Tag: Section 330

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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.

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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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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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HRSA Service Area Competition (SAC) Grants: How to Defend Your Turf or Deftly Lift a HRSA Grant from an Unsuspecting Grantee

The Health Resources and Services Administration (HRSA) recently issued a Funding Opportunity Announcement (“FOA,” which is HRSA-speak for RFP) for the Service Area Competition (SAC) program. This program provides extremely valuable (for reasons we’ll explain in this post) five-year grants to operate one or more Federally Qualified Health Centers (FQHCs).

There are three ways to get become an FQHC, which will let an organization access Section 330 funds: (1) apply to have an existing health clinic certified as an FQHC (this is an incredibly complex process because the regulations are a nightmare); (2) wait for HRSA to issue a New Access Points (NAP) FOA and apply for a grant (this can be done in any community that meets Section 330 requirements, and it has a distinct advantage because a grant award is attached); or (3) wait for HRSA to publish a SAC FOA for your service area (which has the same advantage as number two).

The SAC route is probably the easiest because HRSA already knows that the area and residents qualify for Section 330 funds. Each time a FOA appears, existing Section 330 grantees at the end of their five-year grant period have to compete for new money against any other nonprofit or public agency that can (1) meet the eligibility test to become an FQHC and (2) chooses to apply.

This can make for mighty nervous Section 330 grantees, because running an FQHC or three can be a very lucrative undertaking for a nonprofit or public agency. As a result, even nominal collaborators can turn into cutthroat competitors and sack a grantee during a SAC funding cycle.*

Most federal programs require grantees to re-apply for continuation grants, including some (e.g., TRIO grants) that give bonus points to current grantees. Since operating a FQHC requires significant organizational infrastructure (e.g., specialized facilities and equipment, medical staff, HIPAA-compliant records management, and other features that go above and beyond basic nonprofit infrastructure), it is curious that HRSA requires current Section 330 grantees to compete for continuation funding. If a grantee is more or less getting the job done, why not just let them keep on doing what they’re doing? I assume the complicated re-application process is designed to keep the grantees on their toes. It also forces them to be accountable for the objectives stated in their original application (FQHC, NAP or SAC application), as well as the new SAC application.

HRSA Section 330 FOAs also require applicants to state highly specific objectives for required HRSA “Clinical and Financial Performance Measures,” as well for service delivery levels (e.g., number of patients, service encounters, etc.). Many applicants overstate their objectives beyond what is achievable in the real world. While we often differentiate between the Real World and the Proposal World in our approach to grant writing, sometimes the real world is important. HRSA Section 330 proposal writing is a case in point. Because the SAC application includes electronic data forms with highly specific input boxes and the metrics are so easily measured, a grantee can easily get too enthusiastic and wildly overstate the objectives that are likely to be achieved in the real world.

While being grandiose in stating objectives can be okay in many subjective human services proposals, it is a recipe for future unhappiness in HRSA Section 330 proposals. This is because failure to meet stated metrics will likely annoy your Program Officer, assuming you submit reasonably honest reports. An annoyed Program Officer is likely to torpedo your next SAC application or even cut back your current grant.

For example, a few years ago we wrote a number of funded HRSA, CDC, and foundation proposals for a Section 330 client in the midwest. While the client had no big problems in implementing several complex programs, she unfortunately got crosswise with her HRSA Program Officer over the stated objectives. Incredibly, the Program Officer got so annoyed that the client was forced into a SAC FOA three years ahead of schedule. With HRSA grants, don’t make this mistake and lose millions of dollars by overstating what your organization can do.

If your agency decides to try for the funding of an existing Section 330 grantee, it would be a good idea to request copies of their original application and reports. Just call up your competitor and ask them for these documents (note: this is joke, as no one in the real world would make this call). What you really want to do is call the HRSA Program Officer with the request and, if necessary, follow-up with a Freedom of Information Act (FOIA) request. Keep in mind that FOIA requests can take a long time, so it is best to plan your ambush well in advance.

* For more on the “collaborative” aspects of HRSA FOAs, see “Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?.”

** See also The Real World and the Proposal World.

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$700,000,000 in the Affordable Care Act Capital Development Fund: Building Capacity and Immediate Facility Improvements Programs — See, I Told You The Feds Weren’t Broke

HRSA just issued two Funding Opportunity Announcements (“FOAs”) for the Affordable Care Act Capital Development: Building Capacity Grant Program and the Affordable Care Act Capital Development: Immediate Facility Improvements Program”. The first program has $600,000,000 available and the second has $100,000,000. These are significant grant opportunities for existing Section 330 grantees, which include Community Health Centers (CHCs), Migrant Health Center (MHCs), Health Care for the Homeless (HCHs), and Public Housing Primary Cares (PHPCs) providers.

If your agency is a Section 330 provider, you should definitely apply for one or both programs, which will fund facility improvements—an otherwise difficult project concept. Even if your organization is not eligible, you should take heart because it means there are many grant opportunities out there as long as you go fishing for grants. Also, the funding authorization for these two HRSA gems is in the Affordable Care Act (“Obama Care”), and no further congressional budget action is needed. As I’ve blogged about before, there are approximately 50 discretionary grant programs funded in the Affordable Care Act, which will continue to become available in coming months. In most case, the applicants do not have to be Section 330 providers.

Ever since the Great Recession hit, I’ve had to remind readers that the Federal government continues to make billions of dollars in competitive grant funds available across thousands of discretionary grant programs. When you’re right, you’re right, and I’m right.

If you are a Section 330 provider, keep in mind that HRSA uses a two-step application process involving a fairly simple initial application submitted through our old friend Grants.gov. In this case the initial application is due October 12. The second, much more complicated application is submitted through a HRSA portal called Electronic Handbooks (EHBs). The EHBs deadline for these two programs is November 22, which is a thoughtful two days before the Thanksgiving holiday. Of course, HRSA won’t actually let you see the EHBs application kit until the Grants.gov application is submitted, adding needless complexity to an already complex process.

Writing a HRSA proposal is not a good idea for a novice grant writer or the faint of heart. But we’ve written many funded Section 330 and other HRSA proposals and know the arcana of the HRSA pack of tarot cards well. We’re tanned and fit from a summer of boogie boarding and bike riding in Surf City and ready to write.

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January Links: Health Care, the Affordable Care Act Teaching Health Center, the Maternal and Child Health Pipeline Training Program, and more

* Isaac was interviewed on Nonprofit Spark Radio.

* As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years: “A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.” Limited access to care health care is already here—not because of insurance, per se, but because many people on Medicare/Medicaid simply can’t find providers who take either.

* As Grant Writing Confidential readers already know from reading “Be Nice to Your Program Officer: Reprogrammed / Unobligated Federal Funds Mean Christmas May Come Early and Often This Year,” unspent grant dollars tend to get spent. Politicians evidently don’t know that or don’t want to admit this, as evidenced in “Unspent Stimulus Tough to Retrieve” from the Wall Street Journal.

* The New York Times: “Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses.”

* Strapped Cities Hit Nonprofits With Fees.

* The [Unjust] war against cameras:

Police across the country are using decades-old wiretapping statutes that did not anticipate iPhones or Droids, combined with broadly written laws against obstructing or interfering with law enforcement, to arrest people who point microphones or video cameras at them. Even in the wake of gross injustices, state legislatures have largely neglected the issue.

* Modern Parenting: If we try to engineer perfect children, will they grow up to be unbearable? Fortunately, I do not believe this was a problem for me growing up.

* You should blog even if you have no readers.

* Eminent domain now effectively has no limits, and that’s definitely a bad thing.

* A study confirms every suspicion you ever had about high-school dating.

* The last time the Maternal and Child Health Pipeline Training Program appeared in the Seliger Funding Report was 2005. Unless we managed to miss a year, it’s been a while since we’ve seen this program.

* The challenge to German liberalism, which may have its lessons for the United States as well.

* The Problem of Measurement in evaluating teachers, with these problems still being better than no measurement at all, which currently exists.

* A hacker’s guide to tea. This is really worth reading—who knew that “Tea contains L-theanine, an amino acid that promotes mental acuity. The combination of L-theanine and caffeine creates a sense of ‘mindful awareness.’ ”

* Apparently, the Nissan Leaf is pretty good.

* Touching Your Junk: An Ontological Complaint.

* To mildly alleviate the doctor shortage mentioned above, HRSA released the Affordable Care Act Teaching Health Center Graduate Medical Education Payment Program. But there’s something unusual about this RFP: HRSA says $230,000,000 is available for 10 awards of up to $900,000 each. We sent out this caveat in the Seliger Funding Report:

Note that the bizarre numbers in the amount ($230M), number available, and max grant size are HRSA’s (10 x $900,000 = $9M; where are the other $221M?).

* This is not good but, regardless of whether it’s good, may simply be the new state of things: “In essence, we have seen the rise of a large class of “zero marginal product workers,” to coin a term. Their productivity may not be literally zero, but it is lower than the cost of training, employing, and insuring them.”

* Not Really ‘Made in China’: The iPhone’s Complex Supply Chain Highlights Problems With Trade Statistics. The short version: beware trade statistics, especially those related to manufacturing.

* The Future of China? Look at Mexico.

* Department Of Education Study Finds Teaching These Little Shits No Longer Worth It.

* Close the Washington Monument.

* Shortage of Engineers or a Glut: No Simple Answer.

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Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?

HRSA just issued a Funding Opportunity Announcement (FOA, which is HRSA-speak for RFP) for the Service Area Competition (SAC). SAC FOAs are issued each year for different cities and rural areas in which HRSA has existing section 330 grantees, including Community Health Centers (CHCs), Migrant Health Center (MHCs), Health Care for the Homeless (HCHs), and Public Housing Primary Cares (PHPCs). Without going too far inside baseball, as section 330 grantee contracts expire, HRSA groups them together and forces them to reapply while encouraging other organizations to complete for the contracts. Hence the word “competition” in SAC.

SAC applicants are required to respond to a section of the FOA called “Collaboration” by describing “both formal and informal collaboration and coordination of services with other health care providers, specifically existing section 330 grantees, FQHC Look-Alikes, rural health clinics, critical access hospitals and other federally-supported grantees.” I’m guessing that if your organization is applying to take the contract away from the current Section 330 grantee, that grantee is probably not going to be in much of a mood to collaborate with your application and give you a letter of support.

To put a requirement for “collaboration” in a FOA that uses the term “competition” in its title demonstrates HRSA’s cluelessness. A particularly fun aspect of the SAC FOA is that HRSA pats itself on the back by stating in the Executive Summary that “For FY 2011, the HRSA has revised the SAC application in order to streamline and clarify [emphasis added] the application instructions.” The instructions are 112 single-spaced pages and the response is limited to 150 pages! And there a two-step application process involving an initial application submitted through our old friend Grants.gov, as well as a second application with a second deadline through a HRSA portal called Electronic Handbooks (EHBs). That’s what I call streamlining and clarifying. I would hate to see the results if HRSA tried to complicate and obscure the application process.

HRSA has another FOA process underway for the New Access Points (NAP) program, which I recently wrote about in “The Health Resources and Services Administration (HRSA) Finally Issues a New Access Points (NAP) FOA: $250,000,000 and 350 Grants! (Plus Some Important History).” A quick search of the FOAs reveal that the term “collaboration” is used at least 32 times in the NAP FOA, compared to 8 times in the SAC FOA. I suppose collaboration is four times as important in writing a NAP proposal that in writing a SAC proposal. For those with inquiring minds, the word “competition” is not used at all in the NAP FOA. As far as I can tell, HRSA does not let NAP applicants know that, if they are successful, they will eventually have to compete to keep their contract, while simultaneously committing to collaborating with their competitors. Since I have written many NAP and SAC proposals, I know how to thread this word needle by writing out of both sides of my Mac. But novice grant writers and new HRSA applicants will find this a challenge.

For more of my reasoning on the essential pointlessness of requiring grant applicants to profess their undying commitment to collaboration, see “What Exactly Is the Point of Collaboration in Grant Proposals? The Department of Labor Community-Based Job Training (CBJT) Program is a Case in Point.”

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The Health Resources and Services Administration (HRSA) Finally Issues a New Access Points (NAP) FOA: $250,000,000 and 350 Grants! (Plus Some Important History)

The Health Resources and Services Administration (HRSA) just issued a Funding Opportunity Announcement (FOA, which is HRSA-speak for RFP) for the New Access Points (NAP) program. There is $250,000,000 available and 350 grants up to $650/000/year for five years! The deadline is November 17. This the first NAP FOA in over three years, and the NAP program is the best way to fund primary health care and prevention for medically indigent folks. In other words, this is a great opportunity. The real question is, where has the NAP program been for the last three years?

I have no idea why HRSA has not issued any NAP FOAs lately, but it may have something to do with the change in administrations and the extended health care reform debate. The NAP program was greatly expanded during the Bush administration, and HRSA issued NAP FOAs frequently during the early and mid years of the decade. We wrote many funded NAP grants and became very familiar with the program in the process. Then funding for NAP was either not included in HRSA appropriations or HRSA slowed down the grant making process, causing NAP to disappear beneath the waves a year or so before President Obama assumed office. But NAP funding was included in the recently passed Health Reform Act of 2010. This Act authorizes dozens of new competitive federal grant programs, as well as some old friends like NAP, and voila, HRSA issues this enormous FOA, so it seems that the NAP program is once again in favor.

For those not in the know, to be eligible for a NAP grant, the applicant has to be, or agree to set-up, a nonprofit “Health Center” under Section 330 of the Public Health Service Act (42 USCS § 254b), or, as they are termed in the trade, a Section 330 provider. Older terms that are sometimes used, like Federal Qualified Health Centers (FQHC) or FQHC Look-Alikes. Without getting too far inside baseball, the intent of such health centers is to provide access to patients who are eligible for public insurance programs, such as Medicaid, Medicare and SCHIP, or have no insurance. Although services are nominally provided on a sliding scale and no one is supposed to be turned away, Section 330 providers have to keep the doors open and, like all health care providers, they prefer patients with third party payers.

The entire Section 330/FQHC/FQHC Look-Alike system grew up to replace the chaotic but never dull “free clinic” model of the late 1960s and 1970s, which was pioneered to serve assorted hippies, druggies, runaways and other youth by the Haight Ashbury Free Clinic and LA Free Clinic. When I moved to LA in 1974, I almost went to work for the LA Free Clinic’s founding Executive Director, Lenny Somberg, who was a very interesting guy but was unfortunately killed by an intruder a few months after I met him.

While I didn’t get the job, I eventually volunteered and served on the board of the Harbor Free Clinic in San Pedro*, another one of the original free clinics. The basic idea of free clinics was to use volunteer docs and allied health professionals to provide free health care while not accepting Medicaid or any other insurance. Although some organizations retain “Free Clinic” in their name, I don’t think any still use this model, having shifted long ago to some version of the Section 330/FQHC paradigm—in other words, they are primarily Medicaid/Medicare providers and use paid medical staff.

These days, if an organization wants to provide primary health care for the uninsured, publicly insured or underinsured, they become a Section 330 provider, and a NAP grant is the organization’s ticket into the Medicaid reimbursement world. This is the first opportunity to compete for a NAP grant in three years, so start writing f you’re eligible. Who knows when the next NAP FOA will pop up in the federal trough?

*Pronounced “Peedro” by residents, not “Paydro,” and often affectionately termed, “The city where the sewer meets the sea.” I lived in Pedro for a few years and can attest to its many charms. Among other things, Pedro often turns up as a locale in movies and TV, including the most recent episode of my favorite TV show, Mad Men, “The Good News.”