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Modern HIV prevention and education grant-funded programs

Astute healthcare-related nonprofit and public agency managers who follow grant opportunities have probably noticed how many of those grant opportunities use specific, somewhat coded language to express whatever it is that they want (read a lot, and you’ll start to see patterns in RFP verbiage). We’ve written many modern HIV prevention and education grant-funded programs, and, consequently, we’ve gotten very good at designing how those programs should be pitched to funders—the most common being the Health Resources and Services Administration (HRSA). Still, HRSA Notices of Funding Opportunity (NOFOs) are often opaque about how exactly the applicant is supposed to provide services and what precisely the applicant should do. The purpose of being opaque may be so that applicants can signal their underlying competence and knowledge.

Many HIV-services programs can be divided into two categories, although the categories can overlap: prevention/education and treatment. We’re going to focus on the former, at least in this post, though some grant-funded programs will ask for both components. A typical grant-funded project purpose for a program designed to provide prevention and education is something like “reduce HIV transmission via outreach and engagement.” The target population will usually be persons at high risk for HIV/AIDs, but who are known to not be HIV+. Federal funders like vaguely bureaucratic terms like “persons” over more human terms like “folks;” the more bureaucratic and less human a proposal sounds, the more funders will typically like it.*

The applicant agency should typically propose a project that will use peers of the high risk population—that is, people who are “culturally and linguistically like the target population”—to do outreach, engagement, and education. A common term for such a position is a “Community Health Worker” (CHW). CHWs are often paired with Registered Nurses (RNs) or similarly licensed clinicians: the CHW goes out, finds the target, high-risk population, talks to members of the target population, and gets them to be tested.

This involves some combination of on-the-spot rapid HIV testing to see if the high-risk person might already be positive, along with education and the like if they’re not. Education includes things like “why using PrEP is a good idea,” “how to avoid sharing needles,” etc. The CHW will encourage the at-risk person to reduce risky behaviors (e.g., sharing needles, or unprotected sex with multiple random partners, and the like). This kind of outreach effort is sometimes done with a mobile outreach unit, often a van, that’s owned/leased and operated by the applicant. In some grant programs, it’s possible to buy the van with grant funds, but, even when the van isn’t covered, leasing and operating costs (e.g., gas, maintenance, insurance, etc.) should be eligible grant costs.

In addition to culturally and linguistically street-based education and rapid HIV testing in the outreach van, CHWs try to get who are found to be HIV+ via rapid test a follow-up laboratory confirmation test. If the lab test confirms the person is HIV+, the CHW tries to get help that person get into treatment. Persons who are positive should in particular be targeted for entry into services.

But funders usually also want all high-risk persons who are engaged by the team to establish a medical home and, for HRSA, this means at a Federally Qualified Health Center’s (FQHC). In the real world, many FQHCs aren’t excited by the prospect of new, high-risk, and difficult-to-serve patients, but HRSA and other funders want to hear that this is going to happen.

HIV+ persons obviously need care, and consistent care, both to ensure their own safety and to reduce the likelihood of community transmission. Modern, consistently applied HIV treatments haven’t, to our knowledge, been shown to conclusively, completely, continuously prevent HIV transmission, but they can make the virus nearly undetectable in the body, which likely reduces transmission (if there is evidence one way or another, please cite it in the comments). PrEP in the high-risk, but uninfected population, in combination with effective, consistent usage of anti-HIV drugs in the infected population, is a potent combination to reduce HIV prevalence, which is why almost all modern HIV-prevention programs want this approach, whether they say so directly or not.

The peer-to-peer outreach approach, in which the organization hires CHWs with the “street cred” to engage the target population, ensures that the target population is more likely to accept some level of engagement, education, and behavior changes to reduce risks. The peer positions receive training in HIV and how HIV prevention works, and then go into the community to seek high-risk, hard-to-reach persons. Applicants should also propose more general outreach efforts focused on social media. Virtually all targeted persons will have smart phones; even most homeless people do, today.

The approach we’ve discussed above can be described in more detail or less detail—for example, what specifics will the educational effort cover? How long will CHWs seek to talk to each person who is reached out to?—but the basic structure has been consistent for years.

Continue reading Modern HIV prevention and education grant-funded programs

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Substance Abuse Disorder/Opioid Use Disorder (SUD/OUD): Traditional treatment versus harm reduction for grant writers

We’ve been writing Substance Use Disorder / Opioid Use Disorder (SUD/OUD) treatment grant proposals since 1993, so we’ve been at it for long enough to see waves of funder preferences around approaches come and go. SUD/OUD are hard problems, and made harder because of the misinformation and disinformation about Oxycodone and Oxycontin that Purdue Pharma and its subsidiaries spread for decades, in a way that’s likely worse than the way the cigarette companies once marketed their wares.

For the first 20 years or so in business, the SUD/OUD treatment grant proposals we wrote were usually based on the standard “Step-Down” paradigm, in which people with addiction receive treatment along a continuum of care from a high level of care and then “step down” to lower care levels in increments, leading to eventual recovery and self-care. Following engagement, referral, or self-presentation and development of an individual treatment plan (ITP), the step-down levels are more or less like this:

  • Detoxification/hospitalization
  • Inpatient treatment
  • Intensive outpatient treatment
  • Outpatient treatment, often including 12-Step peer support groups and, for those with OUD, medication assisted treatment (MAT)
  • Recovery and self-care

The levels can be further broken down, but the above is a common schema. As patients move down the treatment continuum, they usually receive case-managed wraparound supportive services—like legal assistance, workforce development, primary/dental care, affordable housing, etc.— at least until they are in recovery and have been “clean and sober” for six to twelve months. The “affordable housing” part has gotten much harder, though, because most cities use zoning laws to restrict the supply of housing, which causes prices to rise, which makes a given housing unit difficult for a grant-funded organization, or a person with drug addiction, to afford. Also, it’s an unfortunate reality that most people with SUD/OUD will relapse multiple times, sending them to the top of the treatment pyramid again. In this way, step-down treatment is something like the classic board game Chutes and Ladders I played as a kid. “Step down” was the main “treatment game” available for decades, although methadone was sometimes used for what we now call OUD.

About ten years ago, we began noticing a difference in SAMSHA, HRSA, and other RFPs for SUD/OUD: those agencies now want usually applicants to augment treatment to include “harm reduction.” As defined and described by SAMHSA, “Harm reduction is critical to keeping people who use drugs alive and as healthy as possible, and is a key pillar in the multi-faceted Health and Human Services’ Overdose Prevention Strategy.” Most of our clients resisted this shift but have gradually gotten on board the harm reduction train as pure harm reduction RFPs, like SAMHSA’s “FY ’22 Harm Reduction NOFO,” began to appear. The shift isn’t surprising, because in grant seeking it pays to follow the golden rule. No, not that golden rule, this one: “The people with the gold make the rules.”

Harm reduction projects usually involve a van-based outreach model in which Peer Support Workers (PSWs) go in teams to what are termed “hot spots” to engage people living with SUD/OUD. “Hot spots” include places like homeless encampments, shelters, parks, etc. The outreach effort can be either obvious (e.g., signage on the van and PSWs in logo t-shirts) or on the down low (e.g., plain white van and PSWs in street clothes), or a hybrid version using magnetic signs placed on the van, or removed from it, depending on the needs of a particular location on a given day. The PSWs distribute harm reduction supplies like clean syringes (with or without exchange), alcohol swabs, sterile water ampules, spoons, fentanyl test strips, sharps containers, and condoms, along with emergency food, clothing, hygiene items, and so forth. The outreach van is also used to provide some direct services in the field like wound care, rapid HIV tests, and naloxone administration.

The most extreme version of harm reduction are safe injection sites: while these are illegal in most of America because the drugs themselves are technically illegal, if widely available, three safe injection sites have recently and prominently opened, two in NYC and one in San Francisco. One key problem with a safe injection site initiative is that few businesses or residents want one near them, much like no one wants to be in proximity of a methadone clinic, so permitting is a real challenge. We’ve yet to write a safe injection site proposal but likely soon will.

A key difference between the standard treatment model and the harm reduction model is that clients are typically not tracked (when Joe or Mary shows up for supplies, their identity isn’t verified and they aren’t entered into a client database for tracking), and, most significantly, services aren’t case-managed. PSWs will offer “warm handoffs” for follow-up treatment like MAT and other center-based services, but there’s no automated follow-up from the harm reduction team.

We’re just grant writers, so we don’t have an immediate opinion as to whether step-down treatment or harm reduction is more efficacious, and most studies on the subject are somewhat questionable, although every treatment/harm reduction proposal we write claims the project design uses “evidence-based practices” (EBPs). When in doubt, claim both “evidence” and “innovation” for your program, leaving aside that those two are often mutually exclusive. If your agency provides SUD/OUD treatment, consider adding a harm reduction component, as this is clearly where the feds are going with grant funds. A cynic might conclude that the feds are pushing harm reduction because it’s much cheaper than providing longitudinal case-managed treatment, but we’ll leave that conclusion to others.

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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. Apple.com 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.

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Links: Healthcare and how it’s eating the world, education, homelessness and weird public policies, the nature of the good life, and more!

* “The Pedagogical Lessons and Tradeoffs of Online Higher Education.” Education and healthcare both seem to lack silver bullets, although we keep looking for them. See also us on the need to boost apprenticeships and vocational education. This is based in part on my experiences teaching college students.

* “The U.S. Furniture Industry Is Back—but There Aren’t Enough Workers: Companies expanding American production due to consumer preferences and tariffs are finding a dearth of skilled workers.”

* “As Homelessness Surges in California, So Does a Backlash.” Who could have predicted that homelessness is part of the regulatory environment that precludes the building of homes?

* “Apple Commits $2.5B to Ease California Housing Crunch.” Unfortunately, money is not the big problem here—zoning policies that prevent new housing from being constructed is the problem. Until we decide that more housing is a good idea, more money is mostly going to be used to bid up the prices of existing housing. Oregon, for example, has legalized townhomes statewide, and California should be doing the same. We’ve worked on some homeless-service proposals, but it’s depressing to see California raise a bunch of money that then can’t be used efficaciously because of their zoning policies.

* “The Key to Electric Cars Is Batteries. Chinese Firm CATL Dominates the Industry.” Have not seen this triangulated from other sources, however.

* Unraveling an HIV cluster.

* “Why It’s So Hard to Buy ‘Real Food’ in Farm Country. An exodus of grocery stores is turning rural towns into food deserts. But some are fighting back by opening their own local markets.” Seems like an Onion story, but seemingly not.

* “San Francisco Board of Supervisors questions $900K/unit cost for Sunnydale ‘affordable’ housing.” Until we do zoning reform, we can’t build affordable housing, as noted above. Meanwhile, southern California is little better: “Some of Los Angeles’ homeless could get apartments that cost more than private homes, study finds.”

* $30 million in grants to fund nuclear fusion research. That’s cool.

* Air Pollution Reduces IQ, a Lot. If you are worried about human welfare, attacking air pollution is key. Normal people can do this, too, by choosing low-emissions vehicles.

* Medical billing: where all the frauds are legal. We’ve heard that many healthcare providers, including FQHCs, are forced to be medical billers first, and everything else second, or third, or worse. In related news, A CT scan costs $1,100 in the US — and $140 in Holland.” You’ve heard it before, but: price transparency now. What’s stopping this? “Doctors Win Again, in Cautionary Tale for Democrats: Surprise billing legislation suddenly stalled. The proposal might have lowered the pay of some physicians.” There are few if any easy wins.

* Why white-collar workers spend all day at the office. It’s a signaling race. Most writers know we have 2 – 4 decent hours a day in us for real writing, for example.

* “California population growth slowest since 1900 as residents leave, immigration decelerates..” This is purely a political and legal problem, which means it’s very solvable. Also, “‘Garages aren’t even cheap anymore:’ Bay Area exodus drives lowest growth rate in years.” California is a gerontocracy ruled by zombie homeowners who bought their properties decades ago, pay low property taxes on them, and now block anyone else from building anything, anywhere.

* Magic mushroom compound psilocybin found safe for consumption in largest ever controlled study.

* AI and adaptive learning in education. This could and should be a big deal.

* “Denser Housing Is Gaining Traction on America’s East Coast: Maryland joins Virginia with a new proposal to tackle the affordable housing crisis. And it’s sweeping in its ambition.”

* Dan Wang on science, technology, China, and many other matters of interest.

* Letting nurse practitioners be independent increases access to health care? See also my post, Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school. Healthcare fields seem to have near-infinite job growth, which is useful knowledge for job-training programs.

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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.

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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.

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“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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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“Your methods are unorthodox”

As GWC readers know, getting information about state and local grants is often tricky. Every state and municipality is different, and, like foundations, few if any make any effort at standardization or the user experience; most just assume that the usual suspects will apply for grants, and consequently they end up forming de facto cartels. In theory, too, all government grant information is also public information, but that’s a little like the theory that DMV employees are public servants who work on behalf of taxpayers: connecting theory to practice can be hard or nonexistent—naive visitors to the DMV learn.

Anyway. I spent some time attempting to get into the Wisconsin “Division of Public Health Grants and Contracting (GAC) Application” page, which is stashed behind a password wall for no reason I can discern. In the process I ended up emailing “Yvette A Smith,” a contracting specialist, to request access, and in reply, she told me that “Your request is unorthodox.” While not quite as good as “Your methods are unsound,” I did actually laugh out loud; I do like to imagine I’m the grant-world equivalent of Captain Willard talking to Colonel Kurtz in Apocalypse Now.

And Yvette is right: our methods are unorthodox and we do disturb the fabric of the grant/proposal world. That’s part of the reason we’re effective.

Still, I had no idea that there’s an orthodoxy in the State of Wisconsin. And if there is, what is that orthodoxy? Is it John 16:10 that describes how users should access GAC Application information? Or does orthodoxy emerge from other texts?

Alas, I didn’t inquire that far, and I also never quite got access to the GAC Application Page, but I was able to find the information I needed elsewhere. Still, I did learn just a little about the quality of governance in Wisconsin. A famous paper looks at “Cultures of Corruption: Evidence From Diplomatic Parking Tickets,” and the authors find that “diplomats from high corruption countries (based on existing survey-based indices) have significantly more parking violations, and these differences persist over time.” I wonder if my own experiences interacting with local and state governments are similar: the worse the quality of random bureaucrats, the worse the overall level of governance.

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FQHCs, Reproductive Health/Family Planning Services, and Planned Parenthood: An Uneasy but Symbiotic Relationship, Centered on Title X Funding

We often write about Federally Qualified Health Centers (FQHCs), in part because we often work for them in part because FQHCs illustrate many challenges facing other nonprofits. This post discusses a service that FQHCs could provide but mostly choose not to—a common circumstance among certain classes of nonprofits, like foster family agencies and substance abuse treatment providers.

To understand the dilemma, you have to know that the Health Resources & Services Administration (HRSA) funds FQHCs under Section 330 of the Public Health Services Act and FQHCs are sometime referred to as “Section 330 providers.” While FQHCs do collect copays and most take insurance, a large chunk of their funding comes directly and indirectly (via Medicaid) from the feds. FQHCs are mandated to provide “integrated full life-cycle care” (HRSA-lingo here), including reproductive health/family planning services. Still, many of our FQHC clients are skittish about promoting these services and are consequently reluctant to seek other grants to support family planning.

Thus, FQHCs have effectively ceded the huge pot of Title X family planning grants ($288 billion in 2016) to specialized family planning clinics, which are mostly but not exclusively operated by local affiliates of Planned Parenthood. While Planned Parenthood provides great women’s reproductive and related preventative health care, with an emphasis on low-income women and girls, unlike FQHCs, their clinics do not provide full life-cycle care.

From what we can tell, FQHCs and Planned Parenthood clinics seem to operate in a symbiotic, but parallel manner, in which both stay out of each other’s turf (if you have even more specialized knowledge about this situation, feel free to leave a comment). There are about 650 Planned Parenthood clinics, which serve about 2.5 million women annually with family planning services (this does not include abortions). In contrast, there are about 1,400 FQHCs, which serve about 17 million patients annually, and these numbers are growing rapidly due to the expansion of Medicaid under the ACA. More than 50% of FQHC patients are women, so let’s call it 9 million. FQHCs serve many more women than Planned Parenthood, but readers would never know this from the media.

While I don’t know this for sure, one presumes this is because, bureaucratically speaking, there are at least two parts to Planned Parenthood that are structured separately: the family planning side, which is touted by progressives, and the abortion side, which is demonized by some conservatives. The nascent FY ’18 federal budget battle between the Trump administration/Republicans and Democrats is being fought partially over Title X funding. The media usually obfuscates the Tile X grant aspect, focussing instead on the much more sensational issue of Planned Parenthood funding.

I assume that, if Congress passed legislation making Planned Parenthood ineligible for Title X (unlikely but possible), other providers, like FQHCs, would start applying for Title X grants. In other words, no matter what happens, as far as I know, there are no proposed cuts to Title X (again, if you have specialized knowledge, leave a comment). It’s just a question of which agencies will provide Title X funded services and how those agencies will link with Planned Parenthood, which presumably would continue as the nation’s main abortion provider.

I know the potential competition between FQHCs and Planned Parenthood clinics is a big issue for Planned Parenthood, as Title X provides more or guaranteed funding to keep the lights on—a concern for all nonprofits. This basic issue was confirmed by several interesting pieces I found and that the Alan Guttmacher Institute published (it’s more or less the research affiliate of Planned Parenthood).* For example, this article makes the curious argument that FQHCs couldn’t expand to provide family planning service now being provided by Planned Parenthood:

FQHCs are an integral part of the publicly funded family planning effort in the United States, but it is unrealistic to expect these sites to serve the millions of women who currently rely on Planned Parenthood health centers for high-quality contraceptive care.

As a grant writer, I admire the carefully crafted but entirely specious reasoning, which reminds me of our needs assessments, I’m pretty confident that FQHCs would have no trouble picking up the slack and the Title X grants—if they wanted to. We have some FQHC clients with over 40,000 patients, and at that size they can begin to resemble something larger than a community clinics. At the moment, they’re mostly reluctant to tangle with Planned Parenthood—but, again, they could.

And they might.


* The Guttmacher Institute is a great source, albeit one with a point of view, for studies and data relating family planning, teen pregnancy, and the like. We sometimes use their citations in writing needs assessments. If you’re curious about research organizations with a point of view, Daniel Drezner’s book The Ideas Industry is good.