Category Archives: HRSA

Review of “Dreamland: The True Tale of America’s Opiate Epidemic:” A must-read for grant writers

Sam Quinones has written a compelling, profoundly depressing exposé about how the twin tidal waves of prescription opiates and Mexican brown heroin have devastated much of suburban, small town and rural America, Dreamland: The True Tale of America’s Opiate Epidemic. If you’re a grant writer or involved in any way with human services delivery, buy and read it now.

Dreamland_qThe “Dreamland” of the title nominally refers to the long-closed Dreamland Swimming Pool in Portsmouth, OH, a small city on the banks of the Ohio River with the ironic slogan, “Where Southern Hospitality Begins.” The defunct Dreamland Pool is an apt metaphor for the hazy memories of smaller, hollowed-out communities in the heartland. The shoelace factories that once powered the Portsmouth economy, as well as the steel mills, textile and furniture factories, and coal mines, of similar communities from the Midwest through the Rust Belt to Appalachia are gone. Despite the manufacturing renaissance in the U.S., employment in the sector is never going to reach anything like its 20th century heights.

In light of economic conditions, each of these places in flyover country had its own Dreamland, along with a vibrant main street, Friday night football games in the fall, and a thousand other threads that glued them together. Now, the communities have become Dreamlands or perhaps more appropriately, Nightmarelands of opiate abuse and hopelessness.

We’ve written proposals for nonprofits in Portsmouth, as well as dozens of other, similarly forlorn communities, and consequently we’re familiar with the raw data. Some sections of Quinones’s book could have been lifted verbatim from these proposals. Here’s a quote from an actual funded proposal I wrote in 2001 (only the name of the town has been changed):

In many ways, Anyville is not really unique, as it is similar to many other small, rural communities across southern Illinois. It has seen virtually no growth in recent decades, there are few local economic opportunities, the tax base is stagnant at best, and young people tend to leave in search of more opportunities following their secondary education. There are few resources: no movie theater, bowling alley, skating rink, ice cream store, etc. There is little before or after-school programming, or structured recreational activities. At night, teens cruise and park on Main Street, with its mostly vacant storefronts.

The rural story is always the same: few jobs outside of state and local government agencies, hospitals, and big box retailers; desiccated main streets with vacant buildings, party stores, and storefront churches; high schools closed and consolidated in larger towns, due to declining enrollment and stressed tax bases; few supervised youth activities; the demise of the family farm in favor of agribusiness; enormously high rates of working age adults on disability; rampant opiate addiction, with concomitant ODs; and so on.

Although I’ve been writing versions of this proposal concept for over 20 years, Dreamland explains, in a way that I hadn’t fully grasped, the interlocking societal forces that have created this Nightmare on Main Street. If I didn’t grok this reality after writing so many proposals for the Portsmouths of the nation, seemingly no one else did, until Quinones applied the skills of an investigative reporter and borne storyteller to lift the veil.

Some changes to small-town American have been widely reported: the flight of manufacturers to emerging nations (or the growing efficiency of manufacturing plants), changing energy priorities due to climate change and fracking, stagnant incomes that result in the need for two wage earners, the rise of out-of-wedlock births and single parent households, declining populations as young people move to the coasts and Sunbelt for better employment opportunities, the atrophy of churches and fraternal organizations (see Robert Putman’s 2000 book Bowling Alone), the rise of social isolation among young people, etc.

We use these threads constantly in grant writing. In the Portsmouths we write about, the Dreamland is now the Walmart or retail mall at the edge of town. Even these ersatz community gathering spots are struggling as Amazon and other online retailers proliferate. Offline retailers are increasingly concentrating on city centers and first-tier suburbs, where the money is. In much of America, there is simply no longer a real community. Keep in mind that neither Quinones or me are talking about devastated urban neighborhoods like those in Detroit or Baltimore. Rather, the ones we’re referring to are mostly white and formerly working class to upper middle class places.

In Dreamland Quinones describes significant societal changes that are mostly unreported, not discussed, and never interwoven into the story of the decline of American communities. These include:

  • The change in the view of doctors over the last 30 years to see pain management as a “fifth vital sign” and a new imperative to treat chronic pain (often with opiates).
  • Unscrupulous pharma companies, with Purdue Pharmaceuticals noted in particular, flooding the market with a class of powerful opiates like OxyContin and Oxycodone. Doctors were convinced to prescribe these drugs based in part on faulty research studies claiming, erroneously, that these prescription opiates were not addictive, because the patient’s underlying pain was supposed to counter addiction. Many patients figured out almost immediately that it was easy to get high and stay high with these prescription drugs.
  • The rapid proliferation of “pill mills” run by avaricious doctors in forgotten places, who would prescribe literally hundreds of pills to anyone who walked or crawled in the door with $250 in cash for the “examination and diagnosis.” Interestingly, the very first pill mill in America was in Portsmouth.
  • Wide distribution of “black tar heroin” by an army of mostly undocumented immigrants from the town of Xalisco, in the small Pacific coast state of Nayarit. Quinones terms these dealers “Xalisco Boys.” Hidden in plain sight among the waves of hard-working Mexican immigrants who spread throughout America to work in slaughterhouses, industrialized hog and chicken farms, field work, and construction, the Xalisco Boys act more like pizza deliver guys than traditional street corner dealers, bringing the heroin to the user by car. Black tar heroin is purer and cheaper than the powdered heroin from the Middle East found in large cities like New York. By the early 2000s, a hit of pure black tar heroin could be bought in the Portsmouths of America for $5—less than the cost of a six pack of beer. This heroin is also cheaper than prescription opiates and it did not take long for the thousands of new pill-based addicts to switch to ubiquitous heroin. The result was (and is) an avalanche of ODs, as reported in “For Small Town Cops, Opioid Scourge Hits Close to Home.”
  • As reported by the American Society of Addiction Medicine (ASAM), “Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014.” Even though I work with these kinds of data all the time, it was quite shocking to realize after reading Dreamland than annual ODs deaths are approaching car crash deaths.

Unfortunately, Quinones runs out of gas at the end of Dreamland. After telling this remarkable story, he drags out the usual nostrums to combat the problem—community involvement, better access to treatment, more and “smarter” law enforcement, and so on. He doesn’t ask about the economic viability of places like Portsmouth: Maybe the small towns that once existed in agricultural or manufacturing economies can’t really be saved.

In addition, having written dozens of substance abuse proposals and talked candidly with many Executive Directors of large treatment providers, I know that none of the usual strategies like community involvement and “smarter” policing actually works in fighting opiate addiction. It’s a sad reality that most Oxy or heroin addicts will eventually either OD or age out of use when, as is said in all addiction treatment programs, “they get sick and tired of being sick and tired.”

It’s very much in the interest of Seliger + Associates to encourage huge new government grant programs for treatment. One of HRSA’s favorites involves medication-assisted treatment (MAT), which I wrote about at the link. There’s about $1 billion in HRSA’s FY ’17 budget for MAT and I’m sure we’ll be writing many MAT proposals for FQHCs in the coming year.

Still, it seems to me that the only real solution to the drug component of the problems afflicting small towns is a combination of heroin legalization (or decriminalization), safe needle exchanges, medically supervised places to shoot up, and lots of education and prevention. Once the market dries up, the Xalisco Boys can find other work, and the next generation of Americans will find other ways to deal with the loss of their local Dreamland.


Jake also writes about Dreamland here.

HRSA makes it harder for NAP applicants to shoot themselves in the foot

Many of you are working on HRSA New Access Points (NAP) applications, and this year HRSA made a revealing change on page 3 of the FOA:

Form 2: Staffing Profile will no longer collect salary or federal funding data to reduce duplication with the Budget Justification Narrative. Fields have been added to collect information on use of contracted staff.

The phrase “to reduce duplication” implies that previous applicants would enter one set of positions in the Staffing Profile and another inconsistent set of positions in the Budget Justification Narrative. Those kinds of errors often lead to rejected proposals—even when the applicant does much else right. HRSA, to its credit, is trying to reduce the potential for such errors by putting salary information in one place, instead of two (or twelve: with the feds, trying to find all the places that must match is often challenging).

We’ve written before about the importance of internal consistency in grant proposals. Internal consistency is one of the most important aspects of a proposal. The other day I met with a client who is a grant-world novice and who provided a recently finished proposal she had written for a technical project concept. We were to use her previous proposal as a starting point for the new proposal we were writing. As we went over the budget, budget narrative, and program narrative of her old proposal, I pointed out several key inconsistencies, and those inconsistencies had likely caused the proposal to lose enough points to become non-fundable. I stressed that internal consistency is more important than perfect fidelity between proposal and project implementation.

Why? Most grant programs have some amount of slack in project implementation—that is, grant applications are proposals, and the actual activities may change (slightly). If you do slightly different project activities or have a slightly different staffing plan, you’ll be fine. With NAP, for example, it’s common for applicants to change sites after they’re funded. They might change a nurse practitioner to a family doc or vice-versa. As long as the funded applicant ultimately opens up a new primary health center and deliver primary health care, they’re going to be okay.

But to get that far, NAP applicants need internal proposal consistency as much as they need to demonstrate site control, even if they snag a different site later. Otherwise they’re unlikely to get funded, making the site issue moot.

Who are the HRSA peer reviewers? An anecdote from the New Access Points (NAP) Program

Federally Qualified Health Centers (FQHCs) know that the Health Resources and Services Administration (HRSA), like some other federal agencies, uses peer reviewers for proposals. That can lead to some entertaining coincidences and collisions. We were recently hired by a client who had previously served on a review panel for the last New Access Points competition. In talking with him, I mentioned that we’d written a funded NAP proposal about a year ago for a client in an unusual location. It turned out that our new client had been on the review panel for that proposal (which, fortunately, was funded).

Peer review can in effect shrink the size of the grant world. Peer reviewers also (usually) know something about the programs and processes being discussed, which isn’t necessarily the case with staff reviewers. In some funding agencies, like the Department of Labor, peer reviewers generally aren’t used; if there aren’t enough reviewers, the DOL may grab staffers from other federal agencies to review proposals. That implies grant writers should explain more about basic ideas, rather than assuming that reviewers actual understand the program they’re reviewing. So for staff-reviewed proposals, it’s a good idea to explain more than might be necessary in peer reviewed proposals, since the staffers may not be up-to-date on, say, prisoner reentry common practices, or the finer parts of the parole system.

Because of the small-world effect in peer-reviewed proposals, it can be particularly important to turn in high-quality proposals, because you never know when your proposal is going to act as an inadvertent resume. If you’re part of the Greater Seattle FQHC and someone from the Greater Nashville FQHC reads and likes your proposal as a reviewer, you may much later get a call from them offering you a job.

Don’t underestimate the power of “avoiding social embarrassment” in the list of motivations underlying human behavior.

In grant writing, you don’t have to be great; you only have to be better than the other guy

You don’t need to submit the perfect grant application (assuming the “perfect application” even exists); you just need to be better than the other guy.

A story: Years ago we we wrote a string of funded grants for a majority-minority California city. The city was not particularly well run and some of its workers were indicted for corruption. But the feds kept pouring money into the city because, while it was messed up, it was still better run than other majority-minority cities at that time. The city wasn’t going to win any good government awards, but it was less corrupt than the alternatives. So the proposals we wrote got funded because the feds wanted to fund a majority-minority city somewhere west of the Mississippi and there weren’t (and still aren’t) many choices.

This pattern repeats itself. A couple years ago we wrote a funded HRSA Service Area Competition (SAC) proposal for a Federally Qualified Health Center (FQHC) in a medium-sized city.* In and of itself this isn’t interesting, because we write lots of funded HRSA proposals. This FQHC client, however, failed to tell us that, as we wrote the first draft, some of their officers were being indicted on corruption charges. Our FQHC client had competition from another large, local nonprofit, which applied for the same SAC grant.

Given our client’s legal problems, we figured they’d never get their SAC grant renewed. We were wrong.

We later discovered why HRSA funded our client: The other SAC applicant was facing corruption charges too, and it had a big federal grant pulled. Our HRSA client kept getting funded because, it was probably the lesser of two evils, and HRSA had to fund someone. Without a SAC grantee in the city, at least 15,000 Medicaid patients would’ve had nowhere to go for primary care.

What makes this story even more fun is the the second nonprofit was also a former client, albeit for a non-HRSA grant. And, of course, the second client also didn’t tell us about their corruption woes when we were writing their proposal.

One sees this general principle in other areas. Tech workers, for example, are now increasingly fleeing Silicon Valley. San Francisco’s draconian land-control policies mean that expanding housing supply is almost impossible. Restricting supply in the face of rising demand causes prices to rise. Silicon Valley’s situation is uniquely insane on the national stage, as this article describes.

Seattle—while not exactly a paragon of good, fast local governance—is allowing more housing units to be built than San Francisco, and it’s even building underground light rail services that are getting done on-time and under-budget. Light rail construction is going so well that residents want more transit tunneling. There is also no income tax in Washington State, which makes Seattle a much less expensive place to live than the Bay Area. Consequently, tech companies and tech workers are leaving California for Seattle—not because Seattle is perfect, but because it’s better and more functional than its southern neighbor. Even highly paid tech workers are voting with their wallets and feet.

Analogies to dating are so obvious that I won’t belabor them here, although I will say that Briefly noted: Date-onomics: How Dating Became a Lopsided Numbers Game is an excellent take on the subject.

Potential clients often ask us whether they should apply for a particular grant. We can never tell them definitively, but we do say that if they don’t apply, they definitely won’t get funded. We’ve seen numerous apparent underdogs get funded because they applied and the presumed favorites didn’t, or because they applied and the presumed favorites messed up their application, or because they applied and the funder was sick of the presumed favorite. To get funded, you don’t necessarily have to be the “best,” whatever that may mean. You only have to be better than the other guy.


* At least one Section 330 SAC grant is available for virtually every geographic area in the United States; those grants are used to fund primary healthcare services for predominantly low-income people. Without them, many large FQHCs would not be able to operate. Funded FQHCs must compete to keep their Section 330 funding about every three years when HRSA issues a new SAC RFP for their area.

The Distinction Between Services Offered Now and Services Later, Illustrated by the HRSA Oral Health Service Expansion (OHSE) Program

When you’re writing a proposal for a grant intended to expand an existing program or service, it is extremely, ridiculously important to distinguish between what your organization is currently doing and what it’ll be doing with the new money. Failure to do so means that a) you raise the specter of supplantation, b) you sound like you don’t need the money because you’re already offering the services, and c) someone with a better grant story will get the money. Applying for a grant leads to a binary outcome—either you get the grant or you don’t. There are no half grants.

Let’s use HRSA’s Oral Health Service Expansion (OHSE) Program as an example. As the name of the program implies, OHSE is designed to provide additional dental services to underserved low-income patients.* A good OHSE proposal describes what, if anything, the applicant is currently doing with respect to oral health services (e.g., no services, pediatric only, pregnant women only, Medicaid only, etc.), and then describes what will be done differently. The applicant should say what additional services will be offered (e.g., sealants for children, dentures, etc.), and show how the dental patient population will be expanded. The applicant might serve additional existing FQHC medical patients, other service area residents, left-handed one-eyed cyclops, and so on.

A reasonable expansion might be as simple as saying, “The Toppenish Community Health Center currently serves 2,000 patients with 4,000 dental visits annually. The OHSE grant will allow TCHC to serve 3,000 high-risk patients, including at least ten cyclops.” What the organization can’t do, however, is claim that the CHC already serves 2,000 patients, and the grant will allow the CHC to keep serving those patients with more or less the same services. Patients have to be served in either greater number or greater services, or both.

Many  FQHCs that seek OHSE grants will also have long waiting lists, which can be used to bolster need: If the current waiting list for a new dental appointment is six months, that indicates a severe shortage of oral health service capacity. It doesn’t held your proposal to say proudly that the CHC’s wait time for a new dental patient is two days.

In short, applicants shouldn’t ever write or imply that they won’t actually serve more patients, or a larger area, or provide additional services. This may seem obvious, but we’ve seen proposals written by others that fail to remember this rule and that are primarily boasts about how much they’re already doing. That flaw won’t always be fatal—the funder may just want to fund that particular applicant or that particular service area—but it should still be avoided.


* Fun fact: Some dentists prefer the term “oral cavity” rather than “mouth.” I’m not sure why, since to me the former term sounds vaguely pornographic, and the latter term sounds normal.

HRSA Randomizes FQHC Program Officers, Likely Trading One Set of Problems for Another Set of Problems

In days of yore, most federal grantees had a dedicated program officer who handled budget issues, contract amendments, reports, and the like; the program officer would often conduct site visits, getting to know the executive director and the nuances of the agency and target area. This system began to atrophy during the Reagan administration with cutbacks to federal travel budgets, and today grantees rarely if ever see their program officer. For example, we’ve written many funded YouthBuild proposals for a South Central LA nonprofit, which hasn’t had a site visit from their HUD program office in 20 years of implementing over ten rounds of YouthBuild funding. Still, most grantees develop a virtual relationship with a specific program officer.

We write many HRSA proposals and were surprised to learn during a scoping call with the CEO of a long-time FQHC client that HRSA has changed this system. Instead of having an assigned program officer, HRSA program officers are now randomized. This means that when an FQHC—which often juggles multiple HRSA grants—has an issue, the problem is randomly assigned to one of a pool of program officers. This is more or less the system used when one waits in line at the DMV or Katz’s Delicatessen. At the DMV, this prevents a clerk from issuing fake drivers licenses for a bribe and the counter man at Katz’s from adding a little extra corned beef to his pal’s sandwich every day at lunchtime.

I assume the same reasoning applies at HRSA: randomizing program officers presumably is aimed at preventing special treatment for favored FQHCs or, I suppose, outright graft. Avoiding special treatment has a cost, though, as it’s likely to wildly increase inefficiency and systemic friction. One sees such problems most clearly in defense contracting, but any large bureaucracy can develop them.

In a randomized oversight management system, the program officer handling a particularly issue will have no agency background or context for the problem. I’m sure that HRSA management thinks thinks will lead to “fair” treatment for all grantees, while minimizing the potential for corruption, but it will also clog the system. HRSA program officers are probably GS 11s and 12s and, like most bureaucrats, they aren’t especially motivated to quickly solve grantee problems. Relationships with the grantees can improve motivation because most of us don’t want to be considered jerks by people we know and have repeated interactions with (why this is true is beyond the scope of this post, but Joseph Henrich’s account in The Secret of Our Success is recommended; it’s also a popular book written by a scholar, not a self-help book). Program officers get paid every two weeks, whether they solve problems or create them, as long as their breath clouds a mirror (to prove they’re still alive) when the paychecks are passed out.

HRSA is changing one set of real or imagined problems for a different set of problems. An unintended consequence of this change is also likely to be more congressional interference.

Why? Let’s say you’re the CEO of the fictional Owatonna Community Health Center and need a rapid decision to amend the agency’s NAP grant budget. In the Ancien Régime, the experienced program officer could probably be sweet-talked into a quick budget revision because of the interpersonal relationship and agency knowledge. In the new system, however, the program officer might put the request under her coffee cup and leave for five days of training, followed by vacation. Why does she care about what some random FQHC in Minnesota or wherever thinks or does?

Without any other recourse, the panicked CEO is likely to call their congressperson’s district office for relief, which will result in a field deputy harassing upper level HRSA management in Washington. This will lead to more friction and bad vibes, as management puts the congressionally-induced hammer to the program officer. The program officers will become even more bureaucratic in response, and they’ll make sure every last rule gets followed. Meticulously following rules is actually a CIA-approved method for organizational sabotage. No, seriously, it is: follow the preceding link.

We’ve written about the challenges of managing grants before. Like grant writing, grants management involves a specific set of skills and experience. Anything that makes managing grants harder is not going to help HRSA or FQHCs in the long run.