Monthly Archives: March 2018

Preventive care doesn’t save money, bankruptcies aren’t widely caused by lack of insurance, and FQHCs

Preventive Care Saves Money? Sorry, It’s Too Good to Be True” tells you everything you need to know in the headline, though you should of course read the article. The point is important because a lot of Health Resources and Services Administration (HRSA) funding for Federally Qualified Health Centers (FQHCs) is premised on the idea that more primary preventive care will save money and slow the seemingly inexorable rise in healthcare costs. There’s an intuitive, seductive logic to the argument: it seems like it should be true that prevention is superior to treatment.

But we, collectively, don’t actually know if most healthcare is good for most people most of the time. The Robin Hanson and Kevin Simler book The Elephant in the Brain has a chapter on medicine that demonstrates most medical care is actually wasted and unnecessary. We still pursue costly, low-importance care for status reasons that are too long to describe in this post, but interested readers are directed to the book. The idea that preventive care doesn’t reduce costs and may do little to improve health is congruent with the Hanson-Simler idea that most healthcare is not actually about health.

In other healthcare news, at least one expert wonders: “Are Hospitals Becoming Obsolete?” One hopes so: many are dysfunctional and won’t reveal prices to patients, leading to wild cost inflation and the “mystery bill” phenomenon many of us, myself included, have been subjected to. In healthcare, it seems that the prices are the problem, and most healthcare players are working to maintain price opacity. At the same time, there’s very little political or media noise about this issue.

Americans read and hear a lot about insurance issues and almost none about prices and transparency. Mandating price transparency would be a huge win for patients and, maybe, for cost. Yet politicians of all stripes show little interest in this obvious (and very cheap) policy choice. I don’t know why. I have only a very small platform, but I’m going to use it to propose price transparency. Small-scale studies like “Research finds nearly 8-fold price differences at Minnesota hospitals” show that the price of healthcare varies enormously. But it’s hard if not impossible for patients to gather information about pricing (as I discovered recently).

When you get a shockingly high mystery bill, just try getting an explanation about why the price is the price. I have. Good luck. Hospital bureaucracies are enough to make one wonder if single payer really is next: the healthcare experience for many Americans is already so close to the DMV, why not just go all the way?

I’m not advocating for single payer as a political position: this is a non-political space devoted to analyzing grant writing, grant source research, and grant makers. But it is worth analyzing how the world works, how that relates to larger political questions, and what those larger questions mean for practitioners on the ground.

In the first section of this essay I wrote about primary preventive healthcare access doesn’t appear to lower costs. That’s a common idea that doesn’t appear to be true; there are other things we think we know that just aren’t true. During the ACA debate, for example, many claimed the medical bills bankrupted vast numbers of people. Turns out it just ain’t so:

The fraction of bankruptcies caused by medical events is just 4 percent. And even among those bankruptcies, it seems that medical bills may be less of a problem than the other things associated with an illness, such as lost labor income. […]

That jibes with what’s evident in the bankruptcy data since Obamacare passed. If medical bills really were driving so many people into bankruptcy, then we would have expected filings to plummet after 2013, when millions of people gained health insurance coverage. Instead we see a smooth decline from the recession-era peak.

So if we’re worried about poverty, as many of us in the nonprofit world are, health insurance access may not be the most important way to tackle that issue. The data on bankruptcy filings from 2013 to the present are particularly compelling. It may be that lost income is the bigger issue for people who get sick. Or some other factor may be at work. It’s hard to know.

Perhaps the best way to save money and improve health as an individual is to quit eating sugar and get sufficient exercise. Those things would also be good for the larger society, but “we” (the mandarin know-it-alls like myself and those who dictate healthcare policy) have no way to make that happen. Despite decades of effort—much of it misguided, granted—we have no way of improving people’s habits on the macro level. It turns out that “American Adults Just Keep Getting Fatter:” “New data shows that nearly 40 percent of them were obese in 2015 and 2016, a sharp increase from a decade earlier, federal health officials reported Friday.” Obesity is not a perfect proxy for health, but it’s a useful starting point.

Much of this essay won’t make it into the proposals we write for FQHCs and other primary care providers. Proposals are about mythology, not actuality, unless the funder specifically demands reality (most don’t). But it’s good for applicants to keep the grant world and proposal worlds straight. Reading widely and deeply is still one of the open secrets of good grant writers—and good writers of all kinds. The information is out there. Whether you choose to access it is up to you.

USDA Community Connect program: Technological change and bringing broadband to rural America

The USDA just released the Community Connect Grant program RFP, which has $30 million to fund 15 projects that will provide broadband in underserved rural communities. We’ve written a bunch of proposals related to rural Internet access, most during the heyday of the Stimulus Bill around 2010. Almost all of those projects involved, on some level, either digging a trench or stringing a wire. Both activities are very, very expensive, so not that many people can be served.

Google has discovered as much, albeit in urban areas: the company famously launched an effort to roll out gigabit fiber Internet about eight years ago, but relentless and ferocious legal and regulatory pressure from incumbents has led the company to scale back its plans. The combination of regulatory capture from other Internet providers and the inherent cost of digging and stringing defeated even Google.

But, at the same time, Google has also announced plans to offer wireless gigabit services in some cities, by placing antennas on the roofs of multifamily buildings and using an antenna-to-antenna system to bypass the digging-or-stringing-a-wire problem.

By now, you can probably see where I’m going. In the old world—like, the world of ten years ago—Community Connect-style programs only really worked with wires. But today, wired hubs combined with radios or lasers may allow projects to deploy broadband to far more locations with far less funding. I can’t speak to the technical feasibility of such projects (though we often write scientific and technical grants). But it doesn’t take an electrical engineering degree to know that “costs less” and “provides more” is a winning argument. I think that smart rural utilities will be looking into wireless systems for last-mile connections. The technology, it would appear, is here; it wasn’t in 2010. As you can likely tell from the title of this post, grant writers who can argue that the technology is here should be able to demonstrate cost benefits over fully wired systems.

We may also be in an interregnum period: While SpaceX has proposed low-latency satellite Internet, that technology is in the prototype stage and is not here yet. Ten years from now, low-orbit satellites may provide latency times as low as 25ms.

Overall, technological change should drive a change in the way Community Connect proposals are written. Many human-service grant programs change very little over time; eight or nine years ago, we began mentioning social media in proposals, but for the most part human service programs have the same fundamental structure: an organization gets some people with problems to come to a facility to receive some services, or the organization sends some expert workers to people with problems to receive some services. Even today, however, most human services nonprofits don’t make much use of social media in service delivery, although it is often used for volunteer recruitment, donations, etc. Technical grant proposals like those being written for Community Connect, though, can and should be driven by technical change.

Links: The changing nature of donations, the changing nature of job training, DARE in the time of legalized pot, and more!

* “No One Wants Your Used Clothes Anymore.” Actually, most nonprofits don’t want clothes or volunteers or anything else, except money, because money is way more efficient; it’s much easier to transport and deploy. People like giving away physical stuff, but that’s just not a great way of benefiting actual recipients.

* “‘People are freaking out.’ Will electric vehicles doom your neighborhood auto mechanic?” The answer is “probably.” Electric vehicles require virtually no maintenance; they need tire changes and windshield wipers and that’s about it. They’re a huge boon to drivers but less good as providing employment for mechanics.

* “The Pool Safely Grant Program” may be my favorite weird grant program to appear in grants.gov recently.

* “How Germany Wins at Manufacturing – For Now.” You may remember our essay, “Rare good political news: Boosting apprenticeships.” Skilled trades and vocational education are wildly undervalued in the contemporary U.S.

* “Nonprofits Are Tapping Outside Firms To Conduct Internal Probes.” This whole “tapping outside firms” thing, among all kinds of organizations, mostly seems like it’s designed to signal caring. I’m also reminded of Laura Kipnis’s endless Title IX trial. That is what universities are spending money on now, by the way.

* “The Current Sex Panic Harks Back to the Era of Coddling Women.”

* “How to Get American Men Back Into the Workforce.” “Public investment in improving skills” is another way of calling for more job training funding.

* “People Aren’t Having Babies Because The Rent Is Too Damn High.”

* “Drug and Alcohol Deaths at U.S. Workplaces Soar.” But the real issues get little airing amid culture-war grievances.

* Portugal is “winning” the war on drugs via decriminalization.

* The lucrative business of America’s opioid crisis.

* “Why American doctors keep doing expensive procedures that don’t work.”

* “The problem with ‘problematic.'” Seems obvious to me.

* Facebook billionaire Dustin Moskovitz pours funds into high-risk research.

* “Los Angeles’s Vermont Avenue Subway Should be A Priority For Metro.”

* “I’m no longer advocating for clean energy; here’s why.” Important though also depressing.

* “American Fertility Is Falling Short of What Women Want.” News rarely heard.

* A sweeping new bill targets California’s housing crisis. Great!

* “Legal pot on the one hand, opioid crisis on the other. What’s a DARE officer to do?” The optimal thing would be to tell the truth—but nah, that’s too hard.