Category Archives: Government

“Currently, [Census] data is not loading properly:” DOL’s YouthBuild FY ’21

Needs assessment experts and data nerds know that, the old primary portal into Census data, is dead, while the new census data portal,, is only somewhat alive. Last year, I started a post about the ways that is broken, but I abandoned it because it was too boring, even for me; last year, was hellaciously slow, often taking 10 seconds for a query (a needs assessment may require dozens or hundreds of queries), and many internal links simply didn’t work. Some of that seems to have been fixed: back then, for example, trying to find specific sub-data sets, like educational attainment, for a given zip code, didn’t work. I sent some feedback to the Census contact person, who was very helpful, and eventually most of the problems disappeared.

But not all, it seems; this year’s DOL YouthBuild NOFA includes a humorous instruction regarding data requirements: pages 84 – 86 offer a 20-step algorithm for acquiring poverty data. That the algorithm has 20 steps and three pages is obviously bizarre: instruction 17 notes, “A table will come up showing the Total Population, the Number in Poverty, and the Poverty Rate. Currently, the data is not loading properly and at first only the overall U.S. data will load and you will not be able to scroll any further to the right to see anything else.” Oh? “Currently, the data is not loading properly:” that seems as if it could be the theme of the new Census interface.

About 10 years ago, there was a popular link-sharing site called Digg, and it introduced a now-notorious redesign that users hated, and those users consequently abandoned it en masse, leading to the rise of Reddit, a now-popular link-sharing site. If Digg had been more careful, it probably would have maintained its previous site design for those who wanted it, while introducing its new site design as a default, but not mandatory, experience. And then Digg would likely have iterated on the new design, figuring out what works. Reddit has somewhat learned this lesson; it now has two interfaces, one primarily living at, which is maintained for people highly familiar with “the old Reddit,” and a newer one that is available by default at This bifurcation strategy allows a smooth transition between interfaces. The Census didn’t follow this strategy, and instead killed the old interface before the new one was really ready. Thus, bugs, like the bugs I’ve noticed, and bugs like those the Dept. of Labor noticed and mentioned specifically in YouthBuild NOFA. The more general lesson is fairly clear: be wary of big user interface changes. If you need Census data, though, you’ll have to use the interface, as is, since it’s the only one available.

For some reason—perhaps latent masochism?—Isaac continues to use MS Office 365 Outlook (not the free version) as an email client, instead of Apple’s, or Thunderbird, and he tells me that every time he opens Outlook, he gets an invitation to try “the new Outlook” interface. So far, he’s resisted, but he also points out that most change is positive: when S + A started in 1993, there was effectively no commercial Internet, and the only way to get Census data was to go to Census Office, if you were near a big enough city, city hall, or a large library, where it was possible to thumb through the impenetrable Census books and maps. After a year or two in business, some vendor got the idea of putting the 1990 Census data on CDs (remember those), for quite a high price. Even though S + A was struggling to control costs, he bought the CDs, since they were better than hours in a Census Office or library. But then he had to buy, and install, CD drives in the Pentium PCs (remember those) we used. A couple of years later, he stumbled into a Census data portal set up by a random university, which worked! So, he tossed the CDs. When the 2000 Census came out, the feds essentially copied the university’s interface, creating, and all was well until came alone. It’ll probably be better than the old interface, at some point.

Complaining is easy and making things better is hard. In the Internet era, both complainers and makers have been empowered, and I appreciate the difference between the two. People who have fundamental responsibility for a product, service, or organization, including the responsibility for making hard decisions that aren’t going to be popular with everyone, have a different perspective than those who can just complain and move on. So I don’t want to be a drive-by complainer, as so many are on “social” media, which seems poisonous to institutional formation and coherence. But, despite those caveats, the instruction from DOL regarding the Census being broken is perversely funny.

New combo COVID-19 stimulus bill and budget bill have tons of grant “ornaments”

The latest COVID-19 Stimulus Bill was signed into law Dec. 27, which, combined with the FY ’21 budget authorization bill, represents a burst of new grant activity. Congress loves to cobble together fantastically complex budget legislation, as this practice, called adding special interest “ornaments,” gives members lots of room for plausible deniability about voting for them; some of the new discretionary provisions include:

    • $82B for “education,” including $54B for K-12 schools and $23B for colleges/universities. Some of these funds will be distributed on a formula basis, likely via pass-throughs to state education agencies, but the rest should be awarded through competitive RFPs, either direct federal applications or RFPs run by the states.
    • $7B for expanding access to “high-speed internet connections,” including subsidies for low-income families. This provision also include $300M for building out broadband infrastructure in rural areas and $1B for tribal broadband programs. We wrote many broadband infrastructure grants following the 2009 Stimulus Bill during the Great Recession.
    • $70B for a slew of “public health measures,” including $20B for “test and trace” programs and “billions for combating the disparities facing communities of color.” This is another way of saying “walking around money” for nonprofits and local public agencies.
    • $10B for child care providers. We write many early childhood education proposals, including Head Start, Early Head Start, Universal Pre-K, etc., and this set of funding provisions will likely be similar. Furthermore, it’s probable that both non-profit and for-profit entities will be eligible, since much of the non-Head Start child care industry is operated by for-profits.
    • $35B for “wind, solar, and other clean energy projects.” These funds will likely be distributed through the Department of Energy, ARPA-E and similar funding agencies.
    • $400M for food banks and $175M for nutrition programs under the Older Americans Act, which will probably be distributed via programs like Meals on Wheels.
    • $5B for the “entertainment industry,” including cultural institutions like theater groups, museums, etc.
    • $14B for public transit.

Some of the other features, listed here more for amusement than anything else, include: a statement of policy regarding the succession or reincarnation of the Dalai Lama; the establishment of two new Smithsonian museums; giving West Virginia a national park; banning the USPS from mailing electronic vaping products; the decriminalization of various minor violations, including the transportation of water hyacinths, alligator grass, or water chestnut plants across state lines and the unauthorized use of the Swiss coat of arms, the 4-H Club emblem, the “Smokey Bear” character or name, the “Woodsy Owl” character, name or slogan, or “The Golden Eagle Insignia; the establishment of an anti-doping program for horse racing; a bunch of foreign aid programs for things like gender studies in Pakistan; and, my personal favorite, a 180-day countdown underway for the Pentagon and spy agencies to reveal what they all know about UFOs.

In other words, the Mulder and Scully Act of 2020” is hidden in this bill. During a conversation with Tyler Cowen, former CIA director John Brennan recently commented on UFOs, saying that he’s “seen some of those videos from Navy pilots, and I must tell you that they are quite eyebrow-raising” and that, after sifting the evidence, “I think some of the phenomena we’re going to be seeing continues to be unexplained and might, in fact, be some type of phenomenon that is the result of something that we don’t yet understand and that could involve some type of activity that some might say constitutes a different form of life.”

We’ll write another follow-up post or two on this topic, as the 6,000 page bill is fully digested.

The 2020 presidential election and grants: A tsunami of RFPs is likely, no matter who wins

America is a day away from what one of my adult kids calls, “this shit-show election.” A bit harsh for me, but certainly, as Jerry Seinfeld might call it, a Bizzaro World election. Still, from a grant seeker’s or grant writer’s perspective, a tsunami of RFPs is likely roaring toward us.

Despite media speculation, the amount of grant funds available almost inexorably goes up; this is due partially to the fact that the federal budget is a baseline, not a zero-based, system. The budget for the federal FY ’21, which began October 1, is essentially the FY ’20 budget, with a cost of living bump and whatever Congress added for COVID-19 and pet interests. With the possible exception of the first two years of the Reagan administration, I don’t think there’s ever been an actual, substantial reduction in federal discretionary grant spending. When your read the inevitable NYT or Washington Post story following a Republican victory about looming “budget cuts,” what’s usually being proposed is a percentage cut to planned spending increases—not actual cuts.

Despite endless polls and punditry, no one knows how the presidential and congressional elections will turn out. But consider, from a grant-seeking perspective:

    • By almost any measure, 2020 is the Year of Chaos and upper level bureaucrats (GS 14s and 15s) who run federal grant making agencies are both overwhelmed by the COVID-19 crisis and frozen in place by the last months of this election cycle. Many of the Republican political appointees (Deputy Assistant Secretary for Funny Walks, ect.) are busy updating their resumes, or are busy with clandestine political work. There have been way fewer FY ’21 RFPs issued so far than would normally be the case by this time of year. When the election miasma lifts in a week or two, the federal bureaucracy will be shoveling RFPs out the door to catch up.
    • In the run-up to the elections, the last multi-trillion dollar COVID-19 relief bill wasn’t passed, yet America is experiencing another series of spikes, which will likely lead to more lockdowns and ongoing economic misery. A huge new relief bill will likely pass during the lame duck session, and it will in turn likely be studded with what are called “Christmas ornaments”—special interest funding items placed amid the larger bill components. Some of the basic relief funding, as well as some the ornaments, should result in new discretionary grants—either for existing programs or new ones that Congress dreams up. These RFPs will add to the torrent of already authorized FY ’21 funding.
    • Even if Trump pulls out a victory, there’ll be many new faces in House and especially the Senate, because there are many more contested races than usual this year. It’ll be almost irresistible for the departing members, as well as the ones who survive, to authorize more FY ’21 spending for discretionary grant programs during the lame- duck session. Congress can pass new budget authorization bills at any time, as long as the spending bill starts in the House, and what better time than just before you return home to look for work after losing an election? Almost all polls find, however, that Democrats likely to keep the House, but the Senate is still in tea leaf reading mode.

The coming RFP flood presents real-world challenges for many nonprofits. The first three COVID-19 bills had many programs (meaning, more-or-less automatic funding without an RRP process) for certain types of grant recipients, and especially for healthcare providers like hospitals and FQHCs. This money is running out and, while it has to some extent cushioned the immediate negative impacts of COVID-19, most nonprofit management teams have been thrown into chaos, with disrupted fundraising plans, curtailed local revenue for city/county funded contracts for human services, and layoffs—often at the same time as service demands have increased. Many nonprofits will lack the internal resources or focus to go after new grants, because management is too busy keeping their boat afloat. This is good news for the nonprofits with the energy (or consultants like us) to gin up technically correct grant proposals in next few months, since the competition should be less for any given RFP process.

Confusing NIH and other Small Business Innovation and Research (SBIR) application guidance

In theory, an “application guide” for a Small Business Innovation and Research (SBIR) grant from a federal agency is meant to make the application process easier: the applicant should presumably be able to read the application guide and follow it, right? Wrong, as it turns out. The difficulties start with finding the application guide and associated RFP (or “FOA,” Funding Opportunity Announcement in NIH-land) . If you go to today, Sept. 9, dear reader, and search for “SBIR,” you’ll get 74 matching results—most for National Institutes of Health (NIH) programs, which we’ll use as an example for the sake of this exercise, and because I worked on one recently. I’m going to use “PA-18-705 SBIR Technology Transfer (R43/R44 Clinical Trial Not Allowed)” program, which has download instructions at When you download and review the “instructions,” however, you’ll find this complication:

It is critical that applicants follow the SBIR/STTR (B) Instructions in the SF424 (R&R) SBIR/STTR Application Guide (// where instructed to do otherwise (in this FOA or in a Notice from the NIH Guide for Grants and Contracts (// Conformance to all requirements (both in the Application Guide and the FOA) is required and strictly enforced.

Notice that the URLs in the quoted section are incomplete: it’s up the applicant to track down the true SBIR application guide and correct FOA. I did that, but the tricky phrase is “follow the SBIR/STTR (B) Instructions […] except where instructed to do otherwise.” For the particular NIH application we were working on, the FOA and the Application Guide disagreed with each other concerning how the narrative should be structured and what an applicant needed to include in their proposal. So what’s an applicant, or, in this case, a hired-gun grant writer, to do? With some SBIRs, there is no canonical set of questions and responses: there’s the “general” set of questions and the FOA-specific set, with no instructions about how reconcile them.

To solve this conundrum, I decided to develop a hybridized version for the proposal structure: I used the general narrative structuring questions from the application guide, and I tacked on any extra questions that I could discern in the program-specific FOA. The only plausible alternative to this hybridized approach would have been to contact the NIH program officer listed in the FOA. As an experienced grant writer, however, I didn’t reach out, because I know that program officers confronted with issues like this will respond with a version of “That’s an interesting question. Read the FOA.”

The challenge of multiple, conflicting SBIR guidance documents isn’t exclusive to the NIH: we’ve worked on Dept. of Energy (DOE) SBIRs that feature contradictory guides, FOAs/RFPs, and related documents. It takes a lot of double checking and cross checking to try to make sure nothing’s been missed. The real question is why inherently science-based agencies like NIH and DOE are seemingly incapable of producing the same kind of single RFP documents typically used by DHHS, DOL, etc. Also, it’s very odd that we’ve never worked on an SBIR proposal for which the federal agency has provided a budget template in Excel. In the NIH example discussed above, the budget form was in Acrobat, which means I had to model it in Excel. Excel has been the standard for spreadsheets/budgets since the ’80s.

We (obviously) work on grant applications all the time, and yet the SBIR reconciliation process is confusing and difficult even for us professional grant writers. The SBIR narratives, once we understand how to structure them, usually aren’t very challenging for us to write, but getting to the right structure sure is. For someone not used to reading complicated grant documents, and looking at SBIR guidance documents for the first time, the process would be a nightmare. Making SBIRs “easier” with extra, generic application guides that can be unpredictably superseded actually makes the process harder. This is good for our business but bad for science and innovation.

HUD’s Lead Hazard Reduction grant program and the hazards of government autopilot

The NOFA for HUD’s Lead Hazard Reduction (LHR) grant program just came out, and it has $275 million to undertake, as usual, “comprehensive programs to identify and control lead-based paint hazards in eligible privately-owned target housing.” LHR NOFAs are issued every year or two, which is fine, but those of you who are alive and able to read or access the Internet are probably aware that there’s another health hazard out there this year, and it’s a health hazard that’s probably more urgent than lead-based paint—lead-based paint has been illegal in the US since 1980 and HUD’s been funding LHR grants for at least 30 years (we know, because we’ve written so many funded LHR proposals). It’s hard to believe that there’re all that many housing units left in the US with lead-based paint, but HUD soldiers on.

Sure, lead is a health hazard, but COVID-19 is also a health hazard; if I had to bet which one most persons would consider more hazardous right now, I’d bet on COVID-19. $275 million may be a small amount of money by federal standards, but I wonder how much the staff at HUD thought about whether public housing authorities (PHAs) and cities want to work on lead abatement this year, versus how much they’d like and need to work on COVID-19 abatement; $275 million can buy a lot of masks, education, and tests (although tests are still in short supply right now). It’s not really the fault of HUD bureaucrats, since LHR grants have been authorized by Congress for for decades and Congress usually just keeps funding programs like this, no matter what’s going on in the real world. Nonetheless, it would seem to me that a simple, bipartisan vote to amend the underlying legislation would be relatively easy—instead, LHR, at this point, is indicative of the dangers of government autopilot. Autopilot is fine in clear, consistent weather, but it can be disastrous during unpredictable storms—and the world has been hit by a storm in 2020.

I’m not presenting an argument against lead-hazard control: I don’t know enough to say whether lead-hazard control remains, in the absence of a pandemic, a (relatively) good idea or a (relatively—compared to other health-related activities) bad idea. I’ll posit, however, that a lot more people are going to die and suffer from COVID-19 this year, than will die or suffer from lead-based paint, and the failure to change course in the face of new events is evidence of deeper malaise.

Generalized human and social services: ACF READY4Life and Fatherhood FIRE RFPs

Astute newsletter readers saw two useful Administration for Children and Families (ACF) Office of Family Assistance (OFA) RFPs with lots of money available (albeit with overly long names) in our last edition: Fatherhood – Family-focused, Interconnected, Resilient, and Essential (Fatherhood FIRE) and Relationships, Education, Advancement, and Development for Youth for Life (READY4Life). Both have grants to $1.5 million for family formation and resilience services. A phrase like “family formation and resilience services” should make smart nonprofit Executive Directors sit up and take notice, because we’ve seen fewer overt generalized human services grants over the past few years—the kind of grants that we sometimes call “walkin’ around money.

Smart organizations figure out that these kinds of grants can be used to fill in the cracks of an organization’s budget, because the project concepts that can be funded are broad. Also, in most cases, only a process evaluation (e.g., number of outreach contacts made, number of referrals, etc.) is feasible, since there’s usually no way to tract outcomes. In the ’90s and ’00s we saw more broad, general-purpose RFPs, but we’ve seen fewer since the Great Recession. The feds seem to have lost interest in many kinds of general-purpose grants and have instead been targeting particular services, like primary health care and job training.

Many organizations are already doing things like fatherhood and family development, but without calling their activities “fatherhood and family development.” Federally Qualified Health Centers (FQHCs), for example, often serve low-income patients who are impoverished by single parenthood, usually in a female-headed household. Nimble FQHCs should apply for READY4Life, Fatherhood FIRE, and similarly nebulous grant programs, since they can re-brand their existing Case Managers and Patient Navigators as “Family Support Coordinators” and “Parenting Specialists.” Obviously, the FQHC wouldn’t say as much in the proposal—that would be supplantation—but, in the real world, a lot of organizations keep their lights on and their clients happy using these strategies.

Organizations apart from FQHCs should be doing this too. Job training and homeless services providers, for example, often work with populations that need family reunification training, and the organizations are already often providing wraparound supportive services. Funders love synergistic proposals that say things like, “We’re going to do job training services for ex-offenders, and those ex-offenders will also be eligible for Fatherhood FIRE services in order to ensure that they remain in their children’s lives.”

Increased funding for generalized human services typically follows some kind of seismic societal shock. Seliger + Associates began in 1993, soon after the Rodney King verdict civil unrest, which was soon followed by the onset of mass school shootings with Columbine. Then came the Great Recession: the feds respond to social turmoil with huge new grant programs (21st Century Community Learning Centers was an example) and big budget increases for existing programs (like the 2009 Stimulus Bill). With the COVID-19 crisis, the cycle is repeating. Since March, three giant stimulus bills have been passed, with at least one more likely. The enormous civil unrest and protests unfolding after the recent police killing of George Floyd will likely lead to grant programs too; the feds’s objective is to get grants on the streets quickly to nonprofits, which act as a kind of buffer to politicians.

With growing “defund the police” sentiment in big, left-leaning cities, politicians are engaging in a sort of bidding war with proposed police budget cuts; politicians say some version of, “We want to redirect huge amounts of police budgets to solving the underlying problems that generate crime.” Translated, this means, “We plan to fund local nonprofits to conduct some kind of human services.”

Foster Family Agencies (FFAs) and why political rhetoric rarely focuses on child abuse

Tyler Cowen asks an interesting question: “Why the low status of opposition to child abuse?” A reader speculates that, on the cultural left, “the highly visible progressive segment that drives wokeness, is culturally powerful, etc.” does not emphasize child abuse, and, “while there’s nothing obviously wrong with their attention to sexual and racial discrimination, the energy put into it is disproportionate to the massive social cost of child abuse.” One possible answer to this query is that, as Cowen posits, “virtually everyone is against child abuse, so opposing it doesn’t make anyone significant look worse.” Another reader lists some reasons the political right could be quiet, and he says that “you can’t even think of a solution [to child abuse] by reasoning from your political views.” I’d venture another component: detecting child abuse is frequently hard because it occurs inside the home and away from most eyes, plus, once it has been unambiguously detected—what then?

What’s the alternative when the family is abusive, or, more readily and frequently, borderline abusive? Many GWC readers already know that the existing foster family system (FFS) can be characterized in a variety of ways, but “harmonious, well-funded, and functional” are rarely among them. Something like “completely f-ed up” is probably more common, in candid conversation if not publicly.* Most foster “family parents” are in effect small businesses in that they receive monthly payments from the contracting foster family agency (FAA),** which are higher for higher-risk kids. With several high-risk kids in the household, monthly payments can rise into the thousands of dollars—the foster kids know this and know they are, in some respects, a commodity. Still, some foster parents are saints (if you are one or know one and you are about to leave a comment, let me say that I’m aware of great and loving foster families) but most are running a very small enterprise on a tight margin. Plus, as much as I hate to say it, some number of foster families are motivated by the the very unattractive, horrific, and illegal impulses that you might imagine motivate them. To counteract bad actors, one needs a whole massive bureaucratic oversight machine, which is itself expensive, invasive, and onerous—and it discourages the well-meaning people who might otherwise participate. Most of us don’t want our homes randomly invaded by snooping, judging strangers.

We’ve worked for many FFAs over the years, and every FFA has the same publicly stated goal, which is aligned with the mission of county child protective services agencies: to facilitate family reunification, whenever possible. Birth families and/or relatives have to be very bad for the kid(s) to be worse off than they are in foster care, given the well-known shortcomings of the FFS. The honest FFAs will admit as much, again off the record. For family reunification, DHHS even has an RFP on the street, “Quality Improvement Center on Family-Centered Reunification.” It only has one grant available, which means it’s wired, so we’re unlikely to write one of these, though we’ve written other proposals in this genre.

It’s also important to understand that FFAs are themselves thin-margin businesses, which are often organized as nonprofits in only the most nominal of senses. The FFS in most states uses contracts with FFAs that reimburse the FFAs for the actual number and types of kids placed and the length of the placement. It is in effect a reimbursed per-capita arrangement that incentivizes the FFA to keep their census of placements as high as possible to cover fixed costs like staff and endlessly recruiting, training, and monitoring foster families. The many things that can go wrong with this structure are fairly obvious.

I have seen occasional articles like “The Best Thing About Orphanages:”

Duke University researchers issued the first report on their multiyear study of 3,000 orphaned, abandoned and neglected children in developing countries in Africa and East and South Asia. About half were reared in small and large “institutions” (or orphanages) and half in “community” programs (kin and foster care). Contrary to conventional wisdom, the researchers found that children raised in orphanages by nonfamily members were no worse in their health, emotional and cognitive functioning, and physical growth than those cared for in their communities by relatives. More important, the orphanage-reared children performed better than their counterparts cared for by community strangers, which is commonly the case in foster-care programs.

I don’t have a final answer to this issue, but orphanages have such bad PR in the United States that I doubt they’ll ever be seriously tried. Any politician who seriously proposes trying them is going to be compared to a Dickens villain and will likely be courting career suicide (on the other hand, I never thought we’d see legal marijuana, and here we are). The last major politician to make a pitch for orphanages was Newt Gingrich in 1990s, and that went nowhere (“[Gingrich] dared to suggest that some welfare children would be better off in private orphanages. In making his off-the-cuff comments, he ignited a media and policy firestorm, the general tone of which was best captured by First Lady Hillary Rodham Clinton, who dubbed the idea ‘unbelievable and absurd'”). Still, given our work with FFAs, I would favor some experimentation in the direction of orphanages, as long as they were re-branded with some clever moniker (“Growth Homes?”). Having a large number of adults watching each other and the kids is probably at least not worse than the current system, although I don’t see orphanages as a panacea. There is no panacea and some problems lack solutions.

All the problems above around foster care enumerated above are only exacerbated by teenagers, who are technically legally “children” but who often have non-childish impulses, are hard to control, and often run away. Even a 13 or 14 year old boy can be six feet tall and weigh 160 pounds or more. Girls present a different set of challenges.

Ideally, most political stances come with a set of solutions, but orphanages have a bad rap, more money would help the current system without alleviating its most pressing problems, and abused kids and FFAs are not large enough interest groups for their votes to be salient to politicians. There are lots of problems that we as a society prefer to sweep under the rug and not think about—it appears, for example, that “Air Pollution Reduces IQ, a Lot.” We could fix a lot of air pollution by depreciating gasoline-powered cars, but most people would prefer to ignore the issue and the incredible damage we do to kids’s health through cars. Animal meat processing factories are another example: if you kick a dog in public, you might be arrested and charged with a crime, but most of us prefer to ignore the horrific things that happen in meat processing factories. Foster care is yet another area in which we hope for the best and prefer not to know too much about what’s really happening.

While I was writing the precursors to this post, I also realized something unusual about grant writing: I don’t know exactly how to describe the vantage point we have, but it’s not a common one: we’re in this purgatory that’s not where most people thinking about social science and government policy reside. We’re in an intellectual and observational place halfway between the on-the-ground implementers and the in-the-tower legislators and academics. We’re not called on to dream up new programs, ideas, problems, or data, like academics and legislators, but we’re also much closer to the problem space, while not being completely mired in immediate day-to-day experience. Because we’re at a higher level of abstraction than most implementers, we can see comparisons that on-the-ground people sometimes miss, while still seeing enough of the ground floor to have a better idea what’s going on than some academic/legislator-types do. Almost no one asks us what we’ve seen and what we can see across organization types—for example, at one point, “We imagined foundations would hire us to help improve RFPs/funding guidelines. We were wrong.” That essay was written in 2015 and since then, zero funders have sought feedback. I’m not sure what to do with this observation, apart from noting that we see some things other people miss.

* We learn many interesting things from clients, most of which we can’t say publicly. Silence is one of our virtues.

** You can tell that we’re dealing with government because of the number of acronyms in play.

You’d think there’s no pandemic going on: The FCC shuts down its COVID-19 Telehealth grant submission portal

One of the bigger and more interesting RFPs on the street right now is the FCC’s “COVID-19 Telehealth Program,” which has $200 million available for obvious purposes—but grants are being accepted, reviewed, and approved on a first-come, first-served basis (federal RFPs usually have a fixed due date).* Lots of FQHCs are also implementing, or trying to implement, telehealth programs on the fly, since COVID-19 has hit them with a structural double whammy: patients with COVID-19 need to be isolated as much as possible from other patients, and other patients are avoiding health clinics for fear of catching COVID-19. This has had the unexpected side effect of lowering patient volumes at FQHCs, which, like other healthcare providers, have reacted by laying off staff. You’d intuitively think that, during a pandemic, the need for healthcare staff would expand, but that’s not happened outside of NYC intensive care units.

So the FCC program is designed to help FQHCs and other providers move relatively quickly to telehealth, which may help FQHCs achieve a higher patient volume. On Saturday we were working to backcheck a client’s online FCC application, since it’s our standard practice to make sure that applications are as complete and technically accurate as possible before client upload. But when we tried to log into the FCC’s application site, we were hit by a message telling us that the FCC had closed its application portal for maintenance. Is shutting a site down for “maintenance” still necessary in 2020? The error message felt very 2003, and, as you probably know, we’re in the midst of a pandemic, when every day counts. I guess FCC didn’t get the pandemic memo.

Eventually the site came back up, but its closure seems like a metaphor for many of the challenges we, as a society, are collectively facing from bureaucrats during these strangest of times.

The FCC COVID-19 Telehealth grant program is also unusual because it specifically says that applicants can only buy Internet-connected telehealth equipment—meaning blood pressure cuffs or pulse oximeters that automatically relay information to healthcare providers. I’ve seen budgets for how much these devices cost, and they’re crazy expensive, as most medical devices are. But: did you know that something as simple as an Apple Watch can function as a pulse oximeter—except that FDA regulations are blocking this use? This is the same FDA whose regulations stopped independent labs from rolling out virus testing in February. We try not to link outrage stories here, but it’s hard to read “The Infuriating Story of How the Government Stalled Coronavirus Testing” without being justifiably outraged.

Today, pointless FDA regulations are blocking people from using a relatively cheap and widely available device from being deployed in a medical context. lists “Series 5” Apple Watches at $399 and they’re shipping today (there’s been a pulse ox shortage). Our FQHC clients already know this, but pulse oxes are useful for determining whether a COVID-19 patient needs to be hospitalized, or needs supplemental oxygen. Most COVID-19 patients can recover on their own without medical intervention, but low blood oxygenation is a key danger metric: a normal blood oxygenation level is around 95 – 100. If a patient’s oxygenation level consistently falls below 90, that patient likely needs advanced care. Most households have a thermometer, but relatively few have pulse oxes. Many COVID-19 patients are suffering from what doctors are calling “silent hypoxia,” in which the patient is essentially suffocating but doesn’t realize they’re suffocating, and pulse ox data can tell the patient whether they need to go in to see their doc or to an ER. It would be relatively easy for Apple to allow Apple Watch users to link their health data with a healthcare provider, and for the healthcare provider go get an alert if a patient’s blood oxygenation level drops below 92 or 90. Cheap solutions exist but the FDA keeps us from implementing them.

* Other federal departments have been funding similar telehealth-related grants programs: for example, the USDA has $40 million available via the “Distance Learning and Telemedicine Grants.” Those grants aren’t due until July 13, however.

Doing business with public agencies in Texas versus California (or New York)

We’re working on a project for a large public agency in Texas, and, like most large public agencies, it has standard vendor signup forms. We’ve also worked for many public agencies in states like California and New York, which are infamous for being unfriendly to business—and, in this instance, the rumors are true. The differences in required vendor forms might be a microcosm for larger differences between California (or New York) and Texas. The Texas public agency has a short, simple vendor form with no attachments other than a W-9.

California and New York public agencies, however, typically have long and onerous forms and processes so complex that sometimes we turn down the assignment. They often require a “temporary” local business license, even thought the assignment will likely be completed in less than six weeks and we’ll never set foot in the jurisdiction; proof of worker’s comp, liability, errors and commissions and even car insurance (all of which we have, but insurance certificates are a pain to produce and may not match the agency’s strict rules); and oddball by-jurisdiction forms that have little or nothing to do with grant writing. The City of Los Angeles, for example, requires forms certifying that Seliger + Associates did not benefit from slavery (for those of you keeping score at home, slavery ended in all U.S. states in 1865, and Seliger + Associates was founded in 1993). Another example, when working for the City of Richmond in California: we have to provide four wet-signed notarized copies of the contract (party like its 1979).

The costs of complying with random forms and local regulations are rarely discussed—but they’re very real and often high. Such requirements even drive up the cost of childcare, in ways that are often invisible to the entities imposing the requirements. Since we work nationally, and sometimes internationally, we’re accustomed to the challenges, but states and municipalities reveal much about themselves even in small ways.

Funders sometimes force grantees to provide services they don’t want to: FQHCs and Medication Assisted Treatment (MAT)

We often remind clients that those with the gold make the rules. Accepting a government grant means the applicant must sign a grant agreement, in which the applicant agrees not only to provide wherever services were specified in the proposal, but also abide by a myriad of regulations and laws. While many applicants will tussle with a funder over the budget, there’s rarely any point in trying to modify the boiler plate agreement—just like one can’t modify Apple or Facebook’s Terms of Service.

In addition to the specific terms of the grant agreement, grantees quickly become subject to other influences from the funder—when the Godfather makes you an offer you can’t refuse, you know that eventually you’ll be told to do something you’d otherwise not much want to do. While a federal agency is unlikely to place a horse’s head in a nonprofit Executive Director’s bed, the grantee might end up having to provide an unpalatable service.

A case in point is HRSA’s relatively recent (and divisive) endorsement of Medication Assisted Treatment (MAT) for treating opioid use disorder (OUD). Since HRSA is the primary FQHC funder, it is essentially their Godfather and has great influence over FQHCs. In the past few years, HRSA has strongly encouraged FQHCs to provide MAT. The CEOs of our FQHC clients have told us about HRSA pressure to start offering MAT. It seems that, even after several years of cajoling, only about half of our FQHC clients provide MAT, and, for many of these, MAT is only nominally offered. Other clients see offering MAT as a moral imperative, and we’ll sometimes get off the phone with one client who hates MAT and then on the phone with another client who sees not providing MAT as cruel.

“MAT” generically refers to the use of medications, usually in combination with counseling and behavioral therapies, for the treatment of substance use disorders (SUD). For OUD, this usually means prescribing and monitoring a medication like Suboxone, in which the active ingredients are buprenorphine and naloxone. While Suboxone typically reduces the cravings of people with OUD for prescribed and street opioids (e.g., oxycontin, heroin, etc.), it is itself a synthetic opioid. While MAT replaces a “bad opioid” with a “good opioid,” the patient remains addicted. Many FQHC managers and clinicians object to offering MAT for OUD, for a variety of medical, ethical, and practical reasons:

  • Like its older cousin methadone, as an opioid, Suboxone can produce euphoria and induce dependency, although its effects are milder. Still, it’s possible to overdose on Suboxone, particularly when combined with alcohol and street drugs. So it can still be deadly.
  • While MAT is supposed to be combined with some form of talking or other therapy, few FQHCs have the resources to actually provide extensive individual or group therapy, so the reality is that FQHC MAT patients will likely need Suboxone prescribed over the long term, leaving them effectively addicted. We’re aware that there’s often a wide gap here between the real world and the proposal world.
  • Unless it’s combined with some kind talking therapy that proves effective, MAT is not a short-term approach, meaning that, once an FQHC physician starts a patient on Suboxone, the patient is likely to need the prescription over a very long time—perhaps for the rest of their life. This makes the patient not only dependent on Suboxone, but also dependent on the prescriber and the FQHC, since few other local providers are likely to accept the patient and have clinicians who have obtained the necessary waiver to prescribe it. Suboxone users must be regularly monitored and seen by their prescriber, making for frequent health center visits.
  • As noted above, prescribed Suboxone can, and is often, re-sold by patients on the street.
  • Lastly, but perhaps most importantly, most FQHC health centers prefer to look like a standard group practice facility with a single waiting room/reception area. Unlike a specialized methadone or other addiction clinic, FQHC patients of all kinds are jumbled together. That means a mom bringing her five-year old in for a school physical could end up sitting between a couple of MAT users, who may look a little wild-eyed and ragged, making her and her kid uncomfortable. Since FQHCs usually lack the resources for anything beyond minor paint-up/fix up repairs, there is simply no way around this potential conflict.

Given the above, many FQHC CEOs remain resistant to adding the challenges of MAT to the many struggles they already face. Still, the ongoing pressure from HRSA means that most FQHCs will eventually be forced to provide at least a nominal MAT program to keep their HRSA Program Officer at bay. The tension between a typical mom and her five-year old against a full-fledged behavioral and mental health program is likely to remain, however. Before you leave scorching comments, however, remember that we’re trying to describe some of the real-world trade-offs here, not prescribe a course of action. What people really want in the physical space they occupy and what they say they want in the abstract are often quite different. You can see this in the relentless noise around issues like homeless service centers; everyone is in favor of them in someone else’s neighborhood and against them in their own neighborhood. Always pay attention to what a person actually does over a person’s rhetoric.