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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 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.

In January 2020, Medi-Cal began reimbursing clinics for screening for and responding to adverse childhood experiences (ACEs) as part of an effort to promote trauma-informed health care (TIHC). Since that time, ACE screening and response has grown rapidly, but unevenly, across primary care clinics across the state. In this evaluation, the authors examine factors that have contributed to variation in ACE screening rates across clinics that serve Medi-Cal beneficiaries. By improving understanding of the reasons clinics differ in screening practices, the authors aim to help tailor and target efforts to promote continued growth in TIHC. This evaluation had two interrelated components. First, the authors used Medi-Cal claims data on screening-related reimbursements to identify groups of clinics with different screening trajectories. Second, they conducted qualitative interviews with clinic representatives in each of those trajectory groups about the factors that influenced their screening practices. Clinics were selected to ensure diversity with respect to region of the state, rural versus non-rural locations, Federally Qualified Health Centers (FQHCs) versus private clinics, and clinics with versus without pediatric providers. Screening was found to vary based on clinic location and the presence of a pediatric provider. Common barriers to screening included lack of awareness and concerns about the availability of referral resources. The authors make recommendations, based on their findings, for actions that address barriers to screening and TIHC for pediatric and adult primary care clinics serving Medi-Cal beneficiaries.

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.

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.

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.

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.

Preventing veteran suicide is a national priority for government, veteran advocacy groups, and the private sector. This attention has led many individuals and organizations to leverage their expertise to create, expand, or promote activities that they hope will prevent future deaths. While the number and array of diverse approaches reflect a nation committed to a common goal, they also can create confusion. Advances in technology also generate questions about the future of veteran suicide prevention. In this study, the authors analyze current and emerging activities to prevent veteran suicide. They introduce the RAND Suicide Prevention Activity Matrix, a framework that organizes current approaches, how they complement each other, how they might change, their evidence for preventing veteran suicide, and why they might (or might not) work. This framework places 26 categories of activities in a matrix based on whom the activity targets (the veteran directly, those who regularly interact with the veteran, or social influences) and what the activity is intended to accomplish (address social conditions, promote general well-being, address mental health symptoms, provide mental health supports, and prevent suicide crises). Entities committed to preventing veteran suicide and seeking to design evidence-informed, comprehensive suicide prevention strategies will benefit from the framework and evidence reviewed in this study, in addition to the recommendations the authors developed from these data.

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.