Tag Archives: health

Washington Post’s story on rural health care ignores Federally Qualified Health Centers (FQHCs) — huh?

Eli Saslow recently wrote a 3,500-word Washington Post story about rural healthcare in “Urgent needs from head to toe’: This clinic had two days to fix a lifetime of needs.” Although it reads like a dispatch from Doctors Without Borders in Botswana, Saslow is describing rural Meigs County TN. Rural America certainly faces significant unmet healthcare needs, but this piece has a strange omission: it doesn’t mention Federally Qualified Health Centers (FQHCs).

The Tennessee Primary Care Association reports over 30 Federally Qualified Health Centers (FQHCs) operating over 200 health clinics in the state, most in rural areas—including at least four in or near Meigs County! FQHCs are nonprofits that receive HRSA Section 330 grants to provide integrated primary care, dental care, and behavioral health services to low-income and uninsured patients. FQHCs also accept Medicaid and, in rural areas, are usually the main primary care providers, along with ERs.

Federal law requires FQHCs to provide services under a sliding-fee scale, with a nominal charge for very-low-income patients—in theory, at least, FQHCs never turn patients away due to lack of ability to pay. Similarly, federal law requires ERs to treat everyone, regardless of income and/or insurance status. Unlike ERs, however, FQHCs provide a “medical home” for patients. There are over 1,400 FQHCs, with thousands of sites, both fixed and mobile, to better reach isolated rural areas like Meigs County. We should know—we’ve written dozens of funded HRSA grants for FQHCs, including many serving rural areas like Meigs County.

The story’s hero is Rural Area Medical (RAM), a nonprofit that appears to set up temporary clinics under the free clinic model. Free clinics emerged from the runaway youth health crisis of the late 60s, starting in the Summer of Love in San Francisco—I was on the board of a free clinic over 40 years ago and understand the model well. While there are still over 1,400 official free clinic sites, free clinics largely depend on volunteer medical staff, may not accept Medicaid, and have insecure funding because they rely on donations (often from their volunteers) to keep the lights on. To operate, a free clinic must necessarily devote much of its resources away from direct services to maintaining volunteers and fundraising, like any nonprofit that depends on volunteer labor (think Habitat for Humanity).

Unlike FQHCs, free clinics patients don’t have a designated primary care provider (PCP), since a given doc or NP might be volunteering or not on a given day—like an ER, free clinic patients lack a true medical home. Free clinics aren’t generally eligible to participate in the federally subsidized 340B Discount Pharmacy Program, so patients don’t have access to long-term, low-cost medications. Free clinics, while once the only source of healthcare for many uninsured, have now mostly been overtaken by FQHCs, much as the days of the independent tutor ended with the coming of public schools. We’ve worked for a few free clinics over the years, and most were struggling to stay open and provided erratic services. Their executive directors could feel which way the wind is blowing and consequently many were trying trying to become FQHCs.

I wonder: has RAM applied to become an FQHC and open a permanent site in Meigs County? I don’t know anything about Meigs County, and it’s possible that the local FQHCs are incompetent or poorly run and could use some new competitors. HRSA just had a New Access Points (NAP) competition, with over $200 million to found and fund new sites. If the the healthcare situation is dire in Meigs County, applying for NAP grant makes much more sense than setting up shop for a weekend. Does RAM refer patients to local FQHCs? That may be a more efficacious long-term solution than the superman approach of flying in, saving the day, and flying out (imagine if education worked the same way, with itinerant teachers stopping by to give a lecture on geometry one day, Shakespeare’s sonnets the next, and the gall bladder the day after).

The original story is great as human interest, but it doesn’t go into root causes. Some consulting organization created the “Five Whys” strategy or methodology, which holds that, for any given problem, it’s often not useful to look at a single moment or cause of failure or inadequacy. Rather, systems enable failure, and for any given failure, it’s necessary to look deeper than the immediate event. Some of the other underlying problems in this story include the American Medical Association (AMA), which controls med school slots, and the individual medical specialty associations, which control residency slots. The U.S. has been training too few doctors and doing an inadequate job getting those doctors into residency for decades. Detail on this subject is too specific for this piece, but Ezekiel Emanuel has a good article on the subject; med school needs to be integrated with undergrad and needs a year lopped off it. The way medical training works right now is too expensive and too long, creating physician shortages—especially in the places that need physicians most. The supply-demand mismatch raises the costs of physician services and mean that physicians charge more for services than they otherwise would.

Rural areas have also faced decades of economic headwinds, with young adults moving to job centers, leaving an aging-in-place population that needs many support services; declining tax base from manufacturing leaving for emerging countries; the opioid epidemic; and so on. While I wouldn’t expect Saslow to fully cover such factors, context is missing and at least a passing reference to FQHCs would make sense.

“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.

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.

Maybe reading is harder than I thought: On “The Comprehensive Family Planning and Reproductive Health Program”

We very occasionally pay attention to bidders conferences; usually, however, we usually avoid them for the reasons last discussed in “My first bidders conference, or, how I learned what I already knew.” Despite knowing that bidders conferences are mostly a waste of time, we’re sufficiently masochistic careful enough that we’ll occasionally look into one anyway.

New York State’s “Comprehensive Family Planning and Reproductive Health Program” bidders conference was a special example of silly because it literally consisted of the presenter reading from slides that regurgitated the RFP. As the “conference” went on, it became steadily more apparent that the conference would literally only consist of . . . repeating what’s in the RFP. This is as informative as it sounds.

After 20 minutes of listening to the presenter read, I gave up. I can read it myself. Still, as I shook my head at the seemingly pointless waste of time, my mind drifted back to some of my experiences teaching college students, and I have to wonder if the presenter read the RFP as a defensive strategy against inane questions that could easily be answered by the RFP. Something similar happens to me in class at times.

One recent example comes to mind. I had a student who seemed not to like to read much (note: this is a problem in English classes), and one day I handed out an essay assignment sheet with specific instructions on it. I told students to read it and let me know if they had questions. This student raised her hand and I had a conversation that went like this:

Student: “Can you just go over it in general?”
Me: “What’s confusing?”
Student: “I mean, can you just say in general what the assignment is about?”
Me: “That’s what the assignment sheet is for.”
Student: “I don’t understand. Can you go over it?”
Me: “What part confuses you?”
Student: “The entire thing.”
Me: “Which sentence is confusing to you?”
Student: “Can you just go over it in general?”

This was not a surrealist play and by the end of the exchange—I did not reproduce the whole exchange—I was somewhat confused, so I began reading each individual sentence and then checking in with the student. This was somewhat embarrassing for everyone in the class but I didn’t really know what else to do.

When I got to the end of the assignment sheet, the student agreed that it was in fact clear. I know enough about teaching not to ask the obvious question—”What was all this about?”—and yet I’ve had enough of those experiences to identify, just a little, with the people running the world’s boringest* bidders conferences.

* Not an actual word, but I think it fits here.

Partnerships to Improve Community Health (PICH)—Riding the CDC Grant Gravy Train

Even after a hundred years as a grant writer, the feds never cease to amaze me. Last week, it was the CDC issuing a Funding Opportunity Announcement (“FOA,” which is CDC-speak for RFP) for an entirely new program: Partnerships to Improve Community Health (PICH). The program is funded through the Affordable Care Act (ACA)—or ObamaCare as it is sometimes known to its many friends.

PICH is great news: as Pink Floyd put it in Have a Cigar: “And did we tell you the name of the game, boy? We call it riding the gravy train.” This post explains the game.

The game is walkin’ around money, as we explain at the link. In this case, there’s $150,000,000 up for grabs, with max grants ranging from $1,000,000 to $4,000,000, depending on the population of the service area.

What makes PICH nearly pitch-perfect walkin’ around money is that the program funds community collaboratives that meet to essentially talk about improving health, but not actually do anything, like deliver healthcare. It’s all process and no services. This means that the grantee only has to form the collaborative, hold meetings, conduct needs assessments and develop the ever popular action plans. Since there are no services, there’s nothing to evaluate, except process objectives like the “composition” of the collaborative, number of meetings held, plans drafted, long tons of donuts consumed during meetings, and the like.

This should make most public health officers and nonprofit executive directors swoon. Get a PICH grant and you’ll definitely be riding the gravy train. And, since you’ll be the one with the gravy ladle, other organizations in your service area will be sitting on their hind legs begging for the sub-grants that are required under PICH.

For example, say you’re Executive Director or Chairwoman of the Healthy Owatonna Collaborative. To make your pitch for a PICH grant, you’ll need to gather input from, and meet the needs of, all segments of the “community.” An easy way to accomplish this is to propose involvement of population-specific or advocacy groups in the planning and implementation process.

If cyclopes are an important population in Owatonna, propose a subcontract in your proposal with the Owatonna Cyclops Improvement Association, which has its eye, so to speak, on health issues confronting cyclopses in Owatonna. The ability to pass out big subcontracts to local advocacy organizations is going to make you very popular, as lots of organizations will try to get their snouts into the PICH trough. The applicant and lead agency is the Gatekeeper to this largesse.*

An interesting aspect of PICH is applicant eligibility:

  • Government Organizations: Local public health offices, American Indian tribes or Alaskan Native villages, local housing authorities, school districts, or local transportation authorities.
  • Non-government Organizations: Nonprofits with 501(c)3 IRS status (other than institution of higher education), or nonprofits without 501(c)3 IRS status (other than institution of higher education.

Two aspects of the listed eligible organizations are curious. First, essentially every kind of non-business entity is eligible to apply for PICH, except colleges and universities, for some arcane reason. Universities are unlikely to want to improve local health, but transportation authorities are? Welcome to the odd world of federal grantmaking.

Second, nonprofits with or without 501(c)3 status are eligible. Most people’s reaction to the eligibility of nonprofit, but not tax-exempt, organizations is probably “WTF?

Let me explain.

Many community collaboratives for various purposes (e.g., health improvement, substance abuse prevention, services to homeless cyclopses, etc.) are actually unincorporated associations composed of representatives of nonprofit and public agencies, who get together once a month or so to eat donuts, drink beer (if they’re lucky), and opine on the subject of interest. In most states, however, it’s very easy to get a charter for the collaborative as a nonprofit corporation. As we’ve written about before, the hard part is not incorporating—it’s getting a 501(c3) letter of determination out of the IRS. So the CDC is encouraging informal collaboratives, which are willing to incorporate, or incorporated nonprofits, to apply. Very sweet.

Now, don’t let the fact that your agency may not actually be part of an existing health collaborative prevent you from applying. Remember, this is the proposal world, not the real world. A good grant writer should be able to create a plausible collaborative out of polka dots and moonbeams. I know we can, as we’ve written many funded proposals like PICH over the years, including an $800,000 HRSA Community Access Program (CAP) grant for a rural public health department in Illinois, a $900,000 OCS CCF-CEY capacity building grant for a youth services collaborative in Wisconsin, a $2,000,000 CDC Capacity Building grant for a national HIV/AIDs coalition serving African Americans, and a $2,000,000 CDC REACH-US grant for a collaborative in Virginia to reduce the incidence of diabetes.

* Sigouney Weaver, as Dana, was possessed by the Gatekeeper demon, while Rick Moranis as the hapless Louis was possessed by the Keymaster demon in the 1984 classic Ghostbusters, which was Jake’s favorite movie as a kid.

HUD’s Lead-Based Paint Hazard Control Program (LBPHC) Program Explained

HUD’s FY 2010 NOFA for the Lead-Based Paint Hazard Control Program (LBPHC) confuses many applicants. We’ve written at least six funded LBPHC grants, so we’re familiar with it. The program is actually simple: it funds the remediation (not necessarily removal) of lead-based paint in privately owned housing occupied by low-income folks.

Applicants, however, often have trouble figuring out how to efficiently spend the grant funds. Lead-based paint remediation usually costs about $15,000 per unit remediated. To make a LBPHC program work, applicants should propose using the LBPHC funds in conjunction with their housing rehabilitation program.

That’s the real secret of the program. Virtually every city has had some form of housing rehab program since the Nixon administration, using a combination of HUD HOME formula grants, CDBG entitlements, state funds, or who knows what. The rehab programs usually entice homeowners and landlords to fix up the housing units by offering small grants for the very low-income (below 50% of area median income or “AMI”) and subsidized loans for low-income and moderate-income (50% to 120% of AMI, depending on the jurisdiction).

The real problem for lead-based paint programs is invariably that the City of Owatonna wants Mrs. Smith the homeowner to fix code violations, remediate lead paint, etc., while Mrs. Jones wants granite countertops, stainless steel appliances, and maybe faster Internet access. The city has trouble spending its rehab funds because Mrs. Smith doesn’t want to borrow money to do things that won’t impress her friends and neighbors.

What to do? The City (or other applicant) gets a LBPHC grant and bungie cords it to their existing rehab program. Now Mrs. Smith can get $15,000 or so in LBPHC sub-grant funds to remediate the lead hazards that the city inspector wants her to do and can use the rehab loan to buy her granite countertops.

The lead remediation grant can be used to entice Mrs. Smith to take the rehab loan. Now everyone is happy, including the local contractors who have some work while waiting around for the economy to improve. As long as a city doesn’t try to run LBPHC as a standalone program, but instead combines it with their rehab effort, HUD will love it. So will everyone in town. It’s remarkable to me how many calls I’ve had over the years from city officials who do not get this idea until I explain it. The ones who follow our direction usually get funded and have great success with the program.