Tag Archives: HRSA

Funders sometimes force grantees to provide services they don’t want to: FQHCs and Medication Assisted Treatment (MAT)

We often remind clients that those with the gold make the rules. Accepting a government grant means the applicant must sign a grant agreement, in which the applicant agrees not only to provide wherever services were specified in the proposal, but also abide by a myriad of regulations and laws. While many applicants will tussle with a funder over the budget, there’s rarely any point in trying to modify the boiler plate agreement—just like one can’t modify Apple or Facebook’s Terms of Service.

In addition to the specific terms of the grant agreement, grantees quickly become subject to other influences from the funder—when the Godfather makes you an offer you can’t refuse, you know that eventually you’ll be told to do something you’d otherwise not much want to do. While a federal agency is unlikely to place a horse’s head in a nonprofit Executive Director’s bed, the grantee might end up having to provide an unpalatable service.

A case in point is HRSA’s relatively recent (and divisive) endorsement of Medication Assisted Treatment (MAT) for treating opioid use disorder (OUD). Since HRSA is the primary FQHC funder, it is essentially their Godfather and has great influence over FQHCs. In the past few years, HRSA has strongly encouraged FQHCs to provide MAT. The CEOs of our FQHC clients have told us about HRSA pressure to start offering MAT. It seems that, even after several years of cajoling, only about half of our FQHC clients provide MAT, and, for many of these, MAT is only nominally offered. Other clients see offering MAT as a moral imperative, and we’ll sometimes get off the phone with one client who hates MAT and then on the phone with another client who sees not providing MAT as cruel.

“MAT” generically refers to the use of medications, usually in combination with counseling and behavioral therapies, for the treatment of substance use disorders (SUD). For OUD, this usually means prescribing and monitoring a medication like Suboxone, in which the active ingredients are buprenorphine and naloxone. While Suboxone typically reduces the cravings of people with OUD for prescribed and street opioids (e.g., oxycontin, heroin, etc.), it is itself a synthetic opioid. While MAT replaces a “bad opioid” with a “good opioid,” the patient remains addicted. Many FQHC managers and clinicians object to offering MAT for OUD, for a variety of medical, ethical, and practical reasons:

  • Like its older cousin methadone, as an opioid, Suboxone can produce euphoria and induce dependency, although its effects are milder. Still, it’s possible to overdose on Suboxone, particularly when combined with alcohol and street drugs. So it can still be deadly.
  • While MAT is supposed to be combined with some form of talking or other therapy, few FQHCs have the resources to actually provide extensive individual or group therapy, so the reality is that FQHC MAT patients will likely need Suboxone prescribed over the long term, leaving them effectively addicted. We’re aware that there’s often a wide gap here between the real world and the proposal world.
  • Unless it’s combined with some kind talking therapy that proves effective, MAT is not a short-term approach, meaning that, once an FQHC physician starts a patient on Suboxone, the patient is likely to need the prescription over a very long time—perhaps for the rest of their life. This makes the patient not only dependent on Suboxone, but also dependent on the prescriber and the FQHC, since few other local providers are likely to accept the patient and have clinicians who have obtained the necessary waiver to prescribe it. Suboxone users must be regularly monitored and seen by their prescriber, making for frequent health center visits.
  • As noted above, prescribed Suboxone can, and is often, re-sold by patients on the street.
  • Lastly, but perhaps most importantly, most FQHC health centers prefer to look like a standard group practice facility with a single waiting room/reception area. Unlike a specialized methadone or other addiction clinic, FQHC patients of all kinds are jumbled together. That means a mom bringing her five-year old in for a school physical could end up sitting between a couple of MAT users, who may look a little wild-eyed and ragged, making her and her kid uncomfortable. Since FQHCs usually lack the resources for anything beyond minor paint-up/fix up repairs, there is simply no way around this potential conflict.

Given the above, many FQHC CEOs remain resistant to adding the challenges of MAT to the many struggles they already face. Still, the ongoing pressure from HRSA means that most FQHCs will eventually be forced to provide at least a nominal MAT program to keep their HRSA Program Officer at bay. The tension between a typical mom and her five-year old against a full-fledged behavioral and mental health program is likely to remain, however. Before you leave scorching comments, however, remember that we’re trying to describe some of the real-world trade-offs here, not prescribe a course of action. What people really want in the physical space they occupy and what they say they want in the abstract are often quite different. You can see this in the relentless noise around issues like homeless service centers; everyone is in favor of them in someone else’s neighborhood and against them in their own neighborhood. Always pay attention to what a person actually does over a person’s rhetoric.

Don’t split target areas, but some programs, like HRSA’s Rural Health Network Development (RHND) Program, encourage cherry picking

In developing a grant proposal, one of the first issues is choosing the target area (or area of focus); the needs assessment is a key component of most grant proposals—but you can’t write the needs assessment without defining the target area. Without a target area, it’s not possible to craft data into the logic argument at is at the center of all needs assessments.

To make the needs assessment as tight and compelling as possible, we recommend that the target area be contiguous, if at all possible. Still, there are times when it is a good idea to split target areas—or it’s even required by the RFP.

Some federal programs, like YouthBuild, have highly structured, specific data requirements for such items as poverty level, high school graduation rate, youth unemployment rates, etc., with minimum thresholds for getting a certain number of points. Programs like YouthBuild mean that cherry picking zip codes or Census tracts can lead to a higher threshold score.

Many federal grant programs are aimed at “rural” target areas, although different federal agencies may use different definitions of what constitutes “rural”—or they provide little guidance as to what “rural” means. For example, HRSA just issued the FY ’20 NOFOs (Notice of Funding Opportunities—HRSA-speak for RFP) for the Rural Health Network Development Planning Program and the Rural Health Network Development Program.

Applicants for RHNDP and RHND must be a “Rural Health Network Development Program.” But, “If the applicant organization’s headquarters are located in a metropolitan or urban county, that also serves or has branches in a non-metropolitan or rural county, the applicant organization is not eligible solely because of the rural areas they serve, and must meet all other eligibility requirements.” Say what? And, applicants must also use the HRSA Tool to determine rural eligibility, based on “county or street address.” This being a HRSA tool, what HRSA thinks is rural may not match what anybody living there thinks. Residents of what has historically been a farm-trade small town might be surprised to learn that HRSA thinks they’re city folks, because the county seat population is slightly above a certain threshold, or expanding ex-urban development has been close enough to skew datasets from rural to nominally suburban or even urban.

Thus, while a contiguous target area is preferred, for NHNDP and RHND, you may find yourself in the data orchard picking cherries.

In most other cases, always try to avoid describing a target composed of the Towering Oaks neighborhood on the west side of Owatonna and the Scrubby Pines neighborhood on the east side, separated by the newly gentrified downtown in between. If you have a split target area, the needs assessment is going to be unnecessarily complex and may confuse the grant reviewers. You’ll find yourself writing something like, “the 2017 flood devastated the west side, which is very low-income community of color, while the Twinkie factory has brought new jobs to the east side, which is a white, working class neighborhood.” The data tables will be hard to structure and even harder to summarize in a way that makes it seem like the end of the world (always the goal in writing needs assessments).

Try to choose target area boundaries that conform to Census designations (e.g., Census tracts, Zip Codes, cities, etc.). Avoid target area boundaries like a school district enrollment area or a health district, which generally don’t conform to Census and other common data sets.

“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.

HRSA makes it hard to target Ryan White Part C EIS “New Geographic Service Areas” applications

FQHCs and other HIV services providers have likely seen the recently issued HRSA “Ryan White HIV/AIDS Program Part C HIV Early Intervention Services Program: New Geographic Service Areas” NOFO and thought, “looks promising.” As usual, though, a potential applicant ought to first check the eligibility criteria. In this case, on page 3 the NOFO cryptically says, “[See Section III-1 of this notice of funding opportunity (NOFO), formerly known as the funding opportunity announcement (FOA), for complete eligibility information.]” Okay. That section says:

Newly proposed service areas must not geographically overlap with existing RWHAP Part C EIS service areas as defined in Appendix B in NOFO HRSA-18-001, HRSA-18-004, and HRSA-18-005.

Okay. So if you up those other NOFOs you’ll find a long table of current providers; the table isn’t organized in a coherent fashion, except by state. There’s no map or list of potentially qualifying zip codes, only a list of current providers and some poorly described service areas for their Ryan White Part C EIS grants. In many places, like big cities, it’s hard to tell which areas/neighborhoods might qualify as new service areas.

Still, the NOFO also listed a webinar, which occurred today. Despite knowing that bidders conferences are a usually waste of time, I participated anyway, and when the presenters finally finish regurgitating the NOFO I asked, “Will HRSA produce a map of areas that it currently considers underserved? That would help a lot, especially in dense urban areas like New York City.” The leader said, “No. The NOFA does not identify specific areas that are underserved. It’s up to the applicant to demonstrate need in a particular service area.” HRSA won’t produce a map showing allowed areas or even a map of currently served areas. Applicants just have to guess. Thanks, HRSA. Helpful as usual.

If you’re interested in the New Geographic Service Areas program and you read the Q & A when it’s released, you may find the question from yours truly. I sometimes tell students that formulating good questions can be as hard as giving good answers. In this case, the answer would’ve been more useful than the question—had it been forthcoming.

HRSA sort of “Streamlines” FY ’18 Service Area Competition (SAC) NOFOs

As happens every year about this time, HRSA has been issuing Service Area Competition (SAC) Notices of Funding Funding Opportunities (NOFOs). As we’ve written before, HRSA requires Federally Qualified Health Centers (FQHCs—otherwise known as Section 330 grantees) to compete every three years against non-grantees to keep their Section 330 grants. About one-third of the approximately 1,400 FQHCs must submit a technically correct SAC proposal every year.

We’re in the early stages of the FY ’18 SAC derby and, while the process is more or less the same this year, we came across this, on page 3 of this year’s NOFOs:

The Project Narrative has been streamlined to reduce applicant burden, more closely align with Health Center Program requirements as defined by statute and regulation, and simplify the collection of information.

(Emphasis added.)

Sounds great in theory, but let’s take a closer as what passes for streamlining in HRSA-land. The term “NOFO” replaces HRSA’s longstanding practice of calling their RFPs Funding Opportunity Announcements (FOAs). Thus, HRSA has replaced one pointless three-letter acronym with a similarly pointless four-letter acronym. In they had to change the acronym, why not just use the more common acronym “RFP?”

The FY ’17 SAC FOAs were 73 single-spaced pages, while the FY ’18 NOFOs are 67 single-spaced pages (NOFO length does not include the 365 single-spaced Service Area Announcement Table). It also doesn’t include the 66-page, single-spaced HRSA SF-424 Two-Tier Application Guide (love the doc name). The Guide has intricate formatting instructions for all HRSA grant submissions but often conflicts with the instructions with particular NOFOs, like SAC. Then there’s the voluminous underlying regs for the Section 330 program, but counting these pages would like counting grains of sand on Santa Monica beach.

In summary, HRSA has shaved six pages off of the 498 pages of instructions, not counting regs, or a generous 1.2%! We must applaud HRSA for this Herculean streamlining effort!

To be fair to HRSA, some items previously required of all applicants, like floor plans, no longer must be submitted by current grantees. Also, current grantees don’t have to answer a few of the repetitive questions in the Program Narrative. Still, the SAC applications may not exceed 160 pages “when printed by HRSA.” Despite the digital application upload process, HRSA still prints and copies proposals for reviewers to read in hard copy—partying just like it’s 1999. This is a good reason to avoid color graphics in federal proposals, as most will be printed and copied in grayscale for reviewers.

For FY ’18, HRSA also still requires a two-step application process: the first step in a relatively simply application uploaded through grants.gov, while the second step is the fiendishly complicated online application through HRSA’s Byzantine Electronic Handbooks (EHB) system.

Without doing a deep dive into the SAC NOFOs, a couple of features remaining in the FY ’18 NOFOs illustrate why HRSA using the term “streamlined” might be euphemistic.

There’s a convoluted section of the Project Narrative called “Governance,” where applicants must explain how their governance structure meets complex Section 330 requirements. For current grantees—some of which have received SAC grants for decades—this is odd, since these applicant couldn’t have been funded before if they didn’t meet these requirements. Also, even current grantees must upload copies of their articles of incorporation and bylaws as attachments. One would think that after, say, four SAC grants, HRSA probably doesn’t need another copies of the Owatonna Community Health Center’s articles and bylaws (I made this up, but there probably is a FQHC in Owatonna, MN).

Also, in addition to the grants.gov application file, Abstract, Project Narrative, and Budget/Budget Narrative, the EHB application includes 13 required forms and 12 required attachments for all applicants, including existing grantees.

Yes, it is possible for your FQHC to lose its HRSA Section 330 grant

If you’re a Federally Qualified Health Center (FQHC), you’ve probably seen announcements like this one, from the Federal Register: “Service Area Competition – Additional Areas (SAC-AA) – Honolulu, Hawaii; College Station, Texas; and Rock Springs, Wyoming.” Those announcements may seem curious: why announce for a strangely small number of additional service areas?

Answers vary. Sometimes it’s because the current FQHC Section 330 grantee has screwed something up badly enough to have its SAC grant yanked (though this is rare). More often, HRSA simply didn’t get any qualified applications for SAC grants in a certain geography, leaving a given area without a Section 330 provider needs for basic healthcare.

We’ve been told some funny stories about HRSA’s reaction to inadequate applicants. Our favorite probably involves an FQHC that called us on a Wednesday or Thursday about a SAC application that was due Monday. We were flabbergasted by this request and knew that a SAC FOA wasn’t on the street anyway. Our client explained what happened: She’d forgotten about the SAC deadline and failed to submit an application. HRSA did the initial review and realized that our client’s application was missing, and no one else had submitted for that rural service area.

HRSA probably isn’t supposed to extend the deadline for applicants who forget about the competition, but HRSA also doesn’t want healthcare gaps. So in the case of our client, HRSA called, told the client to get off their rear, and demanded a proposal by the following Monday. Our client panicked and called us.

We were able to complete the proposal on time (professional grant writer at work, don’t try this at home), and not surprisingly the client got funded. In short, depending on your FQHC’s relationship with HRSA, you can get wildly different outcomes from the same inputs. Our client got lucky. You may not be. We recommend attending to SAC deadlines and making sure you submit a complete, technically accurate proposal before the due date.

We’ve worked on SAC projects for insurgents attempting to take down the current grantee, and we’ve also worked on projects for the current grantee who suddenly realizes that they need a more serious application due to the threat of upstarts. Both kinds of projects are fun for us, albeit in slightly different ways. Both kinds of projects are also a reminder to FQHCs: SAC stands for “Service Area Competition.” Don’t get cocky. We’ve seen lots of cocky clients lose their primary funding streams via hubris, laziness, or both. Success is never final. There are no guarantees in grant writing, and you should know that you may have to compete for your dinner at any time.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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


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