Author: Jake Seliger

Telemedicine and the unstated reason it can save money for Federally Qualified Health Centers (FQHCs) and other providers

You may have read that Walgreens is is shuttering some of its in-store clinic, because the clinics are expensive to operate and, in addition, telemedicine services are taking off. Telemedicine competes with minute clinics, urgent cares, and some primary care offices; right now telemedicine is being vended through a variety of platforms, some of them independent of traditional medical providers (Teledoc is a relatively famous one), while others are affiliated with traditional providers, like FQHCs. The most interesting aspect of telemedicine services might be the one, unstated reason why they’re popular.

The official push towards telemedicine is justified by greater convenience and lower cost. So far, so good: those things are real, as is the nominal improvement in patient satisfaction, but the hidden reason is also revealing: a lot of in-person medical visits aren’t medically necessary and are generated by non-medical desires. Robin Hanson and Kevin Simler talk about this in The Elephant in the Brain: Chapter 13 describes how a lot of medicine seems to be generated by patients wanting reassurance from high-status people (doctors) and doctors wanting to enjoy the status that comes from people seeking out their expert knowledge. To be sure, “a lot of medicine” is not the same as “all medicine,” so you need not leave comments about broken bones being mended or cancers being treated.

A lot of medical office visits are costly for patient and doctor, so telemedicine can reduce the waste. In effect, telemedicine often ends up being triage: the distant provider tries to figure out whether something is genuinely wrong with the patient, and whether that thing needs to be seen in person. Almost all primary care providers have seen lots of patients who come in more for hand holding and an encounter with a sage doc than treatment of underlying condition. I haven’t seen studies describing exactly how many medical visits are really boredom, fear, craziness, improbable uncertainty, and the like, but anecdotally it seems to be high, and Hanson and Simler cite estimates in the 20 – 50% range. This is the sort of thing most of your healthcare provider friends won’t admit to strangers or acquaintances, but they may admit it to close friends or after a couple drinks. FQHC CEOs, who we work for, will sometimes admit this to us, their trusted grant writers (in our own way, we are the “trusted sages” in these conversations, reversing the roles).

So telemedicine can save money because it lets people with common colds, loneliness, and similar real or imagined ailments have a doctor, nurse practitioner, or physicians assistant tell them that they’re okay, bill them maybe less than they’d be billed for an in-person office visit, and then the provider can hang up and talk to another person who is also likely okay. Many people with chronic conditions also just need reassurance, direction to a specialist, or a prescription refilled. That can be done in a few minutes over the phone or via a videoconference. Because it’s socially undesirable and even unacceptable to admit that a lot of medicine is not what we typically think it’s about, not much can be done to substantially improve the system at current levels of technology, but offering telemedicine can be an improvement. HRSA has noticed something like this and is now pushing for FQHCs to offer telemedicine. Healthcare now consumed about 18% of GDP, in a $20 trillion economy, or about $3.7 trillion dollars. There’s enormous pressure on almost every player to try and lower costs as a consequence of these unbelievable numbers. One way or another, the average worker is paying about one in every five dollars earned into medicine—whether that dollar is paid to insurance companies, hospitals, or levels of government via taxes. Strangely, though, regulators are letting hospitals merge and form local monopolies and oligopolies, which is an important exception to the lower-cost trend. Telehealth, however, is right on trend.

Links: Freedom for nonprofits, fun RFPs, car-free LA, insurance weirdness, grant $ spent at strip clubs, and more!

* “Jeff Bezos is quietly letting his charities do something radical — whatever they want.” “[Bezos] has given them life-changing money with virtually no restrictions, formal vetting, or oversight, according to Recode’s interviews with eight of those funded by him and others familiar with his donations.” This is what giving looks like when it’s supposed to be about getting the work done, rather than increasing the status and stature of the funder; note that almost no funders operate this way. This is also somewhat closer to how many VCs operate: they give money to the entrepreneur and tell the entrepreneur to implement more or less as she sees fit. We’ve also written about narrative as Amazon’s competitive advantage.

* “New federally funded clinics in California emphasize abstinence and ‘natural family planning.'” What could go wrong? But, importantly, we also wrote a bunch of Community-Based Abstinence Education (CBAE) grants back in the day, and they were an interesting lesson in how to write “evidence-based” applications when the evidence seemed to point in the opposite direction of what the RFPs required.

* “Baseline Inventory and Assessment of Newly Acquired Lands” is the title of an actual RFP in the Federal Register. I also like this, from grants.gov: “Batty about Bats program.” This program is meant to “increase public education about bats, white nose syndrome, and the importance of bats to the environment.” In Tucson I lived near an underpass that was famous for also being a bat house, which could be better than living near a frat house.

* “Car-Free in L.A.? Don’t Laugh.” There are two major spending categories—housing and transportation—that can be substantially reduced with existing technologies, provided the politics can be solved. Healthcare and education cost rises, however, seem to be due to Baumol’s cost disease and for that reason are likely resistant to substantial reform. But housing (typically the largest cost for a given individual or family) and transportation can both be made far less expensive.

* Insured price $2,758, cash price $521. Perhaps our policy makers ought to do something about this?

* “‘It’s going to be a crisis’: D.C. may be left without a halfway house for men returning from federal prison.” Another story that’s fundamentally about zoning, NIMBYs, and land costs.

* “American With No Medical Training Ran Center For Malnourished Ugandan Kids. 105 Died.” This is the space where “good intentions” meet “lack of knowledge.”

* Give later?

* Is the AIDS Healthcare Foundation fraudulently misusing savings from a federal drug-discount program designed to help poor patients? I have no idea about the merits of this story. Still, it is one of the rare mentions of the 340(b) program I’ve seen in the larger media, although we mention 340(b) in just about every proposal we write for FQHCs—which means we write about 340(b) “a lot.”

* Simple cash transfers might be the optimal way to reduce severe global poverty.

* “A Gates-funded program meant to keep low-income students pushed them out instead.” The author observed on Twitter, probably correctly, “I kind of always beat the same drum when it comes to education policy: we don’t really know how to turn money into results and most programs fail.” Nonetheless, I predict more confident predictions about improving education policy. Confident predictions of success are also an important element of grant proposals.

Plus, “Fail” is a bit tricky when it comes to grants: most grants have multiple purposes, including PR cover and employment, beyond their putative purpose (many high-flying Silicon Valley types miss this distinction and so find grant-funded programs very strange).

* Why is California seeing housing starts decline by 20% amid a housing shortage? These kinds of stories explain why, adjusted for cost of living, California is the most impoverished state in the nation.

* “The Fastest Growing Jobs in America Don’t Require a College Degree.” This is heartening in some ways (college is not the apotheosis of human existence) but also points to some of the bad public policies of the last two decades. We need more work in apprenticeships and less in traditional four-year degrees.

* “Malaria breakthrough as scientists find ‘highly effective’ way to kill parasite.” This is likely to be bigger news than anything else you read this month, if it’s true.

* Health insurance coverage was down in 2018, according to the Census. Does anyone else remember the sound and fury accompanying the Affordable Care Act (ACA)? The way it dominated headlines and generated millions, if not billions, of words, from all kinds of people with all kinds of writing skills and knowledge? And yet it’s turned out to neither be the major blessing supporters hoped nor the catastrophe its opponents feared.

* Greedy hospitals fleecing the poor. And not just the poor, either, as I’ve unhappily discovered.

* “‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles.” Unfortunately, without comprehensive reform of the medical training and credentialing systems, this is unlikely to change. Most doctors are ritzy cosmopolitan types who want to live in or near big cities and can afford to do so. They didn’t go through four years of undergrad, four years of med school, and then three or more of years residency only to live somewhere they don’t want to live.

Right now, this problem is partially being made up for by fly-in doctors who, at great expense, fly into rural areas or hospitals, work a couple days or a week, then fly home.

* “The Atavism of Cancel Culture: Its social rewards are immediate and gratifying, its dangers distant and abstract.”

* Death By 1,000 Clicks: Where Electronic Health Records Went Wrong.

* “Drexel engineering professor ‘blew $190k in federal grant money on strip clubs, sports bars and iTunes over 10-year period.’” This is not how you’re supposed to manage your grant, in case you’re wondering.

Foundation and government grant applicants: It’s “Hell yes” or “No.”

Derek Sivers has a rule for many things:

No ‘yes.’ Either ‘HELL YEAH!’ or ‘no.’” He says, “When deciding whether to do something, if you feel anything less than ‘Wow! That would be amazing! Absolutely! Hell yeah!’ — then say ‘no.’

That principle applies to other fields: are you going to get the job? If the employer really wants you, they are going to be very “hell yes,” and they are going to start courting you. With any reply other than “hell yes,” keep looking. Don’t stop looking till the contract is signed—and don’t be surprised when the employer is a whole lot more excited about you the day after you sign up with another outfit. Same is true in dating: don’t stop lining up leads unless and until that special person says HELL YES! This is also true in applying for most grant funding: assume it’s a “no” until proven otherwise.

We’ve had lots of clients over the years who have been encouraged by foundations that are eager to cultivate applications but seem decidedly less eager to actually cut the check (CTC). Talk is cheap, but the CTC moment has real costs—in pro hoops and grant seeking. Foundations are prone to delaying that magic moment, if possible. Foundations, like many of us, like the flattery and attention that comes with dangling cash in front of people who desire said cash. Note that I’m not arguing this behavior is fair or appropriate—just that it’s common. Foundation officers seemingly enjoy the flattery that comes with nonprofits’s seduction attempts.

To a lesser extent, some government funders at the federal, state, and local level also engage in the dangling CTC approach, but government rules often discourage excess promises from government officers to applicants. If your agency has applied for a government grant, you’re unlikely to hear anything until you get the hell yes email (notice of grant award) or the “thanks for a lovely evening” email (thanks, but no grant this time around). Still, if a funder, government or foundation, requests more information about your proposed budget or asks if you’ll accept a smaller grant, you’ll almost always eventually get the desired response. Few funders will bother with info requests unless they are likely to fund you.

As a rule, though, your default assumption should be that the funder is not going to fund you until they want to fund you. This is a special case of the Golden Rule. Your assumption should be “no deal:” don’t waste time anticipating a promised deal that may not happen. Spend that energy improving your services and pursuing other funding opportunities. Many foundations also like giving out the last check to make the project happen, rather than the first one, so keep chasing early grants—even small ones.

Links: Don’t steal the grant money, where the jobs are, fun grant programs, ameliorating homelessness, and more!

* Don’t embezzle grant funds. If your organization gets grant funding but can’t carry out the proposed services, just admit it and give the money back—or at least stop taking the money. This ought to go without saying and without federal prosecutors getting involved. And, an excellent way of meeting the local US Attorney is to steal grant funds. Some grantees find themselves unable to execute the grant-funded activity, and, while that isn’t optimal, it is okay.

* We have a massive truck driver shortage, and pay is increasing, albeit too slowly, given that shortage. Contrary to the hype, we still appear to be quite far from automating trucking and many other in-demand jobs.

* “There’s a high cost to making drugs more affordable for Americans.” Almost no one is talking about this. We can likely force the cost of today’s drugs and treatments lower—but at the cost of not having new drugs and treatments tomorrow. This seems like a poor tradeoff to me, although that’s a philosophical point. The interesting thing is that no one advocating for price controls admits the tradeoff.

* “Resistance to Noncompete Agreements Is a Win for Workers.” This is an area where the left and right are aligned: the left worries about worker rights, and the right (putatively) worries about free markets. Banning both is a win for left or right.

* My favorite recent grant program: “Supporting Economic Empowerment in the Pakistan Film Industry.” We really want to be hired to write a proposal for this one!

* “Fears grow over ‘food swamps’ as drugstores outsell major grocers: With CVS selling more groceries than Whole Foods and Trader Joe’s combined, researchers fear food ‘deserts’ are becoming ‘swamps’ of processed food.” Another handy proposal term. Both Isaac and I have noticed the expanding food selection at local drug stores.

* More Millennials Are Dying ‘Deaths of Despair,’ as Overdose and Suicide Rates Climb. See also the book Lost Connections.

* “Americans Need More Neighbors: A big idea in Minneapolis points the way for other cities desperately in need of housing.” Obvious but needs to be repeated, as bad land zoning is at the root of many problems in individual cities and America as a whole today. We feel some of the effects when we work on projects like Prop HHH proposals in Los Angeles. If it’s not possible to build a sufficient amount of new housing, then many actors are going to bid up the price of existing housing, and homeless service providers are rarely the top bidder.

* “Los Angeles Is in Crisis. So Why Isn’t It Building More Housing? Rising rents are feeding a surge in homelessness.” The Atlantic is now on the beat Seliger + Associates has been covering for years. These links are congruent with the links immediately above.

* “An Addiction Crisis Disguised as a Housing Crisis: Opioids are fueling homelessness on the West Coast.” Or, as I’d put it, “Both at once, and interacting with each other.”

* The Machiavelli of Maryland: Edward Luttwak is adviser to presidents, prime ministers – and the Dalai Lama. Hugely entertaining, and via MR.

* “Why Transparency on Medical Prices Could Actually Make Them Go Higher.” I’ve long been a price-transparency proponent, but maybe I’m wrong.

* “Housing crisis: Why can’t California pass more housing legislation?” This is much of the reason homelessness is increasing in California: it’s almost illegal to build housing for humans.

* “Why mention the Affordable Care Act (ACA) when Democrats can debate shiny new Medicare-for-all?” I post this not for the political valence but for the discussion of what has and has not changed in healthcare over the last decade; in many ways, there’s been less change than both ACA proponents hoped for and opponents feared.

* Why Are U.S. Drivers Killing So Many Pedestrians? “If anything else—a disease, terrorists, gun-wielding crazies—killed as many Americans as cars do, we’d regard it as a national emergency.” Maybe the automotive era was a terrible, murderous mistake.

* “Progressive Boomers Are Making It Impossible For Cities To Fix The Housing Crisis: Residents of wealthy neighborhoods are taking extreme measures to block much-needed housing and transportation projects.” Not far from what you’ve been reading here for years, but the news is getting out there.

* “Live carbon neutral with Wren: Offset your carbon footprint through a monthly subscription.” Many people wonder what they as individuals can do. Here is one answer.

* “The numbers are in: SF homeless population rose 30% since 2017.” While people are slowly but surely linking SF’s terrible zoning rules with its extraordinary homelessness challenges (just like L.A.), the city isn’t moving fast enough to make real changes. Interesting fact: about one in 100 San Francisco “residents” lack a place to live. And there is purported to be more dogs than kids living in SF.

* “FBI investigating tattooed deputy gangs in Los Angeles County Sheriff’s Department.” This is almost unbelievable, but here it is.

* The radical case for teaching kids stuff. Relevant to those of you running early childhood education programs like Head Start and UPK.

* “Seliger + Associates enters grant writing oral history (or something like that).” This is a favorite essay, as since then we’ve seen, many times, our own phrases and proposal structures come back to us, like ships in a bottle dropped at sea that then wash up on our shores.

Another piece of the evaluation puzzle: Why do experiments make people unhappy?

The more time you spend around grants, grant writing, nonprofits, public agencies, and funders, the more apparent it becomes that the “evaluation” section of most proposals is only barely separate in genre from mythology and folktales, yet most grant RFPs include requests for evaluations that are, if not outright bogus, then at least improbable—they’re not going to happen in the real world. We’ve written quite a bit on this subject, for two reasons: one is my own intellectual curiosity, but the second is for clients who worry that funders want a real-deal, full-on, intellectually and epistemologically rigorous evaluation (hint: they don’t).

That’s the wind-up to “Why Do Experiments Make People Uneasy?“, Alex Tabarrok’s post on a paper about how “Meyer et al. show in a series of 16 tests that unease with experiments is replicable and general.” Tabarrok calls the paper “important and sad,” and I agree, but the paper also reveals an important (and previously implicit) point about evaluation proposal sections for nonprofit and public agencies: funders don’t care about real evaluations because a real evaluation will probably make the applicant, the funder, and the general public uneasy. Not only do they make people uneasy, but most people don’t even understand how a real evaluation works in a human-services organization, how to collect data, what a randomized controlled trial is, and so on.

There’s an analogous situation in medicine; I’ve spent a lot of time around doctors who are friends, and I’d love to tell some specific stories,* but I’ll say that while everyone is nominally in favor of “evidence-based medicine” as an abstract idea, most of those who superficially favor it don’t really understand what it means, how to do it, or how to make major changes based on evidence. It’s often an empty buzzword, like “best practices” or “patient-centered care.”

In many nonprofit and public agencies, evaluations and effectiveness are the same: everyone putatively believes in them, but almost no one understands them or wants real evaluations conducted. Plus, beyond that epistemic problem, even if evaluations are effective in a given circumstance (they’re usually not), they don’t necessarily transfer. If you’re curious about why, Experimental Conversations: Perspectives on Randomized Trials in Development Economics is a good place to start—and this is the book least likely to be read, out of all the books I’ve ever recommended here. Normal people like reading 50 Shades of Grey and The Name of the Rose, not Experimental Conversations.

In the meantime, some funders have gotten word about RCTs. For example, the Department of Justice’s (DOJ) Bureau of Justice Assistance’s (BJA) Second Chance Act RFPs have bonus points in them for RCTs. I’ll be astounded if more than a handful of applicants even attempt a real RCT—for one thing, there’s not enough money available to conduct a rigorous RCT, which typically requires paying the control group to follow up for long-term tracking. Whoever put the RCT in this RFP probably wasn’t thinking about that real-world issue.

It’s easy to imagine a world in which donors and funders demand real, true, and rigorous evaluations. But they don’t. Donors mostly want to feel warm fuzzies and the status that comes from being fawned over—and I approve those things too, by the way, as they make the world go round. Government funders mostly want to make congress feel good, while cultivating an aura of sanctity and kindness. The number of funders who will make nonprofit funding contingent on true evaluations is small, and the number willing to pay for true evaluations is smaller still. And that’s why we get the system we get. The mistake some nonprofits make is thinking that the evaluation sections of proposals are for real. They’re not. They’re almost pure proposal world.


* The stories are juicy and also not flattering to some of the residency and department heads involved.

Links: Housing, grant size, the perils of EMRs, the nature of energy, addiction and treatment, and more!

* Death by a thousand clicks: How electronic medical record (EMR) systems went wrong. We’ve written so many proposals involving EMR systems, and yet it seems they’ve had little if any positive impact on the overall landscape, in terms of health or cost.

* “California Has a Housing Crisis. The Answer Is More Housing.” One of these obvious things, yet here we are.

* “When It Comes To Applying for Grants, Size Doesn’t Matter (Usually).”

* “A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills. I spent a year writing about ER bills. Zuckerberg San Francisco General has the most surprising billing practices I’ve seen.” Remember how we wrote about the need for price transparency? This is another specific instance of that general point.

* Waymo’s CEO says autonomous cars “will always have constraints.” They are not a panacea for urban transit and are not going to be here in the next five years, and they will likely be weather-dependent.

* Is fusion power much closer to becoming reality than is commonly anticipated? If so, it will solve or substantially ameliorate the world’s energy problems, along with the geopolitical conflicts fueled by the world’s desire for oil.

* “Firms Learn That as They Help Charities, They Also Help Their Brands.” This is firmly “dog bites man” story instead of a “man bites dog” story, but there it is.

* “California will sue Huntington Beach over blocked homebuilding.” Good news.

* “Most People With Addiction Grow Out of It,” something not widely appreciated in the larger culture and a factoid we never include in the many SUD/OUD treatment proposals we write.

* Public Education’s Dirty Secret. Congruent with my experiences.

* “Is the Revolution of 3D-Printed Building Getting Closer?” Let’s hope so, as that would likely substantially decrease construction costs.

* Japanese urbanism and its application to the Anglo-World.

* “Climeworks: The Tiny Swiss Company That Thinks It Can Help Stop Climate Change.” Not just the usual.

* From Literature to Web Development: My first 6 weeks at Lambda School.

* * “A Radically Moderate Answer to Climate Change.” You may be getting tired of reading about nuclear power, yet we still seem as a culture not to be paying attention to it. See also “Nuclear goes retro — with a much greener outlook.”

* “This is Roquette Science: How computerized arugula (aka roquette) farms take over the world.”

* How to Create Reality: “So a funny thing happened on Twitter this week, which almost changed the world a little bit. Someone sent me a beautiful 3-D mockup of a fictional, car-free city of 50,000 people, set in the scenic nook of land* between Boulder, Colorado and Longmont, where I live.”

* “Science, Small Groups, and Stochasticity.” In short, we are doing the structure of science wrong.

* “The corporations devouring American colleges.” Colleges are businesses with extremely good PR and marketing arms.

* “The Streets Were Never Free. Congestion Pricing Finally Makes That Plain..” Seems obvious to me.

* “The antibiotics industry is broken—but there’s a fix.”

* “The 2008 financial crisis completely changed what majors students choose.” How could it not?

* “Lambda, an online school, wants to teach nursing.” Good. Competing with existing schools is a feature, not a bug. See also that other link about Lambda School, above.

* Most of America’s Rural Areas Are Doomed to Decline. Basically, agriculture now accounts for perhaps 2% of the workforce; manufacturing accounts for less than 15% of the workforce, and even as manufacturing has increased in value produced, it hasn’t much increased in jobs.

* “Considerations On Cost Disease‘s” money shot:

So, to summarize: in the past fifty years, education costs have doubled, college costs have dectupled, health insurance costs have dectupled, subway costs have at least dectupled, and housing costs have increased by about fifty percent. US health care costs about four times as much as equivalent health care in other First World countries; US subways cost about eight times as much as equivalent subways in other First World countries.

I worry that people don’t appreciate how weird this is.

“How Jeff Bezos Turned Narrative into Amazon’s Competitive Advantage”

How Jeff Bezos Turned Narrative into Amazon’s Competitive Advantage” should be mandatory reading for anyone in nonprofit and public agencies, because narrative is probably more important for nonprofits than conventional businesses; conventional businesses can succeed by pointing to product-market fit, but nonprofits typically don’t have that metric. Nonprofits have to get their stories out in other ways than profit-loss statements or sales.

Bezos is Amazon’s chief writing evangelist, and his advocacy for the art of long-form writing as a motivational tool and idea-generation technique has been ordering how people think and work at Amazon for the last two decades—most importantly, in how the company creates new ideas, how it shares them, and how it gets support for them from the wider world.

New ideas often emerge from writing—virtually everyone who has ever written anything substantive understands this, yet it remains misunderstood among non-writers. Want to generate new ideas? Require writing. And no, “Powerpoint” does not count:

“The reason writing a good 4 page memo is harder than ‘writing’ a 20 page powerpoint is because the narrative structure of a good memo forces better thought and better understanding of what’s more important than what, and how things are related,” he writes, “Powerpoint-style presentations somehow give permission to gloss over ideas, flatten out any sense of relative importance, and ignore the interconnectedness of ideas.”

I’m not totally anti-Powerpoint—I have seen books about how to do it well—but Powerpoint does not substitute for narrative (in most cases). Most people doing Powerpoint have not read Edward Tufte or adequately thought through their rationale for choosing Powerpoint over some other communications genre, like the memo. The other day I did an online grant-writing training session for the state of California for 400 people, and the guy organizing it expected me to do a Powerpoint. I said that using a Powerpoint presentation to teach writing is largely useless (he seemed surprised). Instead, I did a screencast, using a text editor as my main window, in which I solicited project ideas and RFPs germane to the viewers. I picked a couple and began working through the major parts of a typical proposal, showing how I would construct an abstract using the 5Ws and H, and then how I would use those answers to begin fleshing out typical narrative sections in the proposal. Because it was screencast, participants can re-watch sections they find useful. I think having a text document and working with actual sentences is much closer to the real writing process than babbling on about a prepared set of slides with bullet points. The talk was less polished than it would have been if I’d prepared it in advance, but writing is inherently messy and I wanted to deliberately show its messiness. There is no way to avoid this messiness; it’s part of the writing process on a perceptual level. It seems linked to speech and to consciousness itself.

To return to the written narrative point, written narrative also allows the correct tension between individual creativity and group feedback, in a way that brainstorming sessions don’t, as the article explains. Most human endeavors involving group activity require some tension between the individual acting and thinking alone versus being part of a pair or larger group acting in concert. If you are always alone, you lose the advantage of another mind at work. If you are always in a group, you lack the solitude necessary for thinking and never get other people out of your head. Ideal environments typically include some “closed door” space and some “open door” serendipitous interaction. Written narrative usually allows for both.

Nonprofit and public agencies that can’t or won’t produce coherent written documents are not going to be as successful as those that do. They aren’t going to ensure key stakeholders understand their purpose and they’re not going to be able to execute as effectively. That’s not just true in grant writing terms; it’s true in organizational terms. Reading remains at present, the fastest way to transmit information. If you’re not hiring people who can produce good stuff for reading, you’re not effectively generating and using information within your organization.

Coding school is becoming everyone’s favorite form of job training

For many years, construction skills training (often but not always in the form of YouthBuild) was every funder’s and every nonprofit’s favorite form of job training, often supplemented by entry-level healthcare work, but today the skill de jour has switched to software, programming, and/or coding. Case in point: this NYT article with the seductive headline, “Income Before: $18,000. After: $85,000. Does Tiny Nonprofit Pursuit Hold a Key to the Middle Class?” While the article is overwhelming positive, it’s not clear how many people are going to make it through Pursuit-like programs: “Max Rosado heard about the Pursuit program from a friend. Intrigued, he filled out an online form, and made it through a written test in math and logic…” (emphasis added). In addition, “Pursuit, by design, seeks people with the ‘highest need’ and potential, but it is selective, accepting only 10 percent of its applicants.” So the organization is cherry-picking its participants.

There’s nothing wrong with cherry-picking participants and most social and human service programs do just that, in the real world. As grant writers who live in the proposal world, we always state in job training proposals that the applicant (our client) will never cherry-pick trainees, even though they do. In the article, important details about cherry-picking are stuck in the middle, below the tantalizing lead, so most people will miss them. I’m highlighting them because they bring to the fore an important fact in many social and human service programs: there is a tension between access and success. Truly open-access programs tend to have much lower success rates; if everyone can enter, many of those who do will not have the skills or conscientiousness necessary to succeed. If an organization cherry-picks applicants, like Pursuit does, it will generally get better success metrics, but at the cost of selectivity.

Most well-marketed schools succeed in “improving” their students primarily through selection effects. That’s why the college-bribery scandal is so comedic: no one involved is worried about their kid flunking out of school. Schools are extremely selective in admissions and not so selective in curriculum or grading. Studies have consistently suggested that where you go to school matters much less than who you are and what you learn. Such studies don’t stop people from treating degrees as status markers and consumption goods, but it does imply that highly priced schools are often not worth it. Thorstein Veblen tells us a lot more about the current market for “competitive” education than anyone else.

My digs at well-marketed schools are not gratuitous to the main point: I favor Pursuit and Pursuit-like organizations and we have worked for some of them. In addition, it’s clear to pretty much anyone who has spent time teaching in non-elite schools that the way the current post-secondary education system is set up is nuts and makes little sense; we need a wider array of ways for people to learn the skills they need to thrive. If Pursuit and Pursuit-like programs are going to yield those skills, we should work towards supporting more of them.

It is almost certainly not existing schools that are going to boost more people into the middle class, as they’ve become overly bureaucratic, complacent, and sclerotic; see also Bryan Caplan’s book The Case Against Education on this subject. While many individuals within those systems may want change, they cannot align all the stakeholders to create change from within. Some schools, especially in the community-college sector, are re-making themselves, but many are not. In the face of slowness, however, nimble nonprofits and businesses should move where this grant wave is going.

Links: Price transparency in healthcare?, collaboration, debt, the good life, and more!

* “A Billionaire Pledges to Fight High Drug Prices, and the Industry Is Rattled.” This would be very good: healthcare costs are eating the world.

* Collaboration Again: A Story From the Trenches.

* “GM’s electric bikes unveiled.” File under “Headlines I never thought I’d see outside of The Onion.”

* “Cultural barriers still stand in the way of HPV vaccine uptake.” Most importantly, “Every year, nearly 34,000 cases of cancer in the US can be attributed to HPV, the human papillomavirus. The CDC estimates that vaccination could prevent around 93 percent of those cancers.” We should be getting vaccinated. This is an easy healthcare win, and a way to easily reduce healthcare costs.

* “Six Secrets from the Planner of Sevilla’s Lightning Bike Network.” Reducing car usage is another easy cost win. There are two ways to improve well-being: increase incomes and decrease costs. Almost no one talks about the latter. We should talk more about it.

* “Murder Machines: Why Cars Will Kill 30,000 Americans This Year.” An evergreen article. Imagine if 70,000 people were killed by opioid overdoes in the United States every year. Oh wait, that’s actually happening too.

* Single-Family Home Zoning vs. ‘Generation Priced Out.’

* “Doctors Are Fed Up With Being Turned Into Debt Collectors.” Maybe we ought to go back to a world of transparent pricing, paid in advance?

* “Why Cities Must Tackle Single-Family Zoning.” Useful for anyone who thinks their rent is too damn high (like I do).

* “Oil Demand for Cars Is Already Falling: Electric vehicles are displacing hundreds of thousands of barrels a day, exceeding expectations.” We get too little good news; here is some.

* “The Creation of Deviance,” note: “The activities of university administrators may also fit a larger pattern, one in which agents of social control readily create the need for their own services.”

* Scott Alexander: “Preschool: I Was Wrong.” See also us on Universal Pre-Kindergarten and Early Head Start (EHS).

* “Wall Street Rule for the #MeToo Era: Avoid Women at All Cost.” It’s like no one imagined unintended consequences, or understands that incentives affect behavior.

* Greenhouse Gas Emissions Rise Like a ‘Speeding Freight Train’ in 2018.

* “‘Forget About the Stigma’: Male Nurses Explain Why Nursing Is a Job of the Future for Men.” I wrote an essay, “Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school,” that also covers germane points.

* “Workers are ghosting their employers like bad dates?” Ghosting is bad for the ghoster and ghostee, in my view.

* Nashville’s Star Rises as Midsize Cities Break Into Winners and Losers. I liked Nashville.

* Why are construction costs rising?

* Repl.it: Get your ideas out there. What the kids are apparently using to learn how to code.

* 2018 Was the Year of the Scooter?

* The World’s Leading Electric-Car Visionary Is Wan Gang, not Elon Musk?

* “Two Roads for the New French Right,” a much deeper, more substantive piece than the headline implies.

* Hospital prices are about to go public. Good news if true. We’ve written quite a bit, perhaps too much, on the topic.

* “A tour of elementary OS, perhaps the Linux world’s best hope for the mainstream.” It is strange to me that Linux still has so many problems for mainstream use and users.

* “Retraining Programs Fall Short for Some Workers: The goal was to help displaced workers gain skills in new industries. But studies show people are earning less or failing to find work.” This will not shock existing training providers. Re-training is hard, and the older the workers being re-trained, the harder the process is. Careers also tend to have arcs. At some point, if haven’t ascended sufficiently, you’re unlikely to ever build up the ability to do so. I think about myself and writing: it took me about ten years of continuous practice to become a competent writer. Ten years. And that seems to be a common fact for highly skilled people. Medical school + residency is seven years. Law school is only three years, but most lawyers take another five or so years to get really good at their jobs.

* Nuclear energy is key to saving the planet.

* “How economic theory and the Netflix Prize could make research funding more efficient.” The journal article is here. Looks like a good idea to us: some signaling is inevitably wasteful but may also be useful. In the grant world, however, there is far too much wasteful signaling. In this respect, the grant world resembles the heavily-marketed college admissions world.

When you hire consultants, you’re hiring them for all the mistakes they’ve ever seen (and made)

When you hire a lawyer, part of who you’re hiring is someone who has made thousands of mistakes in law school and as a young lawyer. Lawyers, like doctors and other professionals, learn in an apprentice-style system that incorporates the mistakes made by their mentors. Proto-lawyers also make some mistakes of their own—and, ideally, have those mistakes corrected by senior lawyers, and learn to not make those mistakes in the future. Most people don’t think about hiring a person or team specifically for their mistakes, yet this is a useful way to think about most professional services, including our personal favorite: grant writing consultants.

When you’re hiring a grant writer, you’re really hiring the experience that grant writer has. It isn’t impossible to hire a college intern or recent journalism grad and get funded; we’ve seen it happen and heard stories from clients. But the intern and inexperienced writers will make mistakes more experienced people won’t. We’ve written numerous posts about subtle mistakes that are easy to make in all aspects of the grant pipeline, from the needs assessment to the program design to the submission process. It’s also possible to get a competent junior person to write a couple of proposals, but grant writing is very hard and over time they tend to demand more money—or leave. That’s why you have trouble hiring grant writers. Many interns will write a proposal or two, but when they learn how hard and under-appreciated the job is, they often want money commensurate with difficulty. The inexperienced tend to make mistakes; the experienced grant writers tend to charge accordingly.

We are still not perfect (no one is; if anyone think they are, refer to “the perils of perfectionism“). But we have learned, through trial and error, how to make many fewer mistakes than novice or somewhat experienced grant writers. It’s not conceptually possible to eliminate all errors, but it is possible to avoid many errors that scupper most would-be grant writers.

If your organization can get a recent English major to write successful proposals for little or nothing, you should do that. But we’ve also heard from a lot of organizations that have “whoever is around” write, or attempt to write, their proposals, only to fail. Experience matters. You can get the magic intern, but more often you get someone who is overwhelmed by the complexity of a given writing assignment, who doesn’t understand human services or technical projects, is simply terrified by absolute deadlines, etc.

Let’s take as an example a common error that we’ve seen in a spate of recent old proposals provided by clients. Most include some variation, made by inexperienced writers, who want to write that “we are wonderful,” “we really care,” and the like in their proposals. This is a violation of the writing principle “Show, don’t tell.” Most of the time, you don’t want to tell people you’re wonderful—you want to show them that you are. “We are wonderful” statements are empty. “We served 500 youth with ten hours of service per week, and those services include x, y, and z” statements have objective content. It’s also harder to accurately describe what specific services an organization is providing than it is to say subjectively, “We are wonderful and we care.” Whatever is rare is more valuable than that which is common.

The above paragraph is just one example of the kind of errors novices make that experts tend not to. Attempting to enumerate all errors would be book-length if not longer. Experienced grant writers will avoid errors and offer quality almost instinctively, without always being able to articulate every aspect of error vs. optimality.