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Many Proposals Are Swimming Against the Tide: An Example From HRSA’s New Access Point (NAP) FOA

Take a look at the laundry list of stuff that HRSA wants New Access Point (NAP) applicants to somehow improve (the quote comes from page 38 of the 101-page FOA):

Diabetes, Cardiovascular Disease, Cancer, Prenatal Health, Perinatal Health, Child Health, Weight Assessment and Counseling for Children and Adolescents, Adult Weight Screening and Follow-Up, Tobacco Use Screening and Cessation, Asthma – Pharmacological Therapy, Coronary Artery Disease (CAD) – Lipid Therapy, Ischemic Vascular Disease (IVD) – Aspirin Therapy, Colorectal Cancer Screening, New HIV Cases With Timely Follow Up, Depression Screening and Follow Up, and Oral Health.

Improving almost all of those metrics really starts with behavior, not with care. The real way to better health can be reduced to a couple things: 1. Eat better. 2. Get some exercise.* 3. Avoid the obvious drugs. 4. Brush and floss.

But those things have been public health goals for the last 50 years, and in the meantime Americans have gotten fatter and by most metrics less healthy—except, curiously, for longevity. We’ve built cities and suburbs that are actively unhealthy because they force everyone to drive everywhere all the time. Smoking rates have fallen, but they’re still stubbornly high and have been hovering between 20 and 25% for years. Cancer and heart disease look like eternal public enemies who can no more defeated than drug traffickers or superheroes.

Changes can’t and thus aren’t going to come from a bunch of doctors and nurses telling their patients—yet again—to lay off the McDonald’s and the soda and instead hit the gym for squats. HRSA knows this to some extent, and whoever sees the evaluations for NAPs in a couple years is going to know that opening one new primary care health clinics is equivalent to chucking a pebble in the river of behavior and culture. It is true that the federal government also subsidizes big agriculture in various ways that make eating well relatively harder and more expensive than it should otherwise be, but a lot more people could swim against that tide than actually do.

People who get and stay in shape do so because they realize it makes them feel better and because it dramatically increases their mating market value. Until they get sick and tired of being sick and tired—or, rather, until they get sick and tired of being the butt of jokes—no one is going to make them change. Pressure from external sources, like doctors, rarely does it. Treatment will never be as effective as prevention, but prevention can’t be mandated from above. It has to emerge from below. It would be interesting to see a study of the health behaviors of HRSA bureaucrats compared to the general population and a population of their peers.

The other night I was hanging out with a bunch of doctors and almost all of them were smoking cigarettes outside a bar. These are doctors. No one knows more about how dangerous smoking is. But they wanted drinks to take the edge off and for the usual reasons having a cigarette or three helped the relaxation process. I’m not even going to start into the unprotected sex stories—commonly referred to as “raw dogging” among today’s urban 20- and 30-somethings. As usual the stories may be exaggerated, but some episodes may also not bubble up into even impolite conversation.

(By the way, these same doctors like to note how infrequently patients take their standard advice: stop smoking, drink less, lose 20 pounds. To them medicine often feels like a futile endeavor.)

We’ve noticed one other thing, which isn’t related to the main point of this post but is likely to be hilarious to the right audience. CHCs—sometimes called Section 330 providers—must have community-based Board of Directors. At least 51% of these Boards must be composed of “consumers,” and the board is supposed to “Approve the selection/dismissal and conducts the performance evaluation of the organization’s Executive Director/CEO.” HRSA requires that NAP applicants say as much, and say that the Board has control over the Executive Director. This is saying the applicant will certify that the sun rises in the East.

The bylaws of every nonprofit typically state that the executive director/CEO serves at the pleasure of the board. Who else would hire, evaluate and, if necessary, fire the CEO? While some CHC CEOs can come from the clinical side, like a physician, they are often a health administrator type or general purpose nonprofit manager. More importantly, they are often the founder and/or prime mover in the organization.

Let me repeat that: they are the driving force behind the organization. That isn’t true in the largest organizations, but in small ones the Executive Director usually controls the board, no matter what the bylaws nominally say, because taking away the key person who built the organization usually kills the organization. It’s like “firing” the donor keeping the organization alive. It rarely happens in small- or medium-sized organizations. Nonetheless, in the proposal world the patients represented on the board have all the power. Among most actual NAP applicants, the real power isn’t likely to reside in the non-experts who can be rounded up to sit on the Board.


* I’ve become a much more regular lifter since reading “Everything You Know About Fitness Is a Lie,” and to a lesser extent Starting Strength and Arnold: The Education of a Bodybuilder. The last one is admittedly not very good yet I like it anyway.

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Links: The Charity-Industrial Complex, Anthony Weiner Exposed (so to speak), Conventional Wisdom Debunked, Vaccines, Work, the Workforce, and More!

* The charitable industrial complex; I find it revealing that so many people who view how charities work from the inside start to see why so much is amiss with them.

* “‘It’s a circle of hell there’s just no way out of,’ Schochet said. ‘I paid it as long as I could.’

* Why It’s Never Mattered That America’s Schools ‘Lag’ Behind Other Countries.

* We should be suing and charging parents who don’t vaccinate their kids.

* “Open All Night: America’s Car Factories,” with the most interesting quote from a grant writer’s perspective being this, about a plant in Toledo: “Of those who applied for the work, 70% were rejected, mostly because they couldn’t pass initial assessment tests, Mr. Pino said.” “Initial assessment tests” means basic reading and writing skills. Any nonprofit in Toledo that wants to run adult education or after school programs should use this quote.

* “Affordable Excellence. . . This book is a clear first choice on the Singapore health system and everyone interested in health care economics, or Singapore, should read it. It is short, clear, and to the point.” I am struck by how many people have strong opinions about healthcare without really understanding the system. Sloganeering is rampant and understanding scant. This is useful in conjunction with “The two most important numbers in American health care,” which points out that five percent of patients accounts for fifty percent of costs.

* “The U.S. patent system inhibits cancer vaccine development.”

* “Spy Kids,” and the fate of spy apparatuses that depend on cultural concepts long dead in most of American and Western life.

* “The Gender Wage Gap Lie: You know that “women make 77 cents to every man’s dollar” line you’ve heard a hundred times? It’s not true.” More conventional wisdom debunked. Is anyone surprised?

* “If it were cheaper to build apartments the rent would be lower.” This is obvious but bears repeating.

* “Guesses and Hype Give Way to Data in Study of Education.”

* The Turpentine Effect, a brilliant post with an unfortunate title that makes it less likely you’ll read.

* “An Aspiring Scientist’s Frustration with Modern-Day Academia: A Resignation.”

* “The Patriarchy Is Dead Feminists, accept it.”

* “How Anthony Weiner Exposed the Insecurities of the 1960s Generation: A half-century after the sexual revolution, the make-your-own-rules folks are no longer quite so sold on free love.” This has Camille Paglia-esque overtones.

* We are in denial about catastrophic risks.

* NASA’s Plutonium Problem Could End Deep-Space Exploration.

* A geek’s tour of Sigma’s Aizu lens factory: Precision production from the inside out.

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November Links: Healthcare Machinations, Becoming a Writer, Why Your High School Probably “Sucked” Statistically, Demography, Government Pulls in Three Directions (again), the Native American CDFI Assistance Program, and More!

* What makes our healthcare so expensive? Hint: the answer is not simple or obvious. If you hear people say, “It’s x, and chiefly x,” where x might be greedy insurance companies, clueless consumers, the market, regulation, government, greedy doctors, or any noun preceded by the word “greedy,”

* The dangers of Groupon and of discounts in general: “We’ve also learned that the customers you attract only with a discount will disregard what you love about your own business, and won’t treat you with respect; both sides usually regret the transaction.”

* Statistically speaking, my high school sucked. Yours probably did too—you just don’t know it. You should pay attention to this if you write education proposals. See also Your Child Left Behind.

* Global aging: the problem the world faces, it turns out, is not overpopulation, but underpopulation.

* Why New Novelists Are Kinda Old, or, Hey, Publishing is Slow.

* People in polls are lunatics on the budget; they consistently oppose tax increases, oppose spending cuts, and strongly support balancing the budget.

* That’s what life’s about: improving the world around you.

* Your government at work!: When sales of Domino’s Pizza were lagging, a government agency stepped in with advice: more cheese. This is the same government that, for health reasons, is advising less cheese.

* Americans look like Americans wherever we are.

* Guess who is lobbying against marijuana legalization? Yup, beer distributors and the police. Call this another example of people whose job involve fighting a social problem fighting to maintain that social “problem.”

* Why NPR matters.

* This “obscure provision” in the health care bill is completely vital to our business and yet isn’t particularly well-known among people in general. It should be. See this story on the coming 1099 mess.

* The world is richer and healthier than it used to be.

* Dan Savage’s It Gets Better project for gay teenagers already has 200,000 hits for a very good reason: it’s quite moving because it’s unexpectedly earnest, which feels unexpected honest in a media age filled with bullshit. Consider it recommended; see the impetus for it in this column.

See Megan McArdle’s take here.

* One of the funniest sentences I’ve read in a while: “Sarah Palin on the Federal Reserve is one of those immortal phrases, like Lindsay Lohan stars in Anna Karenina, or La Boheme featuring Justin Bieber, a magical, irresistible blend of high and low that might just make mainstream Americans care about monetary policy.”

* Why the U.S. needs a new visa for foreigners who want to start businesses here.

* The Native American CDFI Assistance Program is out, with $12M and a deadline of Dec. 22.

* Scary thoughts that I think are right, from Tyler Cowen.

* Marriage in crisis, or what the recession is doing to marriage, with data stratified by education.

* Dear 22 Year Old: Concerning your Future. And there’s probably no way to stop it, save voting en masse for a political party that doesn’t exist and can’t exist given electoral realities.

* James Fallows, who, if you’re not reading his blog, you should be:

Among the many things wrong with talking-head gab shows, which have proliferated/ metastasized in the past generation — they’re cheap to produce, they fill air time, they make journalists into celebrities, they suit the increasing political niche-ization of cable networks — is that they reward an affect of breezy confidence on all topics and penalize admissions of complexity, of ignorance on a specific topic, or of the need for time to think.

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Health Care Reform Means Green Grass & High Tides for Grant Writers

One of the great ’70s arena anthem songs was the Outlaws’ Green Grass & High Tides, or as it was often misheard, “Green Grass & High Times Forever.” It seems that whichever health care reform bill staggers across the Congressional finish line will make it Green Grass & High Tides for grant writers, since all versions contain lots of hidden grant nuggets. I’m too busy writing proposals for such fun-filled RFPs as HRSA’s Nurse Education, Practice and Retention (NEPR) Program and SAMHSA’s Offender Reentry Program to flyspeck a couple of 2,000 page health care bills looking for prospective grant programs. Fortunately, I came across “Numerous Grant Programs Fatten Cost of Health Care Reform,” which does the heavy lifting for me. Here are some of the new grant programs that may burst forth in 2010:

  • Demonstration Program to Promote Access for Medicare Beneficiaries With Limited English Proficiency (LEP): Section 1222 of the House bill would create three-year grants for nonprofits to offer interpreter services to help LEP residents communicate with medical providers. This is clearly aimed at Section 330 community and rural health centers that provide Medicaid services, often for LEP populations. We work for lots of Section 330 providers, so we love this program concept.
  • Early Childhood Home Visitation Program: Section 2951 of the Senate bill would authorize grants to nonprofits for early childhood visitation programs. The programs would be aimed at improving maternal and newborn health, preventing child injuries and abuse,improving school performance, reducing domestic violence, and improving family economic self-sufficiency. There is $1.5 billion for this gem over five years. We’ve written tons of proposals over the years for similar programs, which are usually called “demonstration homemaker” services. I’ve never seen any data that suggests that such programs work, but they are great ways of employing lots of low-skill workers, usually low-income women, to go into the homes of other low-income women and tell them how to fold their laundry. This ever popular family support service already exists in most American communities. Since Senators must know this, I can only assume that the program will be “walkin’ around money” for the thousands of nonprofits that provide family supportive services through contracts with city, county and state agencies.
  • Grants to Promote Positive Health Behaviors and Outcomes: Section 2530 in the House bill authorizes the award of grants to promote healthy behaviors in medically underserved areas, including education about the risks associated with poor nutrition, tobacco use, lack of exercise and other health problems. I could list about 25 existing federal program that already do this, but the nice part about the federal trough is that there is always room for one more program.
  • Healthy Teen Initiative Program to Reduce Teen Pregnancy: Section 2526 of the House bill establishes a new program to provide $150 million in grants for schools, non-profits and other groups for educational programs to reduce teen pregnancy and the spread of sexually transmitted diseases (STDs). The feds have been funding various teen pregnancy and STD prevention programs for the past 35 years, vacillating between sex education and abstinence approaches, depending on which party controls Congress. We write teen pregnancy prevention programs regularly, so I am very familiar with the data and have yet to see any evidence that such programs do anything except keep armies of earnest, newly minted college grads employed as health educators.

I could go on, but I think readers will get the idea that there are dozens of new grant horses being saddled up in the health reform effort, as well as other emerging federal legislation. I recently wrote about a huge new education program named i3, in Same As It Ever Was: Investing in Innovation Fund (i3), Student Support Services (SSS), TRIO, and More to Come and am tickled to learn that new health related programs are not far behind. If your organization does job training, not education or health services, and you’re feeling left out of the party, not to worry, Congress feels your pain. The LA Times reports that Democrats Work On Multibillion-dollar Jobs Package, so your time is nigh.

I’m hoping for a resurrection of the Nixon-era Comprehensive Employment and Training Act (CETA), which was perhaps the all time best grant program for nonprofit and public agencies, since all it did was provide money to hire people. I wrote many funded CETA proposals in the ’70s and knew lots of unemployed liberal arts grads who entered the government/nonprofit world through CETA slots and clawed their way into permanent jobs, including the holy grail of civil service status. Unlike the Stimulus Bill, it was easy to count jobs created by CETA, as grantees just had to count new noses around the conference table.

For the past year or so, I’ve written many posts on how this is the best time ever to go after grants and the hits keep on coming. Seliger + Associates stands ready to shoulder the burden of writing proposals for the newest crop of federal grants, which indeed seem to be the same as they ever were.