Monthly Archives: November 2018

Grant writing and cooking: Too many details or ingredients is never a good idea

As a grant writer who also likes to cook, I understand the importance of simplicity and clarity in both my vocation and avocation: too much detail can ruin the proposal, just as too many ingredients can produce a dull dish. Ten years ago, I wrote a post on the importance of using the KISS method (keep it simple, stupid—or Sally, if you don’t like the word “stupid”) in grant writing. We recently wrote an exceedingly complex state health care proposal for a large nonprofit in a Southern state, but even complex proposals should be as simple as possible—but no simpler.

As is often the case with state programs, the RFP was convoluted and required a complex needs assessment. Still, the project concept and target area were fairly straightforward. We wrote the first draft of the needs assessment in narrative form, rather than using a bunch of tables. There’s nothing intrinsically better or worse about narrative vs. tables; when the RFP is complex, we tend toward narrative form, and when the project concept and/or target area are complex, we often use more tables. For example, if the target population includes both African American and Latino substance abusers in an otherwise largely white community, we might use tables, labeling columns by ethnicity, then compare to the state. That’s hard to do in narrative form. Similarly, if the target area includes lots of counties, some of which are much more affluent than others, we might use tables to contrast the socioeconomic characteristics of the counties to the state.

Many grant reviewers also have trouble reading tables, because they don’t really understand statistics. Tables should also be followed by a narrative paragraph explaining the table anyway.

So: our client didn’t like the first draft and berated me for not using tables in the needs assessment. The customer is not always right, but, as ghostwriters, we accommodate our clients’s feedback, and I added some tables in the second draft. Our client requested more tables and lots of relatively unimportant details about their current programming, much of which wasn’t germane to the RFP questions. Including exhaustive details about current programming takes the proposal focus away from the project you’re trying to get funded, which is seldom a good idea. It’s best to provide sufficient detail to answer the 5 Ws and the H), while telling a compelling story that is responsive to the RFP.

Then, stop.

The client’s second draft edit requested yet more tables and a blizzard of additional, disconnected details. Our client disliked it the third draft. We ended up writing five drafts, instead of the usual three, and the proposal got steadily worse, not better. As chef-to-the-stars Wolfgang Puck* is said to have said, “Cooking is like painting or writing a song. Just as there are only so many notes or colors, there are only so many flavors – it’s how you combine them that sets you apart.” Attempting to use all the flavors at once usually results in a kitchen disaster.

A given section of a proposal should be as short as possible without being underdeveloped. Changes from draft to draft should also be as minimal and specific as possible.


* Jake sort-of-met Wolfgang, albeit before he was born. His mom was eight months pregnant with him when we went to Spago for dinner. Wolfgang was there in his Pillsbury Doughboy getup, and, despite not being celebrities, he couldn’t have been nicer and made a big deal out of a very pregnant woman dining at his place. I think he wanted his food to induce labor, but that didn’t happen for a couple of weeks; instead, Nate ‘n’ Al’s Deli (another celebrity hangout in Beverly Hills), was the culprit. A story for another day.

“Health insurance security” and FQHCs

I hesitate to post this, because it’s a bit more political than the topics we typically cover, but it’s explanatory more than partisan: “The 2018 Elections Were Not About Obamacare–They Were About Health Insurance Security.” In it, Bob Laszewski describes how “In March of 2016, there were 20.2 million people covered in the individual health insurance market,” but by “March of 2018 the count was 15.7 million.” Why? Because individual market “premiums and deductibles are sky high–for all but the lowest income participants.” Consider this data:

In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits.

That same family, but making too much for a subsidy, as 40% of families do, and a typical family in the affluent Virginia 10th, would have to spend $19,484 in premiums plus a $6,500 deductible, for a total of $25,984 in eligible costs before they would collect any meaningful benefits.

Those are shocking numbers, no? Yet we rarely see them, or numbers like them, in the larger media landscape. Many people have individual experiences of such things, including me; I’m covered by a small group employer plan, not an individual market plan, but my own deductible is now about $5,000. Two years ago, it was $4,500, and when I had a minor procedure to fix a toe I’d dropped a pan on, I spent $4,500 out of pocket almost immediately. Not only that, but when I saw podiatrists to get fee quotes on the procedure, most could not or would not give them to me. Even people who say they want to pay in cash often cannot find out how much a particular service will cost. When I inquired about the price of an office visit, most receptionists were confused but could eventually get an answer, and prices varied hugely, from as little as $40 to as much as $350. Why? I don’t know.

Oh, and the podiatrist billed my insurance for something like $12,000, beyond the $4,500 I paid, and she got $900 out of the insurance company. So her net benefit from the procedure was $4,500 in cash (from me) plus $900 from the insurance company. It is almost impossible to read this paragraph and not think, “Something is horribly wrong here.”

And I am not alone: almost anyone not covered by a very large employer plan, Medicaid, or Medicare has had similar experiences.

There is also an absurdly common misconception among normal people: that “insurance” is what matters for healthcare. Insurance is only part of the puzzle, but “insurance” is only as good as the healthcare we can access with it. Many doctors, for example, don’t accept Medicaid patients. So someone on Medicaid who counts as “having insurance” may not have access to care. Laszewski points out that many people “have insurance” (which is fine), but if the insurance never kicks in for the average person, then it is not functioning like true insurance, but not as the pay-all system that health insurance means to most Americans.

Federally Qualified Health Centers (FQHCs), which are federally funded nonprofits, have supersized in part because of the strange path of the US healthcare markets. Either by accident or design, FQHCs have become the default Medicaid providers in many parts of the country at the same time that the ACA significantly expanded Medicaid eligibility. Policy wonks in DC, along with some politicians, know that “insurance” is not the same as “health care” (as I myself said above). Even if politicians don’t know that, many of their constituents and voters who are on Medicaid know it. FQHCs are a partial solution, because they accept Medicaid patients and self-pays on sliding fee scales. FQHCs have also become front-line purveyors of Patient Navigation services (which link patients with Medicaid or ACA plans). Still, FQHCs usually do not have enough slots for everyone who seeks care, and waits can be long; FQHCs also often have trouble recruiting clinicians and in particular specialties like OB/GYN and psychiatrist.*

So the convoluted and intertwined health insurance and care access problems remain; the present situation likely cannot hold forever; and I do not know what will happen, politically speaking. But I would surmise that, if a family of four making $65,000 a year must pay $10,000 or more in true costs for healthcare before some manner of insurance kicks in, something has to give.

Single-payer is popular in some American political circles, though it’s not my preferred outcome and seems unfeasible financially; I’d rather see price transparency and mandatory health savings accounts coupled with true insurance for catastrophic care. Unfortunately, no one but me and a handful of healthcare wonks desire this outcome, or something adjacent. It’s hard to explain in a soundbite and normal voters have no idea what “price transparency and mandatory health savings accounts coupled with true insurance for catastrophic care” means. It doesn’t map well onto political ideologies. In healthcare, no one wants to talk about or admit to trade-offs. We write many grant proposals for FQHCs, but we never mention trade-offs. Seliger + Associates is a grant writing firm, so we’re firmly in the proposal world. All FQHCs should be in the proposal world when writing HRSA or SAMHSA or foundation applications. In the real world, however, just saying it’s so, doesn’t make it so. Trade-offs are real and pervasive. It may be socially undesirable to acknowledge them, but they are real.

The most likely political outcome will be more kludges on top of existing kludges. Fortunately, “price transparency” would fit this general paradigm. Unfortunately, there seems to be no political constituency for it. I cannot say what will happen next. I did not think Obamacare would happen, and I was wrong about that. I also did not realize that the feds would re-purpose FQHCs in the way that they have, as Medicaid providers, yet here we are. In healthcare, it seems, almost anything is, or has become, possible.


* This is largely due to barriers to entry imposed by existing doctors and especially the powerful American Medical Association. Many things could be done to increase the supply of doctors, including integrating med school into undergrad; shortening med school; allowing foreign doctors to practice without residency; or creating a special one-year residency for foreign doctors. None, however, are on the political horizon.