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Congress mandates that the Department of Defense (DoD) assess and monitor the health readiness of the armed forces. Accordingly, DoD implements a suite of health assessments to monitor service members' health readiness. One annual and four additional deployment-related health assessments screen for issues with physical and behavioral health at specified intervals throughout the deployment cycle to facilitate early intervention and any medical care required to maintain force readiness. The content of many of the items in these assessments overlap, and the required time frames for assessment completion can be very close to one another. In addition, administration of similar assessments can involve unnecessary monetary and other resource costs. The Office of the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute to evaluate DoD's suite of health readiness assessments against their stated objectives and identify potential opportunities for improvement, increased efficiencies, and cost savings. In this study, the authors review the policies behind these health assessments at both department and service branch levels and the assessments themselves for overlaps and gaps, comparing them with U.S. guidelines for health screenings and the use of similar health assessments among high-risk civilian professions. Drawing from this analysis and interviews with military stakeholders, they offer recommendations for improving the health assessments' efficiency and effectiveness.

High rates of mental health issues among service members and a reluctance to access mental health services together represent one of the greatest ongoing threats to U.S. military readiness. Concerns about the confidentiality of mental health services received within the military have been documented as a significant barrier to service members obtaining needed treatment. At times, disclosing mental health information to commanding officers may be necessary so that informed decisions can be made about duty assignments, needed accommodations, unit resources, or deployments. The challenge the U.S. military faces is how to optimally protect service members' confidentiality so that mental health services are sought and needs are not driven underground-while also ensuring the successful execution of the military mission. In this study, the authors examine the potential impact of existing U.S. military mental health confidentiality policies on service members seeking assistance for mental health issues. The authors conducted a multimethod investigation involving key-stakeholder interviews with military mental health providers, commanding officers, and enlisted service members and a survey of the active component regarding knowledge, understanding, and practices associated with mental health confidentiality policies. Findings shed light on the perceptions held by service members on the limits to mental health confidentiality and how policy implementation influences service members' decisions regarding mental health care. The authors recommend steps that the U.S. Department of Defense could take to improve military personnel's understanding of confidentiality policies, strengthen processes to ensure that policies are implemented as intended, and mitigate the consequences associated with the limited confidentiality afforded to mental health services within the military.

Federally Qualified Health Centers (FQHCs) are outpatient health centers that provide primary care and limited specialty-care services to nearly 30 million low-income patients. Prior to the coronavirus disease 2019 (COVID-19) pandemic, FQHCs rarely delivered audio-only or video telehealth visits. However, with both temporary and permanent policy changes to facilitate telehealth use at the state and federal levels, telehealth has become an important modality of care. In 2023, approximately 9 percent of FQHC visits in the United States and 20 percent of FQHC visits in California occurred via video or audio-only visits delivered into patients' homes. In this study, the authors summarize data on the use of in-person, audio-only, and video health visits during September 2022 to August 2024, a period that included the end of the COVID-19 public health emergency in May 2023 and beyond. These data were collected to evaluate the impact of the Connected Care Accelerator program, which is an effort launched by the California Health Care Foundation in July 2020 to support health centers in implementing telehealth for low-income patients in California. This study is the final in a series of studies that were published from 2021 to 2024.

In this study, the authors describe the evolution of the People's Republic of China's global health activities and related policies in Africa from the 1960s through the present and provide field case studies of two African nations-Sierra Leone and Kenya-that have received health aid from China. They then analyze China's use of global health support in Africa as a tool of soft power. The need to understand China's global health activities has intensified, given that Western, particularly U.S., foreign health aid policies are changing, prompting questions about whether China will shift its policies to strengthen its soft power in Africa and away from the decade-old Belt and Road Initiative's overarching Sino-centric trade focus. This analysis of China's health aid history, its current role in African health aid, and its recent reform called for by President Xi Jinping's Global Development Initiative is intended to help U.S. policymakers understand China's decisionmaking and implementation strategy for foreign aid. The analysis of the advantages and weaknesses of China's approaches can offer lessons to both donor countries and African countries that receive global health aid from China. The authors offer policy recommendations for the United States and for African countries.

The ACCESS pilot project - a farmworker health care access initiative - was developed to address toxic stress in farmworker communities and increase farmworker access to health care services through clinic and community connections. The authors present findings from farmworker leader trainings conducted by the ACCESS pilot project to understand leaders' preparedness for educational outreach in farmworker communities across California. They also present results from a farmworker community survey that explored health access in farmworker communities and the impact of the educational outreach intervention. The evaluation was conducted to inform local and statewide conversations on how to improve health and health access for farmworkers through programming and policy interventions. Farmworkers in California experience disproportionately high rates of uninsurance and typically live in rural areas that lack sufficient health resources. In a prior study, more than four out of five California farmworkers surveyed reported experiencing at least one Adverse Childhood Experience (ACE) in early childhood. ACEs are stressful or traumatic events, such as neglect, abuse, and household dysfunction, that can trigger a toxic stress response in the body, leading to poorer physical and mental health outcomes in adulthood. Results from the ACCESS pilot project evaluation demonstrate that a peer-to-peer outreach and education model can build the capacity of farmworker leaders to meaningfully engage their communities in learning about toxic stress and ways to mitigate its negative health outcomes. Insights from a farmworker community health survey reveal that these communities experience significant barriers to accessing affordable health care.

The Military Health System does not have enough military mental health providers to meet demand among active-duty service members, despite efforts in the U.S. Department of Defense (DoD) to leverage special pays to recruit and retain staff. Maintaining adequate military mental health care services is important for maintaining the readiness of the overall force. To expand its mental health workforce and stabilize its care delivery system, DoD needs cost-effective options for increasing the force size of military mental health providers in both the short and long terms. In this study, the authors used the RAND Dynamic Retention Model to simulate how changing retention bonuses for uniformed mental health providers increased active component retention and per capita personnel cost. Using these results, the authors determined the most cost-effective way to increase the force size of the uniformed mental health provider workforce; specifically, accessing more providers or retaining more providers. The authors also compared military compensation for psychiatrists, clinical psychologists, social workers, and mental health nurse practitioners with expected civilian compensation for these types of providers. DoD leaders and personnel managers can use the key findings and recommendations offered to make informed choices among potential strategies for expanding its uniformed mental health workforce.

This study presents West Virginia's rural health challenges-workforce shortages, chronic disease, infrastructure gaps, and access barriers-and describes a preliminary research agenda to guide improvements. The authors identify practical research priorities, highlight promising programs, and emphasize culturally responsive, community-engaged approaches to improve health outcomes in rural health services throughout the state.

In this study, the authors evaluate access to health care services for U.S. Coast Guard beneficiaries (active duty service members, reservists, retirees, and dependents). The authors highlight challenges in obtaining timely care within standards set by the Defense Health Agency (DHA). The authors' analysis of health care appointment and enrollment data, alongside feedback from key stakeholders, reveals that access issues are a significant concern that may affect medical readiness. The study identifies data gaps that hinder effective understanding and resolution of access challenges. The authors emphasize the need for collaboration between the Coast Guard and DHA to identify and address locations with low access to care and monitor ongoing access issues. Additionally, the authors recommend implementing a systematic survey to better gauge beneficiaries' experiences, creating enhanced internal capabilities for tracking access, and addressing barriers specific to reservists and retirees. These capabilities and more-complete data will allow the Coast Guard to systematically determine when it should provide more care to beneficiaries organically to safeguard mission readiness. Effective health care access is crucial for the medical readiness of service members. The Coast Guard is responsible for the care of dependents and retirees. The findings of this study should be of interest to Coast Guard leadership and policymakers aiming to efficiently direct resources to support readiness.

This study presents an evaluation of the University of Minnesota's BOLD Public Health Center of Excellence on Dementia Caregiving, which supports public health agencies in implementing dementia caregiving initiatives. The evaluation covers the Center's activities from 2021 to 2025, focusing on resources provided, usage by public health agencies, partnerships, equitable access, and agency capacity improvements.

Of the U.S. veterans enrolled with the Veterans Health Administration (VHA), 84 percent also have other sources of health care coverage. The author describes the most common other sources of coverage, why veterans may have multiple coverage options, and how other coverage interacts with VHA health care services. She discusses situations that may result in overpayments for coverage and presents future directions for research and policy options.

Concerns about the physical health, mental health, and safety of first responders and law enforcement officers have been increasing for some time. The goal of this research is to synthesize evidence from the growing literature on mental health and wellness programs studied with law enforcement and first responder populations to help the U.S. Department of Homeland Security (DHS) identify and strengthen programs and policies and to conduct an evaluability assessment (EA) to provide direction for future research. This study presents findings from multiple research tasks, including a review of domestic and international literature on first responder wellness programs and interviews with key stakeholders in DHS about existing DHS wellness programs, wellness program implementation, and subsequent challenges. Authors conducted an EA of programs identified as potentially ready for evaluation in the stakeholder interviews. The authors of this study synthesized the findings from these tasks to develop a research agenda for future DHS wellness research efforts.

This study demonstrates that Asia faces high risks for global health security (GHS). The risk is made greater because of uneven capacities to respond among different countries and fragmented public health networks beyond influenza response, further demonstrated by the impacts of the coronavirus disease 2019 (COVID-19) pandemic. The study provides a comprehensive review of the capacity and gaps in Asia's GHS networks and U.S. agencies' GHS efforts in the region. The study includes recommendations aimed at helping U.S. policymakers develop practical steps to reassert GHS leadership in Asia with a whole-of-government approach under the 2024 U.S. Global Health Security Strategy (GHSS).

It is anticipated that extreme weather events due to climate change will increase the prevalence of a number of acute and chronic diseases. As a result, the demand for drugs to prevent or treat those conditions is likely to increase. If the anticipated increase in demand for these drugs is not planned for, already strained medical supply chains will be further strained, resulting in poor health outcomes among affected patient populations and additional costs to health systems. The authors of this study estimated how the anticipated effects of climate change on the prevalence of a sample of four chronic conditions-cardiovascular disease (CVD), asthma, end-stage renal disease (ESRD), and Alzheimer's disease-will affect demand for the drugs needed to treat them (metoprolol, albuterol, heparin, and donepezil, respectively). To generate these estimates, the authors conducted an environmental scan of the peer-reviewed and gray literature and developed a medical condition-specific systems dynamics model. The model can help inform policies for ensuring drug supply under various climate scenarios.

The Army Combat Fitness Test (ACFT) became the U.S. Army's physical fitness test of record in October 2022. The test is substantially different from the previous test and consists of six events intended to measure a more expansive set of capabilities: muscular strength and endurance, power, speed, agility, aerobic endurance, balance, flexibility, coordination, and reaction time. One of the Army's stated goals for the test was to reduce preventable injuries. More than half of soldiers experienced a new injury in 2021, so success in reducing the risk of injury could have a significant impact on both medical costs and lost workdays. Because the ACFT has been administered for a relatively short period, there are limited data available to assess the relationship between the ACFT and soldier health and injuries. Nevertheless, this research effort used available data to gain initial insights into this relationship. This study was part of RAND's independent assessment of the ACFT, focusing specifically on injury risk. To the extent that broader, more-holistic training is motivated by the more-expansive physical requirements of the ACFT, the literature suggests that the ACFT could in the long term lead to an overall reduction in injury rates. Many of the authors' recommendations focus on potential ACFT policy actions that the Army could take to help reduce preventable injuries and assess and monitor soldiers at risk.

Federal spending on evidence-based practices (EBPs) provides significant returns by offsetting billions of dollars in societal impacts each year. Practices are deemed evidence-based because they have demonstrated their effectiveness in addressing various social and health-related challenges. Federal agencies often invest in EBP delivery through discretionary grants, but there is limited guidance on how to optimize these grants to support large-scale EBP implementation. To address this gap, the authors held focus groups with federal and state agency officials (using the findings from ongoing RAND research to frame their discussions) to gather and synthesize their recommendations on how to optimize federal grantmaking for EBP implementation. With the focus group participants, the authors identified seven policy recommendations for federal officials to consider when designing, awarding, and executing grants for EBP implementation, including capacity-building in service delivery organizations to sustain EBPs after grant funding ends. The authors also present real-world case examples to illustrate how funding agencies have put each recommendation into practice.

Nearly 14.5 million individuals are enrolled in California's Medicaid program, better known as "Medi-Cal." Medi-Cal enrollees receive their primary care from both Federally Qualified Health Centers (FQHCs) and non-FQHC clinics and providers. However, not much is known about the extent to which subgroups of Medi-Cal enrollees use these different providers. Developing a better understanding of where different subgroups of Medi-Cal enrollees receive their primary care could inform efforts to improve support for primary care providers and the patients they serve. Using Medi-Cal data from 2022, RAND researchers identified and described the types of providers delivering primary care to Medi-Cal enrollees overall and by select patient characteristics, including race or ethnicity, age, geography, and levels of English-language proficiency. With these data, they were able to (1) identify the providers delivering primary care services to enrollees in FQHC and non-FQHC settings, (2) pinpoint key characteristics about these providers, (3) examine what percentage of providers deliver a high proportion of primary care visits to Medi-Cal enrollees, and (4) determine whether this percentage varies by Medi-Cal enrollee group and county.

Policymakers in Connecticut have used state funding to expand eligibility for HUSKY, Connecticut's Medicaid and Children's Health Insurance Program (CHIP), to children (through age 15) and to pregnant people who do not qualify for federally funded Medicaid or CHIP coverage because of their immigration status. Policymakers are considering further expansions of eligibility for HUSKY for the remaining population of children and adults. In addition to expansions of HUSKY A (Medicaid for children, parents or caregivers, and pregnant people), HUSKY B (CHIP), and HUSKY D (Medicaid for adults without minor children), policymakers are also considering expanding eligibility for HUSKY C, the program for residents who are ages 65 and older, blind, or disabled, to immigrants. In this study, the authors use microsimulation modeling to estimate the effects of expanding HUSKY eligibility to additional groups by age and eligibility category.

Over the past decade, there has been increased awareness that U.S. military veterans often grapple with significant mental and physical health issues related to their service. In response, many policies and programs have been put in place to support veterans and improve their access to needed services. Despite these efforts, prevalence rates for physical and mental health problems and concerns about the health and overall well-being of veterans remain high. Because the specific needs of veterans and the barriers to accessing care likely differ across areas, data at the state level are critical for tailoring policies and programs to make them more effective. This study focuses on veterans in New York, specifically individuals discharged or separated from the military between January 2018 and January 2023. The authors analyzed responses from 1,122 veterans to a survey designed to assess the mental and physical health of this cohort of veterans and their access to, and experiences with, health care and other veteran services. The findings of this study will be of particular interest to policymakers, veterans' advocacy groups, and health care providers who are involved in the design and delivery of services for veterans. Additionally, researchers and academics focusing on social and economic well-being, public health, and veteran affairs will find the data and conclusions useful for further studies.

The authors evaluated Phase II of the No More Adverse Childhood Experiences (NACES) pilot project that aimed to improve farmworker health and health access by increasing knowledge about Adverse Childhood Experiences (ACEs) and toxic stress among farmworkers and providing support to community health clinics that address ACEs in these rural communities. ACEs are traumatic or stressful events that occur in childhood and can negatively impact long-term mental and physical well-being and disproportionately affects low-income populations. More than 60 percent of Californians have experienced at least one ACE in their lifetime, and prior research found that as many as 87 percent of California farmworkers reported experiencing one ACE. In 2023, the California Department of Health Care Services (DHCS) funded the Futures Without Violence National Health Initiative on Violence and Trauma to implement the NACES Phase I pilot project to develop community- and clinic-based approaches to address ACEs in farmworker communities. RAND evaluated the clinic-based implementation of NACES Phase I and found early evidence for the feasibility and acceptability of an ACE education, screening and response model that is informed by farmworker voices. This phase of the project refined the training approach developed in Phase I and tested it in two additional clinic sites while adding a virtual clinical training option that is more accessible to clinicians across the state. Results from the NACES Phase II evaluation support Phase I findings on the feasibility and potential for the positive impact of an ACE education, screening, and response model informed by farmworkers.