An increasing number of U.S. states are implementing or considering alternative policies to the prohibition of some psychedelic substances for nonclinical purposes. The authors present new data and analysis to inform these discussions with survey results on the use of 11 psychedelic substances and detailed information about the prevalence of microdosing (i.e., taking a fraction of a full dose, often on a schedule) for psilocybin, LSD, and MDMA.
In this study, part of RAND's Gun Policy in America initiative, researchers systematically review the scientific literature that has examined the likely effects of various gun laws. In the fifth edition of this study, the authors incorporate more-recent research in their synthesis of the available scientific data regarding the effects of 18 state firearm policies on firearm injuries and deaths, violent crime, suicides, the gun industry, defensive gun use, and other outcomes. By highlighting where scientific evidence is accumulating, the authors hope to build consensus around a shared set of facts that have been established through a transparent, nonpartisan, and impartial review process. In so doing, they also illuminate areas in which more and better information could make important contributions to establishing fair and effective gun policies.
Although progress in biological sciences and technologies will offer more opportunities to improve human well-being in the coming decades, this progress may also lower barriers that are blocking bad actors from engineering pathogens to cause destruction. In severe cases, the harms of future biological attacks may approach the magnitudes of the worst plagues of history-from the devastation wrought by the Black Death to the epidemics that decimated Mesoamerican societies after initial European contact. In this study, the authors offer initial frameworks for thinking about how the United States could achieve resilience against three biological threat scenarios: (1) a fast scenario, challenging countermeasures with a rapidly spreading outbreak of a lethal human-to-human-transmissible pathogen; (2) a silent scenario, challenging detection with a pathogen that infects much of the population before infected people display visible symptoms; and (3) a saturating scenario, challenging countermeasures involving a pathogen that replicates and persists in the environment. The authors recommend actions that governments and civil society can take to work toward resilience, including more in-depth research to better understand these scenarios and possible defenses.
Concerns that artificial intelligence (AI) might enable pathogen design are increasing, but risks and timelines remain unclear. In this study, the authors present findings from a Delphi study designed to assess the near-term limits of AI-enabled biological design (AIxBio). Rather than forecasting specific risks, the authors' central objective was to identify which biological and AI-related constraints might serve as hard or persistent barriers to this specific misuse. To do so, they conducted two parallel Delphi elicitations, engaging experts in biology and AI to independently and comparatively evaluate the limits that each field faces. The authors asked participants in the study to assess the validity and applicability of a set of proposed constraints within the near-term future (from 2025 to 2027). The constraints included biological trade-offs, such as transmissibility and environmental stability, and technical challenges in data availability and AI model generalization. The overarching goal of this study is to inform policy and risk analysis by clarifying which scenarios fall outside the plausible envelope of near-future capabilities and which will remain impossible indefinitely. By focusing on what might be impossible or unlikely, this research can help refine the scope of biosecurity planning and improve the signal-to-noise ratio in discussions about AIxBio.
This study documents the second phase of a project undertaken by the Australian Dental Council (ADC) to develop a framework for understanding and evaluating the impact of its dental education program-accreditation activities. This research builds on a first phase in which an impact framework, as well as a logic model undergirding it, were developed. The second phase captures and elevates key stakeholders' perspectives around the ADC's accreditation activities and proposed logic model for generating impact in greater detail. The applicability of the ADC's impact mechanisms, specified in the first research phase, is also examined. The authors developed recommendations for how these impact mechanisms can be leveraged in light of stakeholder perceptions and feedback so that the ADC can improve its impact according to its strategic and accreditation objectives that are aligned with public health outcomes.
Since fall 2021, RAND researchers have conducted ongoing enumerations and surveys of people experiencing unsheltered homelessness in three Los Angeles, California, neighborhoods: Hollywood, Skid Row, and Venice. These data were obtained to provide policymakers with a deeper understanding of trends in the number of, demographics of, and services being provided to unsheltered people in areas known to be epicenters of the homelessness crisis in Los Angeles. The most recent full year of results from the ongoing Los Angeles Longitudinal Enumeration and Demographic Survey (LA LEADS) study revealed a meaningfully different picture of unsheltered homelessness in 2024 compared with past years. The number of unsheltered people declined, likely driven by increased throughput to interim and permanent housing assets. However, multiple measures of acuity among people remaining on the street appear worse, suggesting that extending the past year's progress may require additional strategies.
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.
Medicaid and the Children's Health Insurance Program together provide health insurance for 78.6 million low-income Americans, including 37.3 million children. This study describes inpatient utilization at select U.S. children's hospitals by Medicaid-insured patients. Legislation passed in July 2025 changed Medicaid eligibility requirements. For this study, RAND researchers processed hospital cost report data for policymakers to analyze.
Evidence-based practices (EBPs) integrate clinical experience, recipient preferences, and the best available research evidence into best practices for health and human services. The use of EBPs plays an important role in delivering high-quality substance use services that improve youth outcomes. Yet there are many challenges to EBP implementation. During a March 2025 roundtable that was hosted at the Joint Meeting on Youth Prevention, Treatment, and Recovery national conference, policy actors with key roles in supporting state service systems discussed how to support the implementation of EBPs for youth substance use equitably and at scale. State service systems include a network of community-based prevention, treatment, and recovery programs for youth substance use that are primarily supported by public funds. Main topics of discussion included the role of federal and state policymakers in supporting the use of EBPs, opportunities and challenges in implementing and sustaining EBPs, and opportunities for partnerships to encourage the use of EBPs. Given the complexity of the topic, partnerships were viewed as key to successful progress in achieving policy action that supports EBP use. These proceedings should be of interest to federal, state, and local policymakers and other related groups, such as policy advocates, youth and their caregivers, and other individuals who are interested in improving the quality of substance use services.
Prescriptions made for GLP-1 agonists under various brand names (e.g., Ozempic, Wegovy) have more than tripled since 2020. However, research on their use and their side effects at the population level is in its infancy. This study presents descriptive findings from a 2025 survey fielded to a nationally representative sample of U.S. adults as part of RAND's American Life Panel that show prevalence rates of GLP-1 agonist use and side effects.
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.
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.
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 article summarizes the Workshop on Assessing Cumulative Benefits of Disease-Modifying Therapies (DMTs) Targeting Synucleinopathies, which was held in New York, N.Y., on November 18 and 19, 2024. This event was hosted by a coalition of nonprofit organizations and brought together representatives from academia, industry, and patient advocacy communities to discuss the cumulative, meaningful benefits of DMTs for synucleinopathies; to identify priorities for the field; and to explore opportunities for collaboration. Synucleinopathies, including Parkinson's disease, dementia with Lewy bodies, and multiple system atrophy, are neurodegenerative conditions that share underlying pathobiology and have many clinical similarities, including difficulties with movement, changes in cognition, sleep disturbances, and autonomic symptoms. Although there are some available symptomatic treatments for synucleinopathies, DMTs-medications that address the underlying biological processes of illness-are currently under development and might obtain regulatory approval in the near future. However, many other factors contribute to whether patients will have access to these novel therapies. Governments, private payers, clinicians, medical professional specialty societies, patients, and care partners think about meaningful benefits differently from regulators, who focus on safety and efficacy. The workshop attendees discussed these factors and considered next steps for understanding the benefits of DMTs for synucleinopathies.
Psychiatric advance directives (PADs) allow individuals with mental health conditions to document preferences for care that they might not otherwise be able to communicate during a crisis. Over the past several years, seven California counties have been collaborating on a Mental Health Services Act Innovation Project intended to increase the availability and uptake of PADs among persons with mental health needs, supported by peer worker outreach and facilitation. In this study, RAND researchers evaluate three aspects of the PADs Innovation Project pilot. First, they present findings from an assessment of post-training outcomes and experiences with real-world PAD facilitation, using surveys and interviews with peer workers. Second, they describe PAD creation rates and outcomes across the participating counties, using a combination of administrative metadata from the PAD platform, a brief user survey contained within the PAD platform, and a follow-up interview and survey with a subset of individuals who created a PAD. Third, they report the perspectives of county implementation staff, who provided overall reflections on the implementation of beta testing through interviews. Finally, the authors summarize their findings and provide a set of recommendations for future PAD implementation.
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.
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.
The authors present results and recommendations based on an evaluation of the impact of the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) on its goals of promoting screening for adverse childhood experiences (ACEs; for example, abuse and neglect) and trauma-informed health care (TIHC) for Medi-Cal beneficiaries. The authors found that UCAAN has had a major impact on the capacity of individual clinicians who treat Medi-Cal beneficiaries to provide TIHC, largely through the Becoming ACEs Aware (BAA) training program. The BAA course has trained and continues to train a significant proportion of Medi-Cal primary care clinicians, and the survey results indicate that the impact of the training on care and on patients is lasting. UCAAN's impact on system-level change has understandably been more gradual. There have been positive impacts, most clearly demonstrated by the fact that clinics have been reimbursed for providing ACE screening and response to more than 2 million Medi-Cal beneficiaries. However, Medi-Cal clinicians who have been trained to provide ACE screening and response indicate that they continue to face barriers to providing TIHC in the clinics in which they work. UCAAN is making important contributions to addressing these barriers. Most importantly, the pilot programs have made major contributions to knowledge of how ACE screening and response and TIHC more generally can be implemented throughout the health care system.
Psychiatric advance directives (PADs) offer individuals with psychiatric conditions the opportunity to document their preferences for treatment and interactions during a mental health crisis before that crisis occurs. In completing a PAD, individuals are encouraged to identify and document their preferences for medication management, setting of care, points of contact, a decisionmaking surrogate, and ways of interacting with emergency response and health care teams. Although PADs have grown in popularity and their legality has been increasingly recognized in international contexts and among individual U.S. states, evidence regarding their use is not well synthesized or documented. In this environmental scan, the authors take a broad approach that combines evidence from systematic reviews, primary empirical literature, and grey literature to better understand the state of the evidence regarding implementing PADs in community, inpatient, and outpatient contexts. The authors sought to identify the potential and realized benefits of PADs, the barriers to the adoption and implementation of PADs, and promising practices for PAD implementation. This study summarizes those findings and can help inform future efforts to develop and implement PADs. Overall, PADs are a promising tool to improve care for individuals with serious mental illness; however, implementation requires clear legal guidance and clinician buy-in to ensure the effectiveness of PADs.
Over the past decade, much has changed in the emergency care landscape in the United States. Hospital-based emergency departments (EDs) and the health care professionals who provide care in them have been at the forefront of responding to the opioid and gun violence epidemics and the coronavirus pandemic, with reported increases in patient acuity and complexity. During the same time frame, there have been unsustainable declines in payment for emergency care, putting the viability of EDs at risk. The authors (1) assess the current value of emergency care, (2) evaluate challenges to sustaining emergency care, (3) measure trends in emergency care payment, and (4) identify alternate funding strategies for emergency care. To achieve these objectives, they sought expert input in the form of a study advisory board and conducted interviews and focus groups, a survey, case studies, an environmental scan of peer-reviewed and gray literature, and analysis of administrative data. The authors find that EDs offer many types of value to various stakeholders in the United States but that, because of the stresses EDs have faced over the past decade, the viability of emergency care as we know it is at risk. The authors offer policy actions that need to be taken on multiple fronts to preserve emergency care.
