Category Archives: SAMHSA

“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.

SAMHSA’s Screening, Brief Intervention and Referral to Treatment (SBRIT) and FQHCs

The Substance Abuse and Mental Health Services Administration (SAMHSA) just issued the FY ’18 Screening, Brief Intervention and Referral to Treatment (SBIRT) Funding Opportunity Announcement (FOA): it has $35 million for five-year grants up to about $1 million per year for assessment/referral to substance abuse treatment—and, most interestingly for our discussion, FQHCs are listed among the laundry list of eligible applicants.

SAMHSA is pointing the way forward for many substance abuse providers: become an FQHC. This may seem odd, because FQHCs are supposed to be primary health care providers, while substance abuse treatment is not considered primary healthcare and is usually provided by narrowly focused agencies. But the depth of the opioid epidemic, in tandem with the overall growth of healthcare funding, means that many substance abuse providers are being pushed towards becoming FQHCs—even as many FQHCs are also being encouraged to expand into substance abuse treatment. And we know that, when it comes to the Feds, “encouraged” is often a euphemism for “get ‘er done.”

Many FQHCs, of course, don’t want to be substance abuse providers—but, as programs like SBRIT show, the amount of money available may be too tempting to refuse. Right now, it’s also tough for FQHCs to stretch their Section 330 grants to provide fully integrated behavioral heath services, including substance abuse treatment. HRSA occasionally issues Notices of Funding Opportunities (NOFOs) for FQHCs to enhance behavioral health services, but the operative word is “occasionally,” and there’s not enough HRSA funding for behavioral health services.

Few, if any, of our FQHC clients, have had SAMSHA grants and most are reluctant to apply. This may be a case of grant “tunnel vision” in which FQHCs focus on HRSA in the same way that public housing authorities (PHAs) often tether themselves to HUD grants. The wider grant universe, however, provides opportunities for diversity that can help organizations weather shifts in funder priorities. And to paraphrase a salesman’s advice given to William Holden’s Joe Gillis in Billy Wilder’s Sunset Boulevard, “As long as the lady is paying for it, why not take the Vicuna?”

NIH opioid research grants are here; expect opioid treatment RFPs to come soon

In his review of Dreamland: The True Tale of America’s Opiate Epidemic” and in his post on the “New grant wave for Medication Assisted Treatment (MAT),” Isaac noted that the heroin and prescription drug addiction epidemic crisis is likely to generate new grant programs. Since then, the crisis has in some ways been getting worse, not better, especially in politically sensitive parts of the country. The federal response has so far been slower than we expected, but the NIH just released a trio of research grant RFPs focusing on “Marijuana, Prescription Opioid, or Prescription Benzodiazepine Drug Use Among Older Adults.” Those grants are under the NIH R01, R03, and R21 categories.

The only surprising thing about these RFPs is how long they’ve taken to hit the street. Every time you see a news article or watch a TV exposé about the opioid epidemic, the likelihood of federal action rises. And every time you see such an article or video, you should be thinking about how it will affect your own proposals.

For example, SAMHSA just released a new RFP for a very old program: “Targeted Capacity Expansion-HIV Program: Substance Use Disorder Treatment for Racial/Ethnic Minority Populations at High Risk for HIV/AIDS (Short Title: TCE-HIV: High Risk Populations).” Someone ought to tell SAMHSA that brevity is a virtue in program titles, but apart from that I’ll note that, if I were writing a TCE-HIV proposal, the needs assessment would be filled with data about opioid use. We have collectively known about the dangers of sharing needles for decades, but the present opioid issue gives new urgency to old problems.

New grant wave forming for Medication Assisted Treatment (MAT)

A new grant wave is forming. An unexpected and shocking epidemic of heroin and prescription opioid addiction has erupted across America and the federal response is going to be a huge increase in funding for treatment and related services.

We’ve already seen signs of the grant wave in HRSA’s Substance Abuse Service Expansion program, which was designed to focus on “Medication-assisted Treatment in opioid use disorders.” Last week, the Obama Administration proposed a new $1 billion heroin treatment initiative involving pass-through grants to the states, which will in turn issue RFPs to local treatment providers, most of which will be nonprofits.

The new Obama initiative is to fund more medication-assisted treatment (MAT). Unlike the old methadone approach, MAT combines behavioral therapy with more modern medications to treat substance abuse disorders. While the Obama initiative is clearly aimed at treatment providers, peripheral grants are sure to become available for ancillary services like outreach, engagement, education and case management, most of which can be implemented by virtually any human services nonprofit.

Unlike many of President Obama’s proposals, the MAT grant initiative is likely to gain strong and quick bipartisan support in Congress, because vast stretches of rural America, as well as many suburbs and cities, are being overwhelmed by heroin, prescription opioid addiction, and concomitant ODs, often in the seemingly most unlikely of places. This includes over 400 ODs in New Hampshire in 2015. This bucolic state is not usually associated with a 22-year old woman overdosing in a squalid Nashua alley.

Listen to this heart-wrenching NRP story about how a middle aged and middle class New Hampshire makeup artist’s step daughter died. The makeup artist specializes in “painting” the presidential candidates that inundate NH every four years; she’s made-up everyone from Bernie Sanders to Mario Rubio this year. Each candidate has gotten an earful of the the addiction/OD crisis while captive in her chair.

In addition, almost every Democratic and Republican presidential candidate, with the possible exception of Hillary Clinton, seems to have been personally touched by the addiction and/or OD of a child, another relative, or a friend. It’s like Traffic writ large. Carly Fiorina and Chris Cristie regularly tell OD anecdotes as part of the their stump speeches, while Bernie and the now-out-of-the-race Rand Paul take a libertarian stand that prefers treatment over legal sanctions regarding substance abuse disorders.

When Bernie and Rand somehow agree on a major domestic policy issue, you know that the problem transcends politics. The US long-ago lost its 40-year “War on Drugs.” After over four decades of draconian law enforcement and incarceration that disproportionately affects communities of color, the net result is that heroin is actually cheaper than ever—the Washington Post reports that a bag of heroin costs less than a pack of cigarettes in much of America! High cigarette taxes are part of the reason, but heroin is not taxed. Taken together, these trends point to the need for nonprofits to be nimble enough to catch this cresting grant tsunami.

Links: Grant writing training, Los Angeles, hospitals, skyscrapers, land use, bikes, SAMHSA disfunction, illnesses and more!

* A new study says it doesn’t matter how much time you spend with your kids. Anxious and neurotic upper-middle-class parents, consider yourself relieved. I don’t (particularly) recall wanting to wanting extensively to interact with my parents when I was a kid, though maybe my memory is flawed. (Lancy’s The Anthropology of Childhood is also relevant here.)

* We’ve updated the Seliger.com FAQ pages. Check it out! There’s even a new question, answered. We’ve also changed our stance, but not our emphasis, on grant writing training.

* “Finding the Dense City Hidden in Los Angeles,” which surprises me too.

* “Radical Vaccine Design Effective Against Herpes Viruses,” which is hugely important in many ways, and the development of this vaccine should retard AIDS transmission.

* As demand for welders resurges community colleges offer classes. Call this a counter-cyclical story!

* “An Interview With the NYU Professor Banned From the United Arab Emirates,” which tells you a lot about NYU.

* On government, voting, and costs.

* “Hospitals Are Robbing Us Blind: Forget Obamacare. The real villains in the American health care system are greedy hospitals and the politicians who protect them.”

* “Skyscrapers are all too evidently phallic symbols, monuments to capitalism and icons of hubris. Yet Will Self can’t help but love them. He explores their significance – from JG Ballard to Mad Men, and from London to Dubai.” I love skyscrapers too.

* “Poor land use in the world’s greatest cities carries a huge cost“—in financial, equality, and other terms.

* “Slumber Party! Casper leads a new crowd of startups in the $14 billion mattress industry, trying to turn the most utilitarian of purchases into a quirky, shareable adventure. Wake up to the new world of selling the fundane.”

* “Why I keep fixing my bike,” which is shockingly beautiful and about more than just the bike.

* “Bungling the Job on Substance Abuse and Mental Health: Employees at this federal agency rank it 298th out of 315 in a list of best places to work in the government.” Based on our interactions with SAMHSA we can’t say we’re surprised. Perhaps they should have more mental health counseling and coaching for SAMHSA staff? If so, we can definitely suggest some curriculums.

* “Thinking too highly of higher ed,” by Peter Thiel, who also wrote Zero to One (which you, like everyone, should read).

The Existence of Drug Courts Implicitly Acknowledgement Failed Public Policy: An Example From the “Grants to Expand Substance Abuse Treatment Capacity” Program

Occasionally, an RFP will inadvertently show how one part of the government recognizes and tries to mitigate the unfortunate effects that come from another part of the government.

We—naturally—have an example of this principle in action: readers of last week’s e-mail grant newsletter probably saw “Grants to Expand Substance Abuse Treatment Capacity In Adult, Juvenile, and Family Drug Courts,” which offers funding “to expand and/or enhance substance abuse treatment services in existing adult, juvenile, and family “problem solving” courts which use the treatment drug court model in order to provide alcohol and drug treatment.”

Creating “‘problem solving’ courts” is another way of saying that conventional drug prohibition has failed, and conventional courts are a poor means of dealing with drugs. According to SAMHSA, they don’t solve problems; they are at best neutral, or they actually create problems. If they solved problems, we wouldn’t need new courts to solve problems.

Conventional courts, in other words, exacerbate the negative societal outcomes that drug laws impose or encourage. Right now, we’ve got a self-reinforcing legal system, because becoming involved in that system will ruin your life because the system itself will ruin your life for you.

SAMHSA realizes this to some extent. By funding “Grants to Expand Substance Abuse Treatment Capacity In Adult, Juvenile, and Family Drug Courts,” a combination of SAMHSA staffers and Congress are implicitly admitting that drug prohibition doesn’t work, and the enforcement effort behind prohibition doesn’t work. This is fairly obvious to anyone involved in the system, or anyone who has seen the movie Traffic and read Daniel Okrent’s brilliant book Last Call: The Rise and Fall of Prohibition. Or anyone who has read articles like “The global war on drugs has cost billions and taken countless lives — but achieved little. The scant results finally have politicians and experts joining calls for legalization.”

We, as a society, had the good sense to give up on Vietnam and now Afghanistan. Vietnam is now trying to join the global economy. The crazy system built around the “War on Drugs” helps no one except people employed as prison guards* and in other enforcement capacities. The money that we currently direct to prisons and police could be directed to treatment and prevention, while the black-market transactions that currently take place on street corners could take place in Rite-Aids and be taxed.

While I wouldn’t recommend that friends starting snorting coke every weekend, there are plenty of functional alcoholics and addicts out there. Alcoholism or drug abuse aren’t attractive lifestyles to me, but some people live them, and the second- and third-order effects of trying to stop those people are worse than the problems those people might cause by indulging in drugs or booze.

(Another note: there was $2,500,000 for this program in 2010 and almost $13,000,000 available now. This could be an example of random program funding drift, or it could say something about current federal priorities.)


* California’s guards are particularly pernicious, as “Fading are the peacemakers: One of California’s most powerful political forces may have peaked” and “Big Labor’s Lock ‘Em Up Mentality: How otherwise progressive unions stand in the way of a more humane correctional system” demonstrate. These problems are well-known to California policy wonks but too little known among everyone else.

Meaning Well is Not Enough: The Role of Research in Grant Writing and Proposals

Chances are good that you, as an applicant, have really wonderful intentions in whatever you’re doing—just like everyone else. You want to help kids succeed, make the world a better place, save the endangered sparrow dragonfly,* impart job training skills, build cool stuff, etc. You know this is a excellent use of time and money. The trick is convincing others that your idea is an excellent use of their time and money.**

Usually you convince them by saying that the target area needs whatever you’re proposing and that what you’re proposing will be effective. To really convince the others with money, you can’t merely say that you know what you’re talking about and therefore they should give you the money. You need to present some kind of research that demonstrates your approach is effective. Merely asserting that your approach will be effective isn’t enough.

Lots of our clients don’t have any research to demonstrate that what they’re doing or want to do might be useful, which means we spend a lot of time conducting research. This probably brings back memories of high school term papers and the like. However tedious or difficult research might be, it’s still necessary if you’re going to have a strong application that sets you a part from others.

Here’s why: funders want to think you know what you’re doing. One way is to show that you know what’s going on in the field and that your project is likely to succeed. Some RFPs even tell you what research to cite and which protocols to use. For example, this year’s SAMHSA Offender Reentry Program (ORP) tells you to use a whole grab bag worth of acronyms (“you are encouraged, when appropriate for your setting and population to implement the Adolescent Community Reinforcement Approach (A-CRA) coupled with Assertive Continuing Care (ACC) and/or Motivational Enhancement Therapy/Cognitive Behavioral Therapy-5 (MET/CBT-5) with juvenile offenders”).

Most RFPs don’t make things this easy, and you have to do your own research. Still, for most human and social service proposals, you also don’t need to write a dissertation: it’s enough to sprinkle some peer-reviewed research in like paprika over a casserole. As Homer Simpson says, “Facts are meaningless! You can use facts to prove anything that’s even remotely true!” The same applies to research. You need to have enough citations to make what you’re doing appear plausible, at least in most cases; for specific research grants or technology projects, you’ll often need someone who is really a domain expert. But for social and human service projects, you usually don’t.

That being said, people make two big mistakes in research for most kinds of grants: too much and too little. The “too much” mistake is less common, but it can happen when a RFP gets released on a short deadline and an applicant agency spends two weeks conducting research, finds a huge amount of material, and then can’t assemble it in an efficient manner to draft a concise and coherent needs assessment.

The “too little” mistake is one we see more frequently: the organization doesn’t have any research or citations whatsoever to demonstrate that their approach is likely to be valid (fortunately, this is an issue we can remedy). For RFPs that require a lot of research, this can be enough to get your proposal thrown out. Teen pregnancy prevention RFPs, for example, usually require a lot of research because of their politically charged nature. They require research even when that research indicates the approach is not likely to succeed, in which case you still need to pretend like the approach will succeed and the research is valid—in other words, you need to focus on the proposal world.

Don’t make either mistake. Use enough research to make your proposal palatable, even if “enough” varies a lot by application. Alas: there’s no real way to gauge how much is enough except through experience, which one uses to judge RFPs on a case-by-case basis. When in doubt, however, cite too much rather than too little.


* Note: this is a made up critter.

** Convincing others doesn’t just apply to funders—it can also apply to potential partners and collaborators. One problem with collaborations that we didn’t mention in our post on the subject is that collaborating agencies might not care about your problem. Sure, the local school district wants, in the abstract, for your mentoring program to succeed. But they already have lots of responsibilities, lots of administrators, and lots of problems, and they get paid average daily attendance (ADA) money whether you get the grant or not. They might care, but not as much as they care about their primary mission.

So What Are You Supposed to do to Respond to the Community Resilience and Recovery Initiative (CRRI) program RFP?

Subscribers to our email Grant Alert Newsletter will see a link to the Community Resilience and Recovery Initiative (CRRI), which is a program designed to provide “Grants to strength families, communities, and the workforce through appropriate, evidence-based interventions.” What does that mean applicants should actually propose to do?

You won’t really find out based on SAMHSA’s grant announcement, which says that you’re supposed to do things like “Reduce depression and anxiety” and “Reduce excessive drinking (and other substance use if the community chooses)” without saying how that is to be done. In other words, whoever wrote the announcement page forgot to answer the 5Ws and H.

From SAMHSA’s page you can download the application kit file, which has lots and lots of stuff about how important evidence is (“The CRRI will use a place-based strategy to implement multiple evidence-based interventions targeted to four levels in the community”), and how important strengthening communities are (“The intent of the program is to help communities mobilize to better manage behavioral health issues despite budgetary cuts in existing services and to promote a sense of renewal and resilience”), and so on, but no definitions of what it means to “promote a sense of renewal and resilience.” Grants are for $1.4 million—maybe you should use that for 20 giant potlucks.

In reading through the RFP, you’ll find several references to “Section I-2.2.” If you search for “2.2,” you’ll finally find what SAMHSA actually wants you to implement:

  • Triple P – Positive Parenting Program
  • Strengthening Families Program
  • Families and Schools Together
  • The JOBS Program
  • Coping with Work and Family Stress
  • Coping and Support Training (CAST)

In other words, it wants a mix of supportive family and jobs services. Even then, the RFP doesn’t tell you what these various programs entail—instead, it tells you go visit yet another website. If you want to figure out what SAMHSA actually wants you to do, you’ll have to drill through at least three levels of cruft: the announcement itself, the RFP, and then the highly intuitive “National Registry of Evidence-based Programs and Practices (NREPP) Web site.”

Alas, the National Registry website isn’t easily reduced to a description appropriate for the newsletter. That’s why you’ll find our somewhat vague description in our newsletter, which mirrors the vagueness of the RFP itself. It seems to me that CRRI is really just Walking Around Money to do “something about substance abuse” for the big cities and counties that are eligible for this odd program.