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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.

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Is Violent Crime Going Up or Down in America? Nobody Actually Knows, But the Debate Illustrates How Grant Proposal Needs Assessments are Written

One of our past posts described how to write proposal needs assessments. A spate of recent articles on the so-called Ferguson Effect provides a good example of how proficient grant writers can use selected data and modifying words to shape a needs assessment to support whatever the project concept is.

Last week Heather Mac Donald’s Wall Street Journal editorial “Trying to Hide the Rise of Violent Crime” claimed that violent crime is rising, due to “the Ferguson Effect,” but that “progressives and media allies” have launched a campaign to deny this reality. Right on cue, the New York Times ran a front page “news” story telling grumpy New Yorkers that “Anxiety Aside, New York Sees Drop in Crime.” Both articles cite the same Brennan Center for Justice study, Crime in 2015: A Preliminary Analysis, to support their arguments.

This reminds me of the old joke about how different newspapers would report that the end of the world will happen tomorrow: the New York Times, “World Ends Tomorrow, Women and Minorities Hurt Most;” the Wall Street Journal, “World Ends Tomorrow, Markets Close Early;” and Sports Illustrated, “Series Cancelled, No World.” One can frame a set of “facts” differently, depending on one’s point of view and the argument being made.

Neither the NYT or WSJ writers actually know if violent crime is going up or down in the short term. Over the past few decades, it is clear that crime has decline enormously, but it isn’t clear what causal mechanisms might be behind that decline.

Perhaps, like Schrödinger’s cat being alive and dead at the same time to explain quantum mechanics, crime is up and down at the same, depending on who’s doing the observing and how they’re observing.

One of the challenges is that national crime data, as aggregated in the FBI Uniform Crime Reporting (UCR) system, is inherently questionable. First, police departments report these data voluntarily and many crimes are subject to intentional or unintentional miss-categorization (was it an assault or aggravated assault?) or under/over reporting, depending on how local political winds are blowing (to see one public example of this in action, consider “NYPD wants to fix stats on stolen Citi Bikes,” which describes how stealing a Citi Bike counts as a felony because each one costs more than $1,000). A less-than-honorable police chief, usually in cahoots with local pols, can make “crime rates” go up or down. Then there is the problem of using averages for data, which leads to another old joke about the guy with his head in the oven and his feet in the freezer. On average, he felt fine.

But from your perspective as a grant writer, the important question isn’t whether crime rates decline or whether “the Ferguson Effect” makes them fall. If residents of a given city/neighborhood feel vulnerable to perceived crime increases, the increases are “real to them” and can form the basis for a project concept for grants seeking. Plus, when data to prove the need is hard to come by, we sometimes ask our clients for anecdotes about the problem and add a little vignette to the needs assessment. A call to the local police department’s gang unit will always produce a great “end of the world” gang issue quote from the Sergeant in charge, while a call to the local hospital will usually yield a quote about an uptick in gun shoot victims being treated, and so on. Sometimes in proposals anecdotes can substitute for data, although this is not optimal.

Within reason and the rather vague ethical boundaries of grant seeking and writing, a good grant writer can and should pick and choose among available data to construct the needs assessment argument for funding anything the agency/community sees a need for.

For example, if we were writing a proposal for an urban police department to get more funds for community policing, we would use up or down crime rate data to demonstrate the need for a new grant. If the crime is trending down, we’d use the data to argue that the police department is doing a good job with community policing but needs some more money to do an even better job, while being able to provide technical assistance to other departments. If the crime data is trending upward, we’d argue that there’s a crisis and the grant must be made to save life and limb. If we were working for a nonprofit in the same city that wants grants for after school enrichment for at-risk youth, we’d cherry-pick the crime data to argue that a nurturing after-school setting is necessary, to keep them protected from the false allures of gangs, early risky sexual experimentation, and/or drugs.

Most grant needs assessments are written backwards. One starts with the premise for the project concept and structures the data and analysis to support the stated need. It may be hard for true believers and novice grant writers to accept, but grant writing is rarely a blue sky/visioning exercise. The funder really sets the parameters of the program. The client knows what they want the grant for. It’s the job of the grant writer to build the needs assessment by including, excluding, and/or obfuscating data. This approach works well, because most funders only know what the applicant tells them in the proposal. Some grant programs, like our old pals DOL’s YouthBuild and ED’s Talent Search, try to routinize needs assessments and confound rascally grant writers by mandating certain data sets. We’re too crafty, however, and can usually overcome such data requirements through the kind of word and data selections that Mac Donald cites in her article.

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We imagined foundations would hire us to help improve RFPs/funding guidelines. We were wrong.

Twenty and change years ago, Isaac was starting Seliger + Associates and expected to be hired by foundations and perhaps even some government agencies who might want help streamlining their RFPs or funding guidelines. Seliger + Associates has unusual expertise on grants, grant writing, and RFPs, which could, in theory, make helping funders part of the firm’s regular practice. Isaac imagined that funders would want real world feedback  to improve the grant making process, make themselves more efficient and efficacious, ensure their money was being channeled in useful directions, and so forth. Even in the early days of Seliger + Associates, we knew a lot that could help funders, and we waited for the calls to start coming.

I was about ten at the time. Now I’m considerably older and we’ve long since stopped waiting. Funders, it turns out, strictly follow the golden rule in this respect: he who has the gold makes the rules. Funders routinely ask applicants and other stakeholders about how to make the world a better place, but they have no interest at all in talking to the people who could conceivably help them most with respect to the funding process. Isaac’s initial expectation turned out to be totally wrong.

Isaac and I were talking about the vast silence from funders in light of Mark Zuckerberg’s recent announcement that he and his wife, Pricilla Chan, plan to donate tens of billions of dollars to nonprofits in the coming decades through newly formed Chan Zuckerberg Initiative (CZI) LLC.* That’s a laudable effort and we’re happy they’re doing this. Still, we wonder if they’ll talk to people who toil daily in the grant writing mines to make sure that the funding guidelines CZI uses and the RFPs CZI issues are grounded in the reality of what would make it easiest to identify applicants most likely to achieve their charitable purposes with the minimum friction for nonprofits. Based on past experiences, we doubt it.

Despite the headlines you may have read, philanthropy as we know it is quite resistant to change—especially on the government side. On the private sector side, signaling and status are far more important than efficiency. Gates and Zuckerberg may be challenging the signaling dynamic, and we’re on their side in that respect, but we think signaling is too ingrained in human nature to have much effect. Overcoming signaling is hard at best and impossible at worst. Look at the way ridiculous SUVs continue to be a status-raiser among many suburbanites for one obvious, easy example of this at work. Geoffrey Miller’s book Spent: Sex, Evolution, and Consumer Behavior details many others.


* The name of the LLC, “CZI,” amuses us: it’s an unpronounceable acronym that sounds like a Cold-War-era Soviet ministry. The first rule of developing grant-related acronyms to to make them pronounceable.

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Community Oriented Policing Services (COPS) is Out and It’s Topical for More Than Just Police Departments

The Community Oriented Policing Services (COPS) program is back, most notably via the COPS Hiring Program (CHP), which has $134.5 million available for local law-enforcement agencies. This Clinton-era program has been around for a while but has special resonance this year due to a spate of police shootings and the civil unrest in Baltimore. President Obama is also giving a speech about community-oriented policing today. This adds up to a greater-than-usual focus on a particular set of grant programs, most of which occur beneath the radar of the media and national politicians.

cops - community oriented policing servicesIssues around policing aren’t coming from nowhere. Last year the New York Times published “War Gear Flows to Police Departments,” which sets the tenor for this year’s COPS programs and for federal restrictions on distribution of military-style equipment to police. The feds recently curtailed so-called “civil asset forfeiture,” which is an Orwellian phrase that means police can steal your property and money without prosecutors even convicting you of a crime.

Now, we’re not sure if police are genuinely killing more African Americans than they used to or if the topic has become more salient in the news. We are sure, however, that good cell phone cameras and widespread surveillance cameras have made it much easier for civilians to challenge police narratives and to show when cops lie. Videos also better show how cops sometimes behave antagonistically or cruelly. It’s impossible to watch the video of Eric Garner being choked to death by a cop and not think, “There has to be a better way to  prevent the sale of single cigarettes.”

Community-oriented policing is part of that idea. It’s opposed to quasi-military, occupation-style policing, which is periodically in vogue. After 9/11, cops became fascinated with military hardware and a war-zone footing (or, alternately, there was just a lot of military equipment and training going around, and a lot of cops also served in Iraq or Afghanistan). The “War on Drugs” uses the rhetoric of war to justify war-like behavior like “no-knock” home raids, but policing and war-fighting are supposed to be very different. Blurring them is not good for cops or societies.

From a grant writing perspective, the marketing blitz around COPS tells us that anything nonprofits propose that has to do with integrating the community with law enforcement is going to be a popular grant topic, because we’ve gone about as far as we can towards the military-style of policing. The legalizing of marijuana in Washington, Colorado, and Washington, DC, along with the de facto legalization in California and elsewhere, may signal a shift in drug prohibition. And federal agencies are probably being directed to take already allocated funds and use it for community-oriented policing and related project concepts when possible. Regulatory changes are likely occurring at the same time.

It isn’t just police departments that should be thinking about this. If you have, say, a Healthy Marriage and Relationship Education Grant application in the works, it wouldn’t be a bad idea to get a letter from the police and to say that you’ll coordinate with cops to use community-oriented policing to, perhaps, encourage child support compliance.

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Some Positive Changes in Federal Grant Grants.Gov Submission Requirements Emerge

Faithful readers know that I’ve been writing federal grant proposals since the last ice age.* For most of the last four decades, federal grant writing has changed little, other than in obvious tech-related ways—computers, online databases, quick and reliable digital literature/data searches, easy access to applicant background info and so on. I recently realized that incremental changes, glacial in speed though they may be, have begun to have a cumulative impact on the way in which proposals, and especially federal grant proposals, are prepared.

The biggest change in federal proposal preparation was the switch from hard copy to digital submissions, starting around 12 years ago. While at first there were a number of portals developed by various federal agencies, over the years most, but not all, have switched to Grants.Gov. For the first five or so years, Grants.Gov was incredibly badly coded, and the upload process was often uncertain and dicey. In recent years, the reliability of Grants.Gov has improved dramatically and the required attachments mercifully streamlined.

In the bad old days of paper submissions, federal agencies usually required a zoo of attachments, like target area maps, evaluator CVs, key staff resumes, job descriptions, organization charts, evidence of 501(c)3) status, bylaws, financial statements, letters of support, MOUs, and the dreaded logic model. The narratives themselves were long, like attention spans back in those days, with maximums sometimes reaching 50 single-spaced pages. It was not uncommon to end up with a 150-page grant application, which usually had be submitted with a “wet-signed” original and up to ten copies. Sometimes the FedEx boxes we shipped to HUD or the Department of Education weighed over ten pounds.

In the early days of Grants.Gov, these attachment requirements continued, making the upload process very complicated (try uploading a 10 megabyte financial statement attached to a Grants.Gov kit file for example) and sometimes impossible, as there might not be an attachment slot for a given required attachment. As time passed, federal RFPs began to strip away attachments or even require only a couple of consolidated attached files. This is much simpler and makes the grants.gov kit file preparation easier and significantly more reliable.

Most federal agencies have also reduced the maximum length of the narrative and settled on a double-spaced, single-sided page formatting convention. For example, Department of Labor proposals now usually have 20 double-spaced page maximums for narratives. Before you say “hallelujah,” however, keep in mind that the RFPs themselves have not gotten any shorter–an RFP could easily be 150 pages, with the questions to be answered in the 20-page narrative actually being many pages longer than the maximum allowed response. It is often harder to write a shorter narrative of, say, 20 pages, than 40 pages, because the writer faces the “building-a-ship-in-a-bottle” problem. Furthermore, despite severe page limitations, all of the headers/sub-headers must be included to enable reviewers to easily find your responses.

Other interesting RFP changes involve the objective and evaluation sections, which are sometimes combined and always intertwined. Until recently, most RFPs let the grant writer essentially make up the objectives. Now, however, many ED programs like Student Supportive Services and HRSA programs like New Access Points provide more or less fill-in-the-blank objectives. I’m fairly sure this trend is to facilitate “apples-to-apples” comparisons by reviewers, but whatever the reason, it makes it easier to stay within the page limit. While evaluation section requirements used to be astoundingly complex, these days, RFP evaluation instructions tend to be much more straightforward and linked to specified objectives.

Now for the bad news. The budget and budget narratives sections have changed little. Grants.Gov kit files still use a variation of the venerable SF-424A budget form, which is actually a summary of federal object cost categories. To create the 424A, any sane person would use an Excel template. The only people in the US who do not seem to grasp the concept of a spreadsheet are federal RFP writers. There is still no federal Excel SF-424A template provided, although we use versions that we’ve developed over the years.** A well-laid-out Excel line-item budget not only displays each line item within each cost category, but it can also double as the budget narrative. See further in “Seliger’s Quick Guide to Developing Federal Grant Budgets.”

The budget narrative instructions in almost all federal RFPs are written as if the response is to be done on a typewriter, circa 1975. The budget narrative is also often excluded from the narrative page limit, with no page limit on the budget narrative. Although we would never do this, we’ve seen proposals from our clients in which the budget narrative is longer than the program narrative. Don’t do this—unless you think the tail wagging the dog is a good approach to life.


* Forty-four years to be exact, but who’s counting?

** We always provide clients with a draft budget in a handy reusable Excel template—which is one good reason to hire us!

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Standard At-Risk Youth or Ex-Offender Empowerment Program: Improve Lives Through “X!”

A standard pitch for at-risk youth empowerment grant proposals is simple: We’ll give youth access to X, and through their love of or learning about X they’ll become better students / scholars / workers / people. “X” can be any number of things: To name a few of the projects we’ve worked on over the years, X can be horseback riding, chess, job skills, academic skills, computer programming, music, outdoor activities, art, photography, or sports. Existing organizations of various sizes attempt to improve lives through X; one of the oldest approaches are police athletic leagues (PALs), which try to get kids to stay out of trouble by learning about and playing sports with cops.

Another example is classical music exposure, which sometimes includes playing an instrument. Various symphonies are engaged in this project by sponsoring youth orchestras or having their players perform for high school students who secretly likely aspire to be Lady Gaga or Kendrick Lamar, not learn to play the oboe.* Gustavo Dudamel, the LA Philharmonic conductor, is famously interested in the youth orchestras.

Still, in the memoir Mozart in the Jungle: Sex, Drugs, and Classical Music, these endeavors are not portrayed as admirable by Blair Tindall; in her rendition art may encourage drug use rather than dissuading students from it. Nonetheless, it also appears that a disproportionate number of highly paid programmers, engineers, and nerds more generally are involved with music, and correlation must imply causation, so we as a society think getting kids involved with music is a Good Thing. Which it probably is! We don’t want to seem overly cynical, and really, who is against music?

Sometimes the youth involved in a particular program have other issues (e.g., foster care, differently abled, cancer, etc.), and sometimes the target population is people with other kinds of life challenges. For example, ex-offenders are a common group, with prisoner re-entry programs becoming more popular in recent years. In addition, not any value can be substituted for “X;” we’ve yet to work on any programs that offer, say, pole-dancing lessons, such that through their earthly love of each other youth will stay out of other trouble.

Programs that bring “X” to youth all have in common taking kids or other targeted high-risk groups out of their normal environments and putting them in a different environment that exposes them to new ideas and skills. Do such efforts work? It’s hard to say: programs like these got started in the Progressive Era, with efforts like the Boy Scouts, PALs and different programs have been emphasized at different times and in different places. Their purposes have changed over time, depending on what society happens to be anxious about at a given moment.

Today, not that many people (with money) care about exposure to rural environments, such as 4H agriculture programs, and so forth. But they care a lot about job training and/or workforce development. They care about education, which they link to job training and/or workforce development. If you’ve got a program that involves education, job training, and/or workforce development, consider whether it takes kids, ex-offenders or other high-risk groups out of their normal environments. If it does, you’ve got an important, time-honored claim: that by giving access to X you’ll also improve Y.

And if you want to do more than claim the mantle of innovation—which as a baseline we recommend you all do—consider this pattern in human services and what, if anything, you might do to break it.

EDIT: In Tiny Beautiful Things, which is a mid-sized beautiful book, Cheryl Strayed describes how she ended up working as  “youth advocate” for girls with serious problems and seriously messed-up families. She writes:

I was meant to silently, secretly, covertly empower them by taking them to do things they’d never done at places they’d never been. I took them a rock-climbing gym and to the ballet and to a poetry reading at an independent bookstore. The theory was that if they liked to pull the weight of their blossoming girl bodies up a faux boulder with little pebble-esque plastic hand- and footholds then perhaps they would not get knocked up. If they glommed on to the beauty of art witnessed live—made before their very eyes—they would not become meth addicts and steal someone’s wallet and go to jail at the age of fifteen.

Instead, they’d grow up and get a job at Walmart.

Strayed would get this post. At least one of the girls, we learn by the end of the essay, succeeds. One senses the combination of desperation and hope Strayed feels. She writes too that the work was “the best job I ever had but I only stayed for one year. It was a heavy gig and I was a writer and so I left it for less emotionally taxing forms of employment so I could write.” How many of us can blame her? She gets the Sisyphean task, but unlike Sisyphus she occasionally gets to leave the rock at the top of the mountain.


* Whatever the merits of the oboe; we respect it as an instrument and do not wish to denigrate any oboists among our readership.

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When All Else Fails, Use Common Sense In Writing Proposals and Developing Budgets

As we’ve written before, it’s important to carefully follow RFP directions when writing any proposal. Still, many RFPs are poorly written, repetitive, and often contradictory. If one finds a significant issue in the RFP, the only recourse is to contact the Program Officer listed in the RFP and ask for clarification in writing. If you get a response at all, it’s likely to be along the lines of “read the RFP.”

While this becomes pretty frustrating pretty fast, stay cool and use common sense in writing your proposal narrative and developing the budget. Let’s think about cost-per-participant issues as one example. In responding to RFPs for most human services project concepts, it’s pretty easy to figure out the capitated (“per head”) cost of delivering the proposed service. For example, if you propose to provide job training to 100 folks over three years and request a $1,000,000 grant, the cost per trainee is $10,000. The key is to make sure that your proposed service delivery model and budget are in line with funder expectations.*

Some RFPs provide specific guidance on the cost per client, such as the DOL’s YouthBuild program, which specifies around $17,000/trainee. Until about 10 years ago, when HUD stopped administering YouthBuild, it was about $30,000/trainee. The primary reason for the dramatic drop was that DOL finally figured out that grantees could easily satisfy the remedial education/GED component of YouthBuild by using a partnering charter school that receives Average Daily Attendance (ADA) funds—at no cost to YouthBuild.

This also creates a nice way of covering the required YouthBuild match. The YouthBuild match requirement has become sort of a legal fiction. Many SAMHSA RFPs include capitated funding ranges that vary by type of service (e.g., outpatient, intensive outpatient and so on). To have any hope of being funded, the budget has to hit those targets.

In some cases, however, the RFP doesn’t directly state a capitated rate. Often, it’s possible to figure out what the funding agency expects, if the overall impact is discussed (e.g., train 10,000 veterans) and dividing this info into the total amount available. In contrast, the ED Student Support Services RFP mandates the maximum grant and maximum number of participants, so it’s fairly obvious what the capitated rate should be, even though the RFP doesn’t explicitly state the capitated rate. One could propose a lower capitated rate, but why would you?

If you have no clue from the RFP regarding an appropriate implied capitated rate, you’re back to using common sense. Let’s say you’re a one high school local education agency (LEA or school district) in rural California with 500 students and one counselor. The counselor’s salary is $50,000/year, so the district is in effect spending $500/year/student on counseling, but wants to expand counseling because of a school gun violence incident, bullying outreach or whatever.

As luck would have it, the Elementary and Secondary School Counseling (ESSC) grant program does just that. In developing your ESSC proposal and budget, however, it’s a good idea to keep reality in mind and use common sense. If you propose a $500,000 annual ESSC grant, that would be a ten-fold increase over current service delivery levels and probably would not be well-received, even though the ESSC RFP does not specify a capitated rate for expanded counseling services. Instead, a $200,000 annual grant, along with an innovative approach to counseling, would be a more reasonable approach.


* You’ll learn how to calibrate expectations for cost through experience and through looking at a lot of RFPs.

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We’re Not Taking Sides: We’re Describing How Grant Programs, Like Those Related to Domestic Violence, Get Funded

In Isaac’s post about the NFL spurring new interest in domestic violence, he points out the likely public response to the issue: more grant money. He’s showing what is likely to happen, and he is tracing the formation of a new grant wave—as we have done before.

We want to clarify one point: we aren’t trying to minimize domestic violence as an issue. Our purpose in writing this blog is never to minimize or maximize issues. In one of our oldest posts, “What to do When Research Indicates Your Approach is Unlikely to Succeed: Part I of a Case Study on the Community-Based Abstinence Education Program RFP,” our goal was not to minimize or maximize teen sex education either: it was to describe real-world issues grant writers face. The job of the grant writer is first and foremost to tell the funder what they want to hear. A secondary job, however, is figuring out what project concepts and services are likely to be funded.

Depending on your perspective, the “right” issue may be highly fundable at a given moment, or the “wrong” issue might be. By definition, not every issue can be prominent at any given time—the word “prominent” does itself imply that an issue is necessarily and in some objective sense more important than another issue. It just means that some impetus or news or ideas have lifted it. If you’re a nonprofit, there is a limited amount that you can do to go against a particular funding tide.

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“You Can’t Shovel Tens Pounds of Shit in a Five Pound Bag:” The New York Times Ignores CHCs, Section 330 Providers, and HRSA

In “For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says,” Robert Pear discovers something that has long been obvious to our many Community Health Clinic (CHC) clients: having insurance doesn’t mean you can see a doctor. Many if not most doctors won’t see Medicaid patients. CHCs, however, are a class of primary care organization designed specifically for Medicaid patients and the uninsured. We’ve written numerous Health Resources and Services Administration (HRSA) proposals for CHCs, and everyone one of those proposals is supposed to expand access to care. This year’s New Access Point (NAP) program, for example, has $100 million available. Pear apparently does not know that CHCs exist and are funded through HRSA mostly to serve Medicaid patients.

The bigger problem regarding real-world healthcare is the number of doctors. Any discussion about the difficulty of finding care that doesn’t mention the limits on the supply of doctors is specious at best. There have been around 100,000 residency slots since the 1980s. Medical schools stopped expanding long ago. These facts are well-known to experts. Physician Assistants and Nurse Practitioners are to some extent filling in the gap, but in most states they still must practice under a doctor.

Our CHC clients’ biggest problem is rarely recruiting patients—when you subsidize goods or services, people consume more—it’s finding doctors. CHCs usually serve a high-need, difficult-to-treat population. Consequently, physicians often prefer to seek higher pay and lower stress jobs. Although there are lots of people trying to go to medical school—in Educating Physicians: A Call for Reform of Medical School and Residency, the authors note that 42,000 people applied for 18,000 medical school spots, and that at least 30,000 were likely qualified to become doctors—med school and residency act as bottlenecks to this process.

You can give every person health insurance without ensuring that they’ll actually get care, much like you can give everyone a degree without ensuring they have a brain. In the United Kingdom, care gets rationed through wait times. In the U.S., a similar dynamic is happening via provider shortages. While it is laudable that the Affordable Care Act (ACA) significantly increased the number of Americans covered by Medicaid, the landmark legislation did little to increase the number of providers to serve the newly insured. Or, as they used to say in the old days, you can’t shovel ten pounds of shit into a five pound bag. It’s a vulgar phrase but applicable to this article and the overall challenge of helping the newly insured actually access affordable, quality healthcare.

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Collaboration Again: A Story From the Trenches

We’re working on a project for a client who needs two things: a lot of data that isn’t easily publicly available and the dreaded letters of collaboration from other local providers (which we’ve written about in the context of Susan G. Komen, Mark Zuckerberg, and Community-Based Job Training). We have to be vague on the details, but our client initially planned to serve a reasonable service area, and we wrote a draft proposal reflecting our client’s plan.

The plan didn’t survive contact with the enemy, however. Our client’s so-called “collaborators” sabotaged the proposed project service area: They refused to sign letters of collaboration unless our client reduced the proposed service area to stay off their “turf.” So much for collaboration among nonprofits. The overall concept of collaboration, as required in most proposals these days, is ludicrous. It’s the equivalent of Burger King getting to veto a McDonald’s location. Alternately, it’s the equivalent of the contemporary market for broadband Internet access, which is totally broken, as demonstrated by the link.

Still, our client can’t effectively get the grant without letters offered by the client’s competitors, who ganged up on our client. She had to change the proposed service and we had to revise the draft to reflect this. The losers are of course the low-income and underserved residents of the removed part of the service area, who will have one fewer option for help and who don’t get a voice in this process, which is occurring entirely behind closed doors.

We’ve said it before and we’ll say it again: forcing nonprofits to “collaborate” makes no more sense than forcing businesses to collaborate.