if it's more healing, she's clearly said that she wants to move forward with East West Rail, and she will appoint a key person who will basically manage this project and push it forward. So now I want to sort of step back a little bit and sort of look at Amherst. Amherst is not on the rail line, of course, but Amtrak does, I'm sorry, Amherst does have a rail corridor that runs north-south. It's often called the Central Quarter. It's the route that is used by the New England Central Railroad today for their freight service. It's also the route that was used by the Vermont until it moved over to the North South Rail through North Hampton and Greenfield. We expect that there's going to be a new station built in Palmer for East West Rail. Sort of the logical thing that should happen is that Amherst needs to be connected if nothing else with a dedicated bus service operated by the PBTA to connect with the rail service in Palmer. So you could get on a bus in either Palmer or a UMass Amherst and connect and get on the train very easily without having to take the bus basically west to Springfield and then get on the train to go east of Austin. That would be a logical thing to do, I would think. But in the short term, where the opportunities arise, it's important for Amherst to continue to step up to support the need for East West Rail, support the need for the new station in Palmer because if there's no new station in Palmer, that means the really the only option is for our whole region is everybody has to go to Springfield. And for people just east of Springfield, that means going backwards before you get going in the direction towards Boston. And then thinking about a dedicated bus going to Palmer. And in the long term, because you do have the rail quarter in place and the tracks in Palmer are actually already lined to go to Boston. It would be really easy if you had a magic wand to have a train that went from Brattleboro to Amherst to Palmer to Boston or from Brattleboro to Amherst to Palmer south to Yukon and New London. These kinds of things are possible, but we need to walk before we run. So we need to get East West Rail well along on its way before you start pushing for sort of the next step. But one of the things we always like to say is if you want rail service, the tracks really need to be there already because it's probably in this country we're not in a position where we're going to put tracks where they don't exist already. Because if the rail quarter is not there, it's really, really, really difficult. In this country in particular to put a new train track in today. It wasn't so difficult in the 1800s. It is pretty difficult today for a lot of reasons. So that's sort of the end of my presentation. I've tried to keep, I think to the 20 to 25 minutes. I hope I haven't gone too quickly or summarized too much, but I'm happy to answer any questions you might have. Bruce, you should go. Thank you very much for all your hard work. My question is mostly about is there any idea of what the speed of the trains would be? Would it be competitive with driving and with taking a bus to go from Boston to Springfield? Yeah, just one second. Let me get my screen to come back so I can see you. Yeah, okay. Yeah, so the plan is that the trip from Springfield to Boston as example will be in the range of probably an hour and 45 minutes. I can't recall at the moment what the pitchfield time is, but it's basically an hour and 45 minutes. And the speed, the top speed will probably be 90 miles an hour. But that really depends on the track. There's areas up in the mountains before you get to Worcester where you can't run at 90 miles an hour. But what they would do is they would get it up to the speed that they could, the maximum speed they could handle with the curvature and basically the track. But in the bottom line, they want an hour and 45 minutes. And I assume this would be diesel rather than electrified. There's no talk at the moment about electrified service. But so it would be diesel. Okay, well, thank you very much. Christine. I wanted to ask is the organization that you're associated with trains in the valley, is that a volunteer organization? It's totally a volunteer. We just, we're trying to see this move forward. We try to sort of step into shoes where no one's standing in the shoes. And sort of the most important thing I think we do is we run a website which has more information than anybody has on this topic anywhere. We try to make the public aware of what's possible. And what they can do to sort of speak up to their elected officials. And I'd like to think that some of the work we've done has really helped to sort of move this forward at the sort of grassroots level. But yes, I know the Pioneer Valley Planning Commission has been involved in promoting rail travel in Western Massachusetts. Do you work with them? Yes, we, we, we, we work with, we have worked with them. We continue to work with them. The former executive director, Tim Brennan, who tragically passed away was very supportive of our work. And right, but he was very helpful with sort of nudging us on to try to, you know, make this happen. At least from our perspective. And I'm just curious, I'm going to just ask one more question. My former boss, Jonathan Tucker was very active in promoting rail travel when he was planning director in Amherst. Is he still, is he involved in what you're doing now? I don't think so. No, I don't know the name actually. All right. Thanks. Thanks very much. Anybody else? Well, I have an idea of a question about just the north south rail, like when you were talking about, like if it was ever expanded back to the east side of the, east side of the Connecticut, like Brattleboro to Amherst or anything. I mean, I, my understanding is that that's the only reason that the tracks changed over to the west side of the Connecticut is that the tracks on the east side of this, the reverse in such bad condition. So like that seems like that would require a lot more infrastructure money and so on. Well, the corner that that runs north of Springfield was in incredibly bad condition 10 years ago. The freight trains on that line could only run 10 miles an hour for the most between Greenfield and Springfield trip from four hours for the freight trains to get greenfield to Springfield was sort of ridiculous. And a lot of federal money became available to increase the speeds on that line. And now there's, there's stretches where it's 80 miles an hour, including, you know, north of North Hampton, in particular, the line that runs through Amherst is primarily a freight quarter today, but I think the speeds there were in the range of 40 to 60 miles an hour. So it wasn't fairly good shape. And obviously it could be improved further. If the money was there to do it. But the real question is put pass through rail on that line. There needs to be sort of a ridership demand for, for running trains of that line. There was a study that was done to do that. About eight years ago. And I think the study at the time in a different, in a different time period, didn't show the ridership to build a quarter from Gratterborough to Amherst to New London. But it didn't say that it couldn't happen in the future. The tracks are there. You know, if, if we were to really start to transition away from the automobile to taking trains, like happens in Europe today, you know, the potentials there to make that happen. Well, and I mean, I remember seeing some Amtrak numbers about them. Since the Amtrak, you know, was expanded to have the value and so on that. The North Hampton Amtrak stop is like, had a huge amount of growth and it's like one of the busiest stops. So it seems, you know, that there is a lot of potential if that was. Yeah, North Hampton will probably have over 30,000 riders this year. Yeah, post COVID. I mean, I mean, compared to like places like Holyoke and things with the ridership is like still smaller. Part of the problem with the valley flyer and the Belmont are in the valley is that it's, sorry. The fairs that have been set by Amtrak are really targeted for intercity travel to New York. So if you want to travel from Greenfield from North Hampton to Springfield, they've set the price of $12. Nobody's going to ride the train for $12. Unless you want a joy ride. So we need to move to sort of the next step as to how do we fill empty seats with more competitive fairs for people who could want to go to Harvard. I'm sorry. Hartford, New London. I mean, we know that there are students who study in New Haven that take the train from New North Hampton down to New Haven. But sort of part of the problem is the train comes back really, really late at night. So it's not very attractive. So we've got to move to this next step past the valley flyer to say, how do we make this work in a way that is not just for people want to go to New York. Or yeah, I mean, I've taken it a number of times to go to DC actually. And the fair, I mean, the last time the fair was like, it was just, you know, it was like a $20, $30 fair. But, but it is like always late night. So you've had a question. Hey everybody. So first of all, I want to say this is super exciting and I'm really glad I came back to this meeting to hear this presentation. Thanks so much for doing it. And it's really great. And I had a question that was sort of related to what you said about people transitioning from cars to trains. I've been following a lot of the state legislation on how to decarbonize. So and the clean, you know, clean energy plan and all that kind of stuff. And I know that, you know, the latest report basically said the next, the next sector that now has the most carbon emissions is transportation. And a lot of people are saying we need to think beyond electric cars because they're not available to everyone and they're not, you know, as much of an environmental justice. So one question is whether this is being linked to that plan and is there any kind of either political will or messaging or money that can be brought to this kind of effort to increase a mode shift that would enable this or support this. That's one question. And then the second question is, I lived in Eugene, Oregon for a long time. And Amtrak contracted out to have some buses that run from Eugene to Seattle. So you could take like an Amtrak bus and that supplemented the Pacific, you know, line that didn't run as often. And I'm wondering if anything is, you know, if that idea has been thought about for some of these shorter hops like the valley. I'll take the second question first. I don't think there's been efforts yet to think about providing an Amtrak operated connecting bus. Possibly because the service by the PBTA is pretty robust in our region. With that said, it's not stated it couldn't happen. It's basically someone would need to look smashed out how to have to initiate sort of a mini study to look at what the potential is there to do it. Vermont is running buses now that connect with their Amtrak service. And I think it's been doing quite well. The second. Sorry, coming back to the first question. I haven't seen a whole lot of discussion. About people sort of at the governmental level that are looking towards how do we transition from personal vehicles to, you know, inner city rail yet. Our network in this country for inner city rail is very thin outside of the Northeast quarter. We've been working with the exception of some states like Oregon, Washington, California. And around Chicago. We're sort of not really there yet to do it. But it is, it doesn't say that we couldn't be there. It's a different mindset to take the train. You know, we're on the, on the valley flyer, the volunteer. We basically since it was shifted, seeing growth in about 10 to 15% per year, which is healthy growth. So it takes a lot of time to get people to think about how do you get on a train versus driving when, you know, You've never done it before. You know, all my neighbors, I live in Hatfield. No, they know what I work on. And they say I've never been on a train. So it's, it, it takes a while to sort of get over that hurdle. So, so what do you think is the most important action item for us as an attack? Do you have a suggestion? I think it's important to follow what's going on and to be ready as needed to sort of speak up to make sure that our elected officials are really sort of pushed on this topic to move it forward. You know, my fear with East rest rail, to be honest, is that it takes 10 years before we see a train run. Because these projects can become incredibly complicated. It's, you know, you've got to get trains to Worcester, which is operated on a quarter rail quarter, it's owned by a freight rail company called CSX. And then you've got to get the trains to run past Worcester on a quarter that's operated by the MBTA. And it very well could be the MBTA says, well, we can't run additional trains, our tracks are full at the moment. So it's important coming back to your question that, we have to keep the pressure up until the trains are running basically, we have to keep the pressure up on getting a station in Palmer and getting the service running and getting the service running, you know, as quickly as we can, even if it's an incremental build, meaning you don't have to wait to run 10 trains all at once. If we had two or three trains, I think most people will be happy with that. If you could get to Boston in the morning in an hour and 45 minutes from Springfield, or maybe an hour and a half from, you know, an hour and 40 minutes from Palmer, I think most people will probably be pretty happy with that. And then back in the evening at a reasonable time, one or two trains, that there'll be a great start.  So I mean, there are people, right? I mean, when I first moved out to Western Mass, I was commuting to work in downtown Boston, and I would commute at least, you know, usually like twice a week. And a lot of times I would take the train, I would take the, the Worcester line or something. And so I would ride dry from Amherst to Worcester, and then get the train into downtown station. Downtown crossing. So, I mean, I guess the thing is, I mean, for people from, I guess from Springfield, it makes no sense. So yes, to go to Palmer, but like from up here, like, you know, from Hampshire County, I'm not sure it would save a lot. You know, if I had to drive, like if Hampshire County or Franklin County people had to drive to Palmer first, you might as well just go right to like T route. I mean, there's even been like various, like the FRTA and things have run various bus services to get to, to, to the rail, like Worcester or to get to the rail that goes into like North Station. Yeah, there was a PB like the Fitzburg line or something. So I'm just, I mean, so for Hampshire and Franklin County, it's not as good a connection. I think Palmer. Right. I think there's two things going on. What if there's a PBTA bus that runs from UMass to Amherst downtown and then I think our long route nine to Worcester to specifically connect with the MBTA commuter rail. I'm not sure how well that's doing. They've tried various ones, like over the years to try to get people to go to East, but some of them is like something kind of scoop through like a bunch of the Hilltowns and things. And they're actually, they take really long time. Yeah. And I think the other thing is there is the logical step would be that the sort of service that runs north of Springfield. So you could get on a train from Greenfield and connect in Springfield, step across the platform and go to Boston. They would connect those services. So you would be hopefully seamless. That would be the logical thing to do. Yeah, but that's that kind of thinking is pretty far down. We're not up to that level thinking. We're just in terms of like ridership. I think the Springfield Boston connections, you know, just the most important in terms of attention. I mean, Greenfield is not, there's not so many people in everything. Right. And really what's important too is that the train be able to pick up ridership in Hartford. Because when they did the first study, it showed that the vast majority Russians in the vast, but a lot of the ridership came from central Connecticut. So it was people who wanted to get on the train in Hartford and get to Boston by Springfield. Okay. So it's, you know, there's, there's a whole corridor of people between New Haven, Hartford, Springfield, Worcester and Boston that want to see this service happen. Sure. Because if you're in Worcester, it's different. It's not so easy to get to New York City by rail. You sort of have to go into Boston backwards and then go down or drive down to a lot of people drive down to New Haven. Yeah. I see one. I see a hand from Bruce. Do you know if there's been any more discussion of electrifying the line between New Haven and Springfield? So there isn't that transition of engines that takes 15 or 20 minutes. Yes. Connecticut's actually, I believe, about to initiate some level of study that's going to look at that. Because of the federal dollars that are available, they're taking that up as something they're interested in doing. So it's the potential is there that it could move forward. Well, that would be good because it would save time going to it from New York and going further south to Washington. Yeah. The other thing that's happening is Amtrak is in the process of purchasing a whole new fleet to operate in the Northeast quarter. And the new engines will be able to, there will be some engines that can transition from diesel to electric without changing. Oh, that would be nice. Yes. Oh, thank you. Yep. Well, and isn't there something too that happened? No, I've been on the train in Springfield at Union Station. And sometimes when it's running, it actually needs to like back up. And can, I mean, does that, is that for all the, like only some runs or. Cause that's another delay that it's like, you know, what's happening that we have to wait for this. So. We're still suffering from decisions that were made decades ago. The tracks and switches aren't set up correctly anymore in Springfield. Okay. Service that runs north and south. So when the Vermont, as example, comes into Springfield from, from the North, it's got to pull down and then back into the station. And then head out. Same thing with the Valley Flyer, even though the Valley Flyer train set. Is configured to run in both directions. Mass dots just kicked off the study. And that's another study to reconfigure all the tracks. And to build a layover yard for East West rail. Near Springfield. And if that project moves forward, which I suspect it will, the money's available, they will reconfigure the tracks. So these backup moves will come to its top. You know, you just put in the train or basically pull into Springfield, change directions and pull out. Got it. Yeah. The, you know, the, the revised station, the renovated station, there's beautiful, but it just doesn't, it doesn't have like the whole capacity. They renovated the station. They didn't renovate the tracks. No. Thank you. Yep. And so I don't know, we do have. Andy, are you still here? I know he had to run to another meeting, but Andy Steinberg is on our town council. Yes, I am. No, just in terms of, I mean, I was curious just to the extent to which the council has talked about, like East West rail. I don't think the council that I can recall. Has ever had a conversation about East West rail, because nobody's brought it forward to discuss. I feel like there was like a resolution or something. I think there was a resolution a couple of years ago. That's what I was recalling. Yeah, I'd have to go back and look. Okay. Thanks. Christine. Hey, you said that we should keep track of what's going on. And what is the best method to do that? Do you think like reading the Gazette or. Well, what's the best way of getting information? Probably the best way is to follow what we're doing on Facebook. If anyone's on Facebook, you can follow our page trains in the valley. We don't post very much and we really try to keep it on topic. We stay way away from sort of the sort of railfan type stuff. People taking pictures of trains. We're interested in getting information out to people that's actionable and useful for, you know, moving this topic forward. So that's probably the best way to sort of see what's going on. Because if anything happens, it goes on our Facebook page. Thanks. Eve. I was wondering if you'd reached out to your math students, because that seems like they could be great advocates for this. We did reach out about four or five years ago. We had a couple of meetings who were trying to organize. Sort of a panel discussion. And unfortunately, we got into spring term. It sort of didn't happen. We could try again, but at the moment we, we'd have to sort of renew our contacts to make that happen. If you had some contacts that you would suggest, I'd be, I'd be happy to hear about them. Well, Tracy's a fan might be one of them, but. Wow. Well, I don't, you know, work with students as much as you use. I think that could be another one actually. Yeah. I mean, there are a number of student groups on campus.  But there are a number of advocacy groups. So, yeah. There's so much work related to climate change. And people are really thinking in creative and broad minded ways about it these days. I just think that this could really be something that people would be excited about. And I, and I think the most salient point that you brought. To us is the fact that there's money available at the moment. And so having, you know, groups like, like yours. Who have thought deeply about this for many years, you know, are really valuable in, in formulate, you know, having plans that are already formulated. And connections that are already generated. That have already been generated. Right. Or bringing ideas or continuing to, to enforce particular ideas that. You know, otherwise, I mean. So thank you for doing that.  That this money may be coming, becoming available. But you know, since you already have kind of a plan and you've been active for so many years. I mean, really what's happened here. Sort of it may sound a little wonky, but the stars are aligned. Yeah, right. I mean, it's been said by others, but between, between Richard Neil, between the Western mass delegation, between President Biden passing the infrastructure bill, between the money that's come out of the legislature, which is a big deal because it takes the legislators in the eastern part of the state to say yes to, you know, it's the stars really have aligned for this to happen. And I think with the new governor, you know, it really could really be full steam ahead as large. We don't get sort of ground down into the bureaucracy of MassDOT in the MBTA. And it takes too long. But you know, I think there'll be some real effort to make this happen as quickly as is feasible. You know, knock on wood. Yeah, thank you. Thanks so much for the work that you do. And the volunteer work that you do now that we know that as well. That's amazing. And then, you know, any of these advocacy efforts too, they just take so long. So. Yep. But, but somebody does need to be the owner of the information and the history and the real world, like understanding of how it works. So thanks for doing that. Yeah. Thank you. Okay. Thanks so much. So, um, yeah, Ben, if you want to, I mean, I don't know if you're on some of the emails or whatever. So we can, I have Ben's information. Oh, Andy has a question right now. He has his hands up, hand up. I just wanted to confirm the information that had been discussed before that there was a resolution that was passed by the council and because I did go through the file quickly while we were talking and the resolution was bad. Um, 19th of October, 2020. Okay. And you can find a copy of it. On the. Town council page. On the website. If you go to the bottom there, say. One link that says resolutions. Council resolutions. And then they're by year. So you can find it if you want to go through it. And then you can actually look at it. I thank you. That's helpful.  Um, if, if, if that resolution. Might want to be renewed or something added to it. Or even just putting a. Um, That there's, there's the possibility Andy in, in front of the council, like making just a one sentence item that you might want to put forward. Why don't you take a look at the resolution as I say, you can find it on the council page. And then if you want to propose something as a, um, you can get it through me and, uh, I'll take a look at it and see if it makes sense to bring it to the council. Yeah. When you look, you know, I didn't look at the resolution again. But as soon as he was mentioned that it was done, I thought it clicked, but I can't remember the content. Didn't. Okay. And I'm going to have to apologize because I'm going to have to sign off in about one minute. In order to transfer to another meeting. Yeah, of course. And I, I mean, that's about the start, but yeah, well, thank you, Ben. Thanks for coming tonight. I will. I will send you a copy of PDF. Okay. Great. You can share that with anybody that you wish. Um, and if there's any follow up by email, it's on the last page of the presentation. Just drop me a note and I'm happy to answer any question that somebody might have. Thank you very much. Thank you. Thank you for inviting me. Thank you. I know Gilford's going to go to. You want to be the host. Well, I'm going to run to the. Not me. To talk about parking. Maybe our meeting needs to adjourn now because I think so. We're losing enough people. I will just say, I, what do you guys, I mean, just a quick. Yeah, maybe one of us can just host for a minute or something.  I mean, in terms of our next meeting, do we think the TSO is only meeting once I think in November? I mean, do we just want to have one meeting in November? Possibly. What? I mean, we don't really have, we're sort of wait, we're in a holding pattern a bit, a little bit right now. I know that the town manager. You know, is interviewing people for tech. Um, I don't know. I mean, I mean, I don't know much that we've been asked to like, we, I mean, there are things that could be referred to us that haven't. I mean, I would like to follow up on some of the discussions we've had when we didn't have a quorum.  That was pretty interesting. And to see if any of us want to work on those things, but. Actually, I haven't. Heard anything from the town about staying on. So. I, nobody has reached out to me about anything. So, yeah, but I haven't heard either. Huh. That's it. They're trusting us. When my, when my term ran out, I was told that I needed to have like submitted an application to stay, which no one had bothered to tell me. So maybe you need to do that. I submitted an application.  I haven't heard anything. I mean, right before the pandemic. My understanding from the town manager is that there were people being interviewed and that. He will be putting a memo. To the council basically go through TSO and then to the council to say, you know, point a new person or two new people as well as. I mean, I, my appointment ended in 2021 too and things. So I think he was planning to kind of bring them all as a group. Yeah. Because we basically have a committee of people whose terms have expired. So. Any of nobody. No wonder we're not getting things done or whatever. But, um, but I don't know. I'm sort of leaning right now. It just November. All these fields like a busy month. So maybe we want to have one meeting. Sure. But I will send out the information trains in the valley info. And I'll look up the resolution. I also, there's information stuff going on at the state level. There's a beyond mobility project that mass DOT is working on. It's like their long range transportation plan. Um, they did do one public server. They actually have a public meeting tonight to discuss. The projects. Uh, but. They, so they did one round of online surveys and they're doing a second one. And the second one I thought was really interesting because it basically. Wanted people to identify, say, say you had like a hundred. You know, a hundred points or whatever, like how much should go to different things. Like where people actually have to like, you know, allocate and add it up. So because you can't do everything at the same time in terms of like priorities. So I'll share that link as well. And, um, Yeah, anything else? Oh, and I know that real customer had, Bob Costner had been in touch with us too about. Some study going on with, um, economic development and the bike trail. Right. To try to expand the bike trail. Like towards Boston. And so there was a, right? There, it is somewhat, um, but there's some sections. And one thing is that there's an economic impact study going on right now. You know, we're there when they're trying to set the interest, but also in terms of. I think as they're advocating for the next phase about what the economic impact could be like in terms of people. On the trail. I mean, this is all for. Um, The other side of Belcher town pretty much, right? Pretty much. Yeah.  Um, but if you had missed it, one of the things that we talked about with valley bikes too is trying to. Maybe, you know, try to maybe find some helmet, like a program or something to get helmets and things. Cause that's a big concern in mind, but that's not something that valley bikes is going to take on. So. Yeah. But anyway. Okay. So should we decide on a date for a meeting? Yeah. And I was just emailing Chris Lindstrom, because she's missed the last like three meetings and she does say that she. Thursday nights are not great for her. I, you know, I didn't get a lot of details on that. I mean, it seems like this is when we've typically met. We used to meet at five because then it would have less time to talk to each other. So, you know, I think that's the way it reflects with TSO. It's hard to sort of move our meetings to a different night. I mean, I think I'll talk to Chris. I'm going to start to give you a call tomorrow, but. I don't know. Do we want to just try to, but almost all of us are here right now. And it seems like it works and it's good for working people. So have it after hours. Yes. Because I was when I was first on the public transportation committee, I was like, I don't know. I don't know. That would not work for me. That's. Yeah. Okay. So. So what do we think? Do we just. So I guess I prefer, you know, especially one Andy to come because Andy hasn't been able to come because he often has a conflict with TSO. TSO is immediate on the 10th. You know, maybe we just meet on like the 17th. Yes. After that next meeting. Yeah. And then because the count, the town manager said. It does have to go to TSO for approval. Oh, we might actually. Yeah. Right. It would be the week because right. Yeah, exactly. So maybe we'll have new people by then. Okay. 17. Maybe we've been voted off the island by then. No. I was contacted and I am to be replaced. So if I don't see you all again, it's been a pleasure. Bruce. They said, you've been on for a while. So. Oh, absolutely. No, it's been a long time.  I was on the planning board for eight years. Wow. Remember, remember Chris. Yeah. Thank you, Bruce. Thank you all. And I might see you again. I think it depends on when they appoint the new people, but yeah, they did say that. And I agreed to be replaced. So it's not like I'm being kicked off. I just was asked if I would mind. And I said, I'm happy to serve and I'm happy to have somebody new. You know, to, to, to join. Thank you so much, Bruce. Thank you. It's been a pleasure getting to know you too. Well, thank you very much. I appreciate that. Yes. Thank you. Thank you. And maybe I'll see you once in a while, just as a guest. And on the bike. And on the bike trails. Right, Bruce. In the bike trail. That would be true. Exactly. All right. Okay. Good night. Good night. Bye. Thank you all. Bye bye.


Okay, so I just want to have a conversation today. I spent four and a half years working on the Hill three and a half years at the House Oversight Committee where I led the committee's oversight of health care programs and entitlement programs and where we did a lot of work on Medicaid. And what we were looking at mostly was the techniques that states use to inappropriately pass costs off on the federal government and how the federal government doesn't really do an effective job of doing oversight of state Medicaid programs. There's a lot of problems with Medicaid and it is the fastest growing program at the federal and state levels. So interrupt me, ask questions, whatever is on your mind. Two main points on Medicaid. The first point is that Medicaid doesn't serve taxpayers or enrollees particularly well and needs fundamental reform and if you're not convinced of that, I hope when you walk out of here today you are convinced of that. The second and something that I spend a lot of time thinking about and working on is that the financing structure leads states to figure out ways to bring loads of federal tax dollars into their state with relatively little incentive for how well that money is spent. Okay, one of the key things, I'm going to go through a couple main sort of basic things to know about Medicaid. Some of you may know all this, some of you may know some of this, I'm sure some of you know some of this. First thing to realize is that there's an uncapped federal reimbursement of state Medicaid spending. Okay, before the Affordable Care Act is afforded for traditional Medicaid populations and traditional Medicaid populations are lower income children and generally their mothers, pregnant women, disabled, so if you're on supplemental security income SSI, you qualify for Medicaid, and also lower income seniors, you can be what's called dual eligible, so you're on Medicaid and Medicare. The reimbursement percentage is based on state per capita income, so the wealthiest states receive a 50% reimbursement. The poorest states typically receive about a 75% reimbursement. On average, if you look back from sort of when Medicaid started in 1965 through 2013 before the ACA Medicaid expansion, the national average was about 57%. Some years that went up during times of economic recession, Congress often found that one way to get aid to states was by increasing the Medicaid reimbursement, so most recently that happened in the stimulus that passed in 2009 that significantly increased the Medicaid reimbursement for states and that was one of the ways the federal government tried to get more money to states who were suffering obviously from the recession. The ACA added a new mandatory population, right, everyone below 133% of the federal poverty level. As was mentioned in the previous panel in 2012, the Supreme Court in a 7-2 decision said that was, Congress didn't have the authority to make that Medicaid expansion mandatory. John Robertson's decision said that's like holding a loaded gun to the state's head because they were threatening to take away all state Medicaid funding for states that didn't expand, so they made that an optional population. But there was a large incentive for states to expand Medicaid in the ACA. From 2014 to 2016, the federal reimbursement rate was 100% for the expansion population. It starts in 2017 to gradually decline. In 2020, it is 90%, and that's the rate that it stays at indefinitely. Medicaid has mandatory versus optional benefits. I listed some of those there. Many states expand their Medicaid programs to cover more than the mandatory benefits. This slide, which is too small a font, unfortunately, shows Medicaid spending by enrollment group. So here are the percentage of enrollees. You can see 48%, I'll read the numbers out, 48% of enrollees in 2013, so this is before the expansion in the ACA were children, 25% were non-disabled, non-elderly adults, 17% people with disabilities, and 9% people who are over the age of 65. And you can see, so Obamacare, what the ACA did, I'll use ACA and Obamacare back and forth, was expand generally this area, so this is going to be much larger now if these numbers were updated for fiscal year 2015. Even though children were about 50% of enrollment, it's relatively small piece of total expenditures. Children are relatively cheap to cover, just 20% of total expenditures, non-disabled adults, also pre-ACA, a relatively cheap population to cover, 16% of total Medicaid expenditures. Here are the sort of two big pieces, the aged and the disabled, total about two-thirds of Medicaid expenditures. The Medicaid program is growing rapidly. These figures here show inflation adjusted amounts. This is, when you see the 1970 here, this is what the equivalent dollars would be in 2015. So the graph is not spaced perfectly here. So you see 1970 to 2000, there's a pretty big jump. And then if you start in 2000, we're tracing every year this area right here, this spike is going to be the Medicaid expansion and you see it just continues its upward trend. CBO in January released their numbers, estimated numbers for 2015 and they have the federal spending at $350 billion. And they said that the federal government now, remember the historic average was 57%. In 2015, federal share was 63%, which is a huge increase. It may seem like only a 6% increase, but when you think about the magnitude of the dollars, it's a huge increase. So we've about $350 billion in federal Medicaid expenditures, about $555 billion total in 2015 when you include the state share. Enrollment is largely driving the increase in expenditures. So this shows enrollment from 1965 through 2015. Again, you see, one of the interesting things is from 1975 through 1990 enrollment was relatively flat. But starting in 1990, we have had lots of state Medicaid expansions prior to the ACA. States have just expanded Medicaid eligibility and then you have this most recent spike here with the Affordable Care Act population. Another really interesting story with Medicaid is that states programs are very different and states spend a lot, dramatically different amounts on enrollees. So what I did was, and this data comes from Kaiser, and I think it is 2011, 2012, or 2013 data. And what I did was show the top two states in spending per enrollee among the four categories and the bottom two states. So you can see average Medicaid spending per aged enrollee. Wyoming and North Dakota are both over $30,000. And Illinois and North Carolina are just over $10,000. So a 3 to 1 ratio between the highest spending states and the lowest spending states for aged enrollees. Disabled enrollees. New York and Connecticut, both over $30,000 per disabled enrollee. Georgia and Alabama, just over $10,000. So again, a 3 to 1 ratio. Average spending per adult enrollee. New Mexico and Montana, both above $6,500. Maine and Iowa at the bottom, just above $2,000. Again, a 3 to 1 ratio. Yes, non-disabled adults, yes. And then children enrollees. Vermont and Alaska at the top of the list. Florida and Wisconsin at the bottom. And again, you see more than a 3 to 1 ratio. Right, so the differences are dramatic. One of the reasons for the federal financing to work the way it did was so these differences wouldn't be as dramatic. The theory behind giving poorer states a higher reimbursement is that that state tax base is going to be less able to finance Medicaid expenditures. Then a wealthier state like New York or Connecticut. They're very wealthy states. So the federal government's going to send money from New York and Connecticut to poorer states like Georgia and Alabama to help those states spend more. And one of the things that we're seeing is that that hasn't worked very well. These wealthier states are, instead of the transfer going this way, these wealthy states spend so much. So look at New York. They're getting 50% of their spending reimbursed by federal taxpayers. So federal taxpayers are spending half of $34,000. So $17,000 goes from the federal government to New York for each disabled enrollee. Alabama has a 70% reimbursement rate. So Alabama is receiving $7,000 per disabled enrollee. So $17,000 going to New York per disabled enrollee, $7,000 to Alabama. So the federal share of these expenditures is also much different and hasn't worked out in the way that when they came up with the FMAP formula that it was designed to work. Yes, sir? I think the reason is because these states have a wealthier state tax base and they have just been able to spend more. So even though they receive a lower reimbursement percentage because they're spending so much more from their own state tax base, they are receiving more in federal contributions even though they have a lower reimbursement percentage. Does that answer your question? That's a good question. And the answer is probably generally no, but certainly something that needs to be studied. Whether this leads to better outcomes. Now you would think it does lead to probably nicer nursing homes in Wyoming and North Dakota than in Illinois and North Carolina. I would expect that because these are largely, I mean spending per agent enrollees for Medicaid is largely going into nursing homes. And that's something I should mention is that Medicaid covers an enormous amount of long-term care expenditures in the U.S. So about 70% of long-term care expenditures are paid through either Medicaid or Medicare. Medicare will pay for the first 100 days in a skilled nursing facility right in nursing home, but after that Medicaid picks up the responsibility for reimbursing. So I think it's between 40 and 50% of long-term care expenditures are financed in the U.S. through Medicaid. Okay, this slide is next three slides. I created late last night to sort of walk you through the financing here. So they're not in probably in Mercatus format. So the graphic arts people in Mercatus will be very mad at me, but oh well. Consider a state with a 60% federal match rate, right? That's the typical scenario. If a state spends a dollar of its own funds, it gets $1.50 from the federal government. Why? Because 60% of $2.50 is $1.50. One of my dissertation advisors, I put this in my dissertation and I needed to explain this to him because he thought that a 60% match rate, they're not going to get $1.50. But they actually do. It actually looks like they're getting 50% more from the federal government and they are. But that's because the percentage is on the total. So a state spends a dollar of its own funds, they get $1.50 from the federal government. Now think about it the other way. A state is having budget problems. And they're trying to figure out where are we going to trim spending. In order for the state to save a dollar, they need to cut their Medicaid program by $2.50. So when states are making decisions about what to cut, are we going to cut from Medicaid, education, transportation, corrections, infrastructure. The way that the federal financing works makes it very difficult for them to cut from the Medicaid program. Because they're taking an additional $1.50 out for each dollar that they cut from the state. So the conclusion is, just with the way this formula works, is the open-ended reimbursement makes it very easy to grow Medicaid. See, and if someone had checked that I would have not put a bad word in there. Makes it very easy to grow Medicaid and very difficult to cut it. Okay, this slide is what I put together to show state expenditure growth from 1990 through 2015. So it includes, and the 1990 values are adjusted for the increase in the consumer price index. So basically, it's almost a 2 to 1 ratio. Not quite where things are, on average, two times more expensive than they were in 1990. Okay, states spent, and this is not $1.8 million. These would be in the trillion. So states spent $1.88 trillion in 2015. Okay, of that, $362 billion on elementary and secondary education, $193 billion on higher ed, $512 billion on Medicaid, $143 billion on transportation, and $661 billion on other stuff. This, by the way, includes federal funds that the state receives. So it's what states spend from their own tax base, as well as what they get in terms of federal funding. Has a percentage of state expenditures in 2015. Medicaid is by far the biggest, 27.4%. The second biggest is elementary and secondary education at 19.3%, higher ed, 10.3%, transportation, 7.7%, and other, 35.3%. And we can send you this PowerPoint, so you don't need to jot this stuff down. In 1990, again, same-dollar values, okay, states spent $900 billion of that. So in 1990, they were spending significantly more in elementary and secondary education than they were on Medicaid. Okay, $205 billion on elementary and secondary education, which was about 23% of state spending, higher ed, $109 billion, which was 12.2%. Medicaid was $112 billion, 12.5%, and you can see the values for transportation and other. Okay, what this last row represents is the increase from 1990 to 2015. So basically, it's just dividing this number by this number and subtracting one. So it's showing you the percent increase. So overall, state expenditures have increased a lot, right? They've more than doubled. They've gone up 108%. What's driving that? Medicaid. Medicaid expenditures have grown 357%. Again, in inflation-adjusted terms, 357% between 1990 and 2015. All the other increases are much smaller. I think it's primarily due to states' increasing enrollment. So part of it is going to be higher healthcare prices and healthcare inflation growing higher than these things. Medicaid higher education has had a lot of inflation since 1990, right? So these things are also susceptible to large price increases. Most of it is just much larger state Medicaid programs, right? Many more enrollees. So I guess what we can see, if we go back to this slide, here is Medicaid enrollment in 1990, right? Probably, it looks like probably just under $30 million, and in 2015, worth $70 million, right? So Medicaid enrollment more than doubled between 1990 and 2015. But I mean, at the same time, it's like, well, the population is growing as well. So that's like, do we have a per capita graph? We do not have a per capita graph. That would have been a good graph to have. It has a percentage of the population. Medicaid now is, so 70 million divided by 315. So it's over 20%. I would say back in 1990, it was probably about 13% of the population. So probably about a 70% increase. Good question. This looks identical to this previous slide, but this just shows federal funding for states. And the point of this is just to show you how much federal funding has increased over time with Medicaid relative to federal funding for the other aspects of state budgets. So in 2015, Washington sent close to $600 billion to states. Of the $586 billion that Washington sent to states, 317 billion of it was through Medicaid. So 54%, more than half of all the money that we send to states goes through Medicaid. You can see the percentages here. 9.2% of what Washington sends to states is on elementary and secondary education. 3.6% for higher ed. 7.2% for transportation. Okay, if you look at in 1990, Washington was still the category of one, I think one observation here is we send a lot more money. And again, these are inflation adjusted dollars. We send about three times as much money to states as we did in 1990. Okay, on Medicaid, we are sending a really, I mean, the difference is dramatic, right? 64 billion to 317 billion. So we're sending more than $250 billion to states through Medicaid than we did 25 years ago. Okay, it's a 400% increase. Other areas of spending have grown, right? Particularly look at higher education is up over 200%, but still they are dwarfed compared to what's gone on with federal funding for Medicaid. Okay, second thing, and this was talked, touched on in the previous, previous panel, the research on the value of Medicaid. So this is Trevor's hand, Trevor's in the back. He's our hand model at Mercatus. We were, we have very smart people at Mercatus. And when I was giving a talk two or three weeks ago and was practicing the talk, I went, talking about this new study by these economists, and these are economists at MIT, Harvard, and Dartmouth, right? And this is the study, the value of Medicaid interpreting results from the Oregon Health Insurance Experiment. It's like, we have to talk about this study, right? This study is really important. They estimated the value of Medicaid recipients, and it's only 20 to 40 cents on the dollar that Medicaid recipients receive. And one of our communications experts was like, you need a visual with that. You need two dimes in a hand. So Trevor went and scoured the internet to find a picture of a hand with two dimes. And surprisingly, there are no pictures on the internet of a hand holding two dimes. So Trevor took a picture of his hand with two dimes in it, and that is the visual that Mercatus brings out to show the value of Medicaid, right? 20 cents on the dollar. The Oregon Medicaid experiment, and I think Megan listed some of the results from the Oregon Medicaid experiment, it's not a perfect experiment for one, right? Because a lot of people who won the lottery did not take steps to enroll. So there was a limited number of spots, people won the lottery and were able to get Medicaid, or lost the lottery and weren't able to get Medicaid. And I mean, one of the things is when it was 40% of people who won the lottery didn't enroll. So that shows you one thing, and that gives you sort of one data point on the value that people place on Medicaid, of the people that did win the lottery and enroll, right? They found that they were much more likely to use healthcare services, right, including both preventative services and ERs. The big finding was no statistically significant effect. They looked at three measures, blood pressure, cholesterol, and blood sugar. Three things that you would expect if you're getting regular medical care, right? You would see a reduction in these three things. No effect, no statistically significant effect on any of those outcomes, and the Medicaid did not reduce the risk of a heart problem. There were two benefits to, so no physical health benefits to Medicaid when you compared the Medicaid population with the control group that didn't receive Medicaid. Okay, it did reduce the rates of depression, I think by 30%, and people felt like better off financially that they weren't worrying about having medical expenses. A lot has been written about Medicaid's quality of care. Yes? It's a good question. The lottery was in 2008, and this study came out in 2013. So I would think at most four. Medu-reval. You know, you're looking at three health conditions that are complicated and have to take a little longer to find, but a discrete, more easy-to-measure instance. So you're asking two questions there. The first, they're very good questions. What you'd want to do is to study at different points in time, right? And follow these people over a short period of time, and then also follow them over a longer period of time. The problem with looking at a longer period of time is that people change coverage, right? And over time, a lot more other explanatory factors can come in. And also in 2014, I mean, you can't really go past 2014 because in 2014, you have the ACA Medicaid expansion. So there are some... Thank you. I'm not taking the experiment. I'm reporting what the findings of the experiment are. So it is very hard to determine on a causal basis, right? If you give someone Medicaid, do they have better health outcomes? Because there are lots of other factors that affect people's health status, whether they have Medicaid or not, right? Whether your age... Yeah, I mean, so Medicaid studies that try to assess factors responsible for health outcomes are fraught with problems, right? One of the reasons that economists really like the idea of the Oregon experiment is because you have random assignment. So the lottery enabled for not a perfect... It wasn't a perfect experiment, right? But it now enabled some sort of control for these unobservable characteristics. All of these... Like most of these studies, and I'm about to get into this now, that people with Medicaid generally have worse outcomes from health care treatments than people with private insurance. Well, people with Medicaid are different from people with private insurance in some ways you can control for. For income, you can control for age, right? You can control for gender. You can control for whether someone's a smoker. But there's a lot of other factors that you can't control for. So you should always take these... They should always be somewhat skeptical on any of these studies that show health benefits or that don't show health benefits. The best study, right, was what I mentioned earlier, the RAND health experiment that had random assignment and followed people for a period of time. What they did was group individuals in four classes based on cost sharing. And the first finding is, yeah, people who had more generous insurance used a lot more health care, right? But then the second finding, they looked at hundreds of metrics. And Megan mentioned they only found two with a statistically significant outcome. In these states, you see throughout a lot of the good health, you see the NZQA previous measures for Medicaid managed care plans as well as CMSs, so I was wondering... So I don't know that I'm not trying to do the study better than I do, but I would guess that those three disease states are simply kind of the same or the important measure to work for proxies and mental health. Yeah, I think that's right. Okay, so good. So now we've gone through the first bullet there in much more detail than I was going to talk about. So that's very good. Thank you for that question. The other question you asked was on cost. And what we've seen with Medicaid expansion generally is because in many states, and this is very state-specific, right, because some states pay Medicaid providers better than other states, but in many states, Medicaid royalties have more limited access to a regular source of care and are more often to use expensive places like emergency rooms. There was a 2011 article in The New York Times where Robert Pair went to Louisiana and found that people in Louisiana were having a very hard time accessing a usual source of care and they would have a Medicaid card, right, but very few people would, very few providers would accept those cards. And in fact, what we're seeing is that Medicaid recipients are increasingly served by a subset of providers, right, and it's also a subset of providers that may be lower quality providers, right, and they don't have the same standard of care as sort of other providers who see only private pay, you know, private pay people do. Let's skip that slide. Okay, I spent three and a half years doing oversight work. On the oversight committee, on Medicaid. This was a lesson I learned before I joined the committee when I was a health policy analyst at the Heritage Foundation. I did a study of New York's long-term care Medicaid complex and we drove around the state of New York talking to providers, talking to interest groups, talking to Medicaid eligibility workers, and I learned that in New York, Medicaid is a verb. Like, what, how is Medicaid a verb? I'm like, yeah, Medicaid it. What does that mean? That means if you see a service that you think can reasonably be categorized as a Medicaid service and get the federal government to reimburse you for that service, you Medicaid it, you bring it, you have Medicaid pay for it, and then you build the federal government and the federal government sends you 50% of whatever the cost of that service is. Okay, all states, it's not just New York. New York sort of is very, they've developed a very elaborate scams and I'll talk more about New York in a little bit, but all states do this, right? 49 states have Medicaid provider taxes, right? They all have an incentive, like I said before, to minimize what the state's share of Medicaid expenditures is, try to make it look like they're actually making expenditures so that those expenditures are reimbursed by the federal government. This is our scenario where we show how provider taxes work. So in a world without provider taxes, right, a state is spending $100 on a provider. The provider is better off by $100. The state sends that bill to the federal government, right? The federal government's like, all right, state, you have a 60% reimbursement rate. We're going to cut you a check for $60. The federal government sends $60 to the state, right? So that the state's really share of that expenditure is only $40. The federal share is $60. Okay, the first thing to realize with provider taxes is that they shift costs to the federal government. So, I mean, one of the really interesting things on provider taxes is how often do you get groups that come to government and say, please tax me, right? It's very rare. So you should think, oh, there's an interesting story behind some, behind phenomena like that. Okay, so what the provider does is works with the state, figures out, all right, state, I'm going to assess $100 tax on you. Okay, the state assesses $100 tax, and the state pays the provider $200, right? They pay them back the $100 in taxes and they pay them the $100 that they originally paid the provider. So the provider is just as well off. The state, then, the federal government comes in and they look at the $200 expenditure. Okay, because that's what the state paid the provider. And the federal government, then, instead of paying the $60, reimburses the state $120. So now the state's collected $120 from the federal government. It has collected $100 from the provider. It's paid the provider $200. You do the math. The state is actually benefiting by $20. And if you look at from the no provider tax scenario, they're actually, the state is better off by $60. Okay, who's worse off by $60? Federal taxpayers. Okay, now, that is assuming the provider taxes just shift the cost from states to the federal government. They certainly do shift the cost from the states from the federal government, but they also increase overall Medicaid expenditures, right? They increase overall Medicaid expenditures because they make the state share of spending less significant, right? And when the state share of spending is lower, right, states have an incentive to spend more on Medicaid than they would otherwise. Yeah? The federal government would be paying to the state if we didn't have the waiver. So don't they have to somehow justify these things? Or are they able to just tap into an unlimited source of reimbursement? So there's two questions. Let me break that up into two pieces. One, there's lots of rules on provider taxes, okay? So the provider taxes are supposed to be broad-based and uniform, which means if you have all the hospitals in the state, you can't just assess the tax on the hospitals that only serve Medicaid beneficiaries and then make those payments back to those hospitals, right? You have to assess the tax broadly on that entire class of hospitals in that... in the entire set of providers in that class, okay? And obviously some hospitals aren't going to like the tax, right? Hospitals that have a lower number of Medicaid enrollees are not going to receive the higher payment rates back through the provider tax mechanism. Now, states can receive waivers from those requirements. Okay, there's also a limit on how much the provider tax can be as a percentage of revenue. So states can't raise... providers can't... states can't raise more than 6% of what their payments are to providers. And if you look at all states, basically states are mostly maxed out. They make as much in provider taxes as they can. But there's waivers, right? So states are allowed to apply to the secretary of HHS for waivers around the uniform and broad-based requirements. And states apply for them all the time, right? And states also make supplemental payments. If you're looking at Medicaid, there's two types of ways providers get money through Medicaid. They get money through regular payment rates, right? And they also get money through supplemental payments. And supplemental payments are growing. And supplemental payments, there's actually very little federal oversight. The oversight of supplemental payments is very weak. GAO has written about this a ton. And it's those supplemental payments that the states can then deliver to individual providers. When I was working at the oversight committee in 2014, we asked GAO to do some... well, we asked GAO to do work on this in 2012. And GAO takes 18 months to do everything. So in the summer of 2014, they came back with us. They looked at three states. They looked at Illinois, California, and New York. California doesn't have data on supplemental payments that they could provide just to GAO. So basically, California told the federal government, we have no idea... we cannot tell you where this Medicaid money is going. We can't match up Medicaid payments on an individual provider basis, right? That raises lots of questions. Illinois and New York did provide this data. There were two hospitals in New York that received in one year close to half a billion dollars, a billion in supplemental payments, even though their Medicaid costs were estimated by GAO at at most $100 million. Those were... actually, I have those on the slide in a little bit. You also asked about waivers. And waivers... so the waivers that I'm talking about are different from sort of the 1115 waivers. So a lot of states have 1115 waivers that allow them to waive Medicaid requirements and receive federal reimbursements. And those are supposed to be budget-neutral. They are often not budget-neutral. I'll give you an example of a state that's not budget-neutral. And that's another concern that GAO has raised on these 1115 waivers, is that they're often not budget-neutral. So the third scenario shows what happens when provider taxes increase the payments that the state makes to providers. The economics says that this is going to increase payment rates to providers. Providers are lobbying for these taxes. They're lobbying for them because they know they're getting higher payment rates. So here we assumed, alright, let's say the state raises the provider rates by 50%. So the state is sending $250 to the provider. The federal government sees that $250 expenditure reimburses 60% of it. They're bursting $150. The state received $100 taxes, received $150 from the federal reimbursement, paid out $250. So they have a wash, right? So they're not spending anything from their state tax base. And if you compare scenario one and scenario three, it makes it pretty clear that states are better off from provider taxes. Providers are better off from provider taxes. The federal government is worse off. And there is a reason that all states but Alaska have provider taxes. And Alaska is, I hired a law firm to or saw an accounting firm to figure out how to institute a provider tax next year. Okay, lesson number two for Medicaid oversight work. Medicaid long-term care is available to just about everyone. So Medicaid long-term care has, there are supposed to be asset requirements on Medicaid long-term care, but there are a huge number of exempt assets. You can have a house worth up to $750,000 and still qualify for Medicaid. Your house is an exempt asset. You can have an unlimited amount of money for a federal retirement account and still qualify for Medicaid. I didn't realize the extent of this problem until I went and we did a trip in Suffolk County, which is Long Island, and we talked to this woman, Janice Eulau, an assistant administrator of Medicaid Services, and she told us it's typical that people come in here owning a house in Long Island. So they're owning a house worth half a million dollars. They have significant money in their retirement accounts for qualifying for Medicaid. And Medicaid is paying for their long-term care services, either delivered at home or in the nursing home. We had a hearing so Congressman Gowdy was our subcommittee chairman and in September 2011 we had a hearing and Janice Eulau testified and this is part of her testimony. So as a long-time employee of the local Medicaid office, I have had the opportunity to witness the diversion of applicants' significant resources in order to obtain Medicaid coverage. It is not at all unusual to encounter individuals and couples with resources beyond exempt resources. So that's the exempt resources would be the house, the IRA, exceeding half a million dollars, some with over a million dollars. There is no attempt to hide that this money exists. There is no need. There are various legal means to prevent those funds from being used to pay for the applicant's nursing home care. Wealthy applicants for Medicaid's nursing home coverage consider that benefit to be their right regardless of their ability to pay for themselves. If you want to get a whole bunch of fun things to read on the internet Google Medicaid estate planning. It's a huge industry and they basically that's what they advertise that they can save you from spending down to qualify for Medicaid. Lesson number three from the Medicaid oversight work that I did on the Hill. The rules are really complicated and CMS doesn't really know what states are doing. For examples, number one New York developmental centers in 2010 a small newspaper in New York the Poughkeepsie Journal anyone ever heard of the Poughkeepsie Journal? I had not heard of the Poughkeepsie Journal. Poughkeepsie Journal wrote an article about facilities in the state of New York that are called developmental centers. They were housing and treating people with developmental disabilities. The daily Medicaid payment rate for those individuals. Anyone want to guess? How much? 100. Anyone else want to guess? We're getting closer. $5,000 daily payment rate for people housed in these developmental centers. $2 million per year. CMS starting in 1993 started approving a states change in a formula that has people would leave these facilities and these facilities by the way they're operated by the state so these are state facilities so that they would for each person that left they would retain basically the cost. Over time has enrollment declined in these facilities the per patient rate skyrocketed which is why they kept all these facilities open. We found across I didn't discover the Pkeepsie Journal story we discovered the IG reported on this and they estimated these overpayments and we read about it and we're like we need to stop this. We called a meeting with CMS and we met with them in June 2012 and we told them that what they were allowing to happen was theft that they were allowing New York to steal from federal taxpayers that that's correct but they were going to allow it to continue for five years because the state had become addicted to basically reliance on these funds. We weren't satisfied with that answer we reported that to Chairman Issa and Chairman Gowdy and we drafted a letter we sent it to CMS we called the hearing and at that hearing they reversed course and they said no we're gonna we've had a change of heart these overpayments and we're going to and we said well you should so we did and anyone heard of Medicaid upper payment limits so Medicaid policy again is really complicated Medicaid is prevented from paying more than what Medicare would pay for like equivalent services and it's really complicated to figure out well is Medicaid actually paying more than Medicare no one really knows how to figure these things out that said I made an estimate that these overpayments started in 1990 and went on through 2011 and the federal share of the overpayments for that two decades was $15 billion just for these facilities in New York which was a small part of New York's overall Medicaid program. CMS eventually went after the state for two years of those overpayments and collected over $2 billion back from the state so that was the day that I said I saved the federal taxpayers more than a billion dollars and when I asked for a salary increase and was denied but the point of this story is that states the state knew what it was doing it knew that these facilities were a cash cow and CMS was either oblivious or beyond negligent in allowing it to happen second case Minnesota managed care so at this we had a hearing in 2010 or 2011 some people in Minnesota started sort of whistleblowers in Minnesota started raising concerns that managed care the state was paying companies to deliver Medicaid managed care way too much way above what the actual real value of that spending would be and Trevor do I have those and what raised Senator Grassley's concern he led this investigation was a refund that one of these insurance companies gave to the state have you heard of the insurance company saying Medicaid's paying us too much so we have to return money to the state so they decided to return $30 million to the state because they received too much in Medicaid payments and this is what the commissioner of the Minnesota Department of Health and Human Services emailed another person in that department about the proper way to discuss this she wrote in order to have a good chance of keeping all this money it must be characterized as a donation if a refund feds clearly get half on redrafting also I thought we were going to handle this through phone calls right so when you get a when you get an email like that and you're working on congressional oversight you're like hot dang we're gonna have this person come and testify and she did come and testify and what Minnesota was doing was very creative they were overpaying the companies for Medicaid they had state only health plans in Minnesota they were underpaying insurers for those state only health plans they made a requirement that if you are going to participate in Medicaid you need to participate in these state only health plans so what was happening there was a cross subsidy coming in the federal reimbursement coming in through Medicaid was cross subsidizing the state only health insurance plans when we wrote to CMS about it we're like did you know what's going on because they're supposed to certify the rates are actuarially sound they're like well we didn't know what was going on right this is we approve the rates but really we didn't know what they were doing third example braces in Texas an investigative journalist out of Dallas did a report in I guess early 2012 called Crooked Teeth and the motivation was all of these little dental Medicaid shops were popping up and putting braces on everybody all these kids they were doing root canals on like toddlers I mean the stuff that they were doing was was abominable Texas spent Medicaid programs so braces are generally not a medical necessity unless you like have some major problem with your teeth and there was supposed to be a review process where people in order to get Medicaid you would get examined and Medicaid would sign off it was just a rubber stamp process where everyone at the state agency that applied through this process they just got braces again federal government had no idea what was going on right until this was highlighted we had a hearing and then a whole bunch of investigations happened and actually I haven't followed I don't know what the conclusion of all this was I know there is some lawsuits have been brought against certain certain of these practices in Texas and in other states the last one is health insurance tax is anyone familiar seeing the news stories on the health and the Medicaid this is a provider tax on insurers in California recently so like I said on provider taxes it is supposed to be broad based so you're not supposed to just single out Medicaid managed care companies and assess the tax on them but states like California and Pennsylvania that's what they were doing if you were an insurance company you weren't selling out Medicaid you weren't facing any pain from this tax so it was really just an explicit kickback to managed care companies in California in July 2014 administrator at CMS I guess the Medicaid director at CMS Cindy Mann sent a letter out that said it was generic said we've heard a lot of states are out of compliance with this tax and you need to come into compliance well it turns out that California was out of compliance and that there was a risk of was it like a billion and a half dollar hole in the California budget and they just came to some agreement on it and I'm not sure what the specifics of the agreement are but there is a quote in the story from someone involved with the negotiations and her quote is basically what we did was so complicated I don't even understand what it is and when you have someone saying this is so complicated I don't understand what it is you should think who understands the complications well it's the interest that are going to benefit from this this was a report that I have on here in 2013 the oversight committee released a bipartisan release the committee report two committee reports in the four years that was chairman this was one of the reports it was on misspending within New York's Medicaid program and it highlighted the developmental center example that I discussed as well as numerous other things that the committee found and highlighted how New York was sort of inflating costs and passing these bills to federal taxpayers lesson number four and I think this is like really important and goes against conventional wisdom conventional wisdom is Medicaid underpays providers and that is certainly true in some cases I think it's generally true for primary care in several states but when you look at one a lot of institutions have lobbied for Medicaid expansion if Medicaid really underpaid why would they want a larger presence in their state and then you have this example of so I think the story is some providers in Medicaid are underpaid but a lot of organized providers in Medicaid hospitals nursing homes they are not underpaid you have dish payments you have supplemental payments that are pretty significant you have the example that I gave in New York City of these two hospitals the $500 million Goldwater that received the $500 million in supplemental payments for less than $100 million in costs ok I'm going to wrap up Trevor big question for thinking about reform I think the program needs reform we're spending a lot of money I don't think we're getting results from the program that justify I'm an economist I think what are the incentives we need to realign the incentives in the program so how can we realign the incentives to get more value for less spending we also have to think this program is so humongous and complicated does it make sense to have a program for lower income kids and their moms grouped with seniors who have long term care needs is there a different way to think about that I think the biggest problem in Medicaid policy is the open-ended reimbursement of state Medicaid expenditures it disincentivizes both states and the federal government from really caring whether we're getting good value for this program I think it obviously biases state decisions in the favor of Medicaid at the expense of other state priorities like education, transportation infrastructure provider taxes I just wrote a paper that we released on Tuesday on Medicaid provider taxes one of the things I really try to do in the paper is emphasize that there is some bipartisan agreement on the problem of Medicaid provider taxes both the Bush and Obama administrations have proposed reducing the amount that states can raise through provider taxes the bull Simpson commission on the bipartisan ideas it's one big Medicaid idea was to eliminate provider taxes Vice President Biden in 2011 during the budget and deficit talks Vice President Biden expressed support for scrapping them by Forbes piece this week was titled Biden was right it's time to scrap the provider tax scam Biden in Bob Woodward's accounting referred to provider taxes a scam and something that Congress and the administration should be able to come to agreement on finally and I skipped I skipped this slide because I'm out of time this is an to your question on 11-15 waivers being budget neutral Arizona received an 11-15 waiver in 2001 and if you look at Arizona Medicaid spending and US Medicaid spending from 97 to 2001 it basically tracks and then in 2001 Arizona received its 11-15 waiver and that's what happened to Medicaid spending in Arizona versus the rest of the country it increased two, three times the rate so thank you