The increasing integration of health information technology (health IT) into the U.S. healthcare system has brought both opportunities for improvement and new vulnerabilities. The 2024-2030 Federal Health IT Strategic Plan emphasizes equitable data access, quality representative data, and the responsible use of artificial intelligence (AI) to improve health outcomes. Yet, the growing complexity of digital infrastructures has amplified risks related to privacy and the security of protected health information (PHI). This study examines U.S. health system vulnerabilities by analyzing reported PHI breaches and situating them within evolving federal health IT priorities. This mixed-methods descriptive study combines quantitative analysis of the U.S. Department of Health and Human ServiCE's (HHS) Breach Portal data (2013-2023) with a qualitative review of federal policy and regulatory developments related to health IT. Breaches of PHI affecting more than 500 individuals were included, consistent with HHS reporting requirements. Duplicate and incomplete entries were removed. Breaches were categorized by cause and type. Quantitative results describe frequencies, proportions, and trends, while qualitative analysis of policy documents and breach narratives contextualizes these findings within the broader framework of digital health governance. From 2013 to 2023, the total number of reported PHI breaches and the share attributed to hacking and IT incidents increased markedly, while those involving theft, loss, or improper disposal declined. Healthcare providers accounted for most reported breaches, followed by business associates and health plans. Despite advances in interoperability and automation, the healthcare sector remains disproportionately affected by cybersecurity incidents. The qualitative analysis reveals persistent gaps between federal strategic goals and the practical implementation of privacy and security safeguards across healthcare. This study underscores the paradox of digital transformation: while health IT adoption improves efficiency, coordination, and data sharing, it simultaneously exposes the healthcare system to new risks. Strengthening system resilience requires harmonized governance, continuous monitoring, and greater investment in digital literacy. As AI use and automation expand, policy reforms must ensure that innovation does not compromise patient privacy or deepen inequities. These findings contribute to a better understanding of health system vulnerabilities and offer insights for enhancing the security and resilience of the U.S. health system.

Since the 1996 passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), states have taken different approaches to noncitizen health coverage. California and Illinois used state funds to expand access, driven by policy innovation and advocacy coalitions, while Texas and Georgia maintained restrictive policies that reflected conservative politics and fiscal concerns. This study used the policy diffusion and policy context frameworks to analyze PRWORA's influence on state decisions about immigrant health coverage. By examining the policy trajectories of California, Illinois, Texas, and Georgia, the authors highlighted the growing fragmentation in immigrant health coverage. The study reviewed trends in health insurance and Medicaid enrollment among noncitizens from 2008 to 2023 using data from the American Community Survey and a RAND cost estimation tool. California and Illinois showed greater improvements in insurance coverage and Medicaid enrollment, while Texas and Georgia had lower gains. The authors found that restrictive policies led to higher uninsured rates and different trade-offs in terms of cost and potential enrollment of noncitizens into Medicaid. Future policy developments will likely be influenced by federal policy changes, demographic shifts, and advocacy efforts. Understanding these dynamics is important for addressing disparities in immigrant health care access and for informing policy debates.

While psychologists possess unique and valuable skills that can contribute to leadership within academic health centers (AHCs), there are common barriers within these institutions that impede psychologists' engagement in leadership. As a result, significant educational efforts and challenges to entrenched norms are often required to advocate for the field of psychology, particularly when working outside of centralized psychology departments. In the following article, four psychologist colleagues working in a centralized department of psychiatry at a single AHC share their recent experiences facing barriers to leadership roles. The authors describe the impact of historical context on the challenges they face, as well as the actions they have taken to support the advancement of psychologists. These actions include leveraging interdisciplinary support, learning from other fields, and developing a curriculum to enhance financial and business acumen in psychology trainees. The authors also review the importance of staying informed about state and federal policy changes that impact healthcare systems, so that psychologists can help lead in responding to these changes in value-consistent ways. By advocating for the unique contributions psychologists offer and addressing the structural barriers in many AHCs, psychologists can more effectively navigate and shape leadership pathways.

How State Factors Moderated the Impacts of the 2021 Child Tax Credit on Mental Health and Financial Hardship.

Retirement, retention, recruitment: Evidence from a federal pension policy

Since President Richard Nixon's 1971 declaration of a “war on drugs,” federal drug policy has been built around a patchwork of institutions that have remained relatively stable despite massive changes in the drug market and drug-related harms, changing cultural norms, and structural changes in social and economic policies. Paradoxically, the authors argue that this apparent stability arises from a lack of consensus about the nature of drug use and addiction in both elite and public opinion (ideological fragmentation), leaving a modest consensus around law enforcement and, to a lesser extent, public health programs. Drug-related issues have spread into other domains of policy such as child welfare, immigration, food assistance, and general health care, where there is often vigorous contestation around the diverging goals of programs and services (policy sprawl). Support for programs and policies has also devolved to state and local governments. An unraveling of the Nixonian consensus may be underway, however, accelerated by diminished confidence in public health programs and looming cuts to federal funding for drug treatment and prevention programs. Future directions remain uncertain, but the immediate outlook suggests a retreat toward more individualistic and market-driven approaches.

EMTALA Turns 40: How Federal Enforcement and Policy Shifts Are Reshaping Air Medical Transports

U.S. states opting out of expanded methadone take-home policies and associated mortality.

Patients with limited English proficiency (LEP) experience more challenges with clinician communication than English-proficient patients. U.S. federal policies require the provision of language services, but little is known about language service availability in adult primary care practices nationally. To identify primary care physician practice capabilities associated with the routine availability of language services for patients with LEP. Nationally representative physician practice survey data from the National Survey of Healthcare Organizations and Systems were linked to IQVIA OneKey data and the American Community Survey (n = 1226). Multivariable logistic regression models were estimated to assess the association of practice characteristics with availability of language services. Whether a practice "always" provides professional language services. Fifty-four percent of U.S. primary care practices always provide language services. In adjusted analyses, practices participating in an ACO (odds ratio (OR) = 2.21, p < 0.01), owned by a healthcare system or hospital (OR = 6.0, p < 0.01), or with FQHC status (OR = 3.10, p < 0.01) were more likely to provide language services than non-ACO, non-FQHC, or independently owned practices. Practices with relatively high revenue from commercial health insurance (OR= 0.76, p < 0.01) were less likely to provide language services, whereas practices with relatively high Medicaid revenue (OR =1.33, p< 0.01) were more likely. Even though it is required by law, almost half of U.S. primary care practices do not always provide language services to patients with LEP. Independently owned practices are less likely to offer language services than those owned by healthcare systems or hospitals, or practices with FQHC status, suggesting practice ownership can influence availability. ACO participation and a higher payer mix of Medicaid revenue are associated with language services availability, highlighting that policy reforms can support the routine provision of language services at the practice-level.

In the United States, immigrants who lack legal immigration status are at risk of being uninsured because they are not eligible for federally subsidized health insurance. Although affordable primary care is available to this population at federally qualified health centers, outpatient specialty care remains unaffordable. The Access Partnership (TAP) began in 2009 at the Johns Hopkins Health System to provide outpatient care access to individuals with financial need who are ineligible for subsidized health insurance. Spanish-English bilingual navigators, located at community-based clinics, help patients with TAP applications and scheduling appointments. Specialty referrals are reviewed for medical necessity. When the Johns Hopkins Health System financial assistance policy was revised in 2020 to remove noncitizen exclusions, TAP eligibility was revised (TAP-FA). From January 1, 2020, to March 31, 2024, 6,053 patients enrolled in TAP-FA. The majority were at least 18 years old (5,209; 86.1%), of Latino ethnicity (5,133; 84.8%), and Spanish speaking (5,422; 89.6%). TAP-FA facilitated 39,061 outpatient appointments: 7,612 (19.5%) for hospital-based primary care, 18,752 (48.0%) for specialty care, and 12,697 (32.5%) for radiology. The most common adult specialty appointments were ophthalmology (n = 4,833), orthopedic surgery (n = 1,520), and cardiology (n = 1,472). Among children and adolescents, the most common specialty appointments were ophthalmology (n = 250), otorhinolaryngology (n = 84), and plastic surgery (n = 68). TAP-FA is an innovative charity care model operationalizing a financial assistance policy for individuals with financial need who are ineligible for subsidized insurance. In the absence of federal policies to expand access to care for immigrants in this population, academic medical centers have an opportunity to address this gap. The TAP-FA model provides a blueprint for the provision of inclusive and equitable care for patients without access to insurance and could be implemented at other academic medical centers.

US electric vehicle charging facilities are not keeping with demand even following the 5-billion federal investment in the program of the National Electric Vehicle Infrastructure and the Bipartisan Infrastructure Law. By mid 2025, there are only 57 charging stations across 15 states, in the rural regions the coverage is lower than 25 percent of what is required and out of every 5 chargers 1 fails because of mechanical difficulties or flaws in the equipment. The paper reviews the policy and regulatory loopholes that led to these failures based on a qualitative case study design that includes the analysis of federal and state policy documents, Government Accountability Office reports, Government Energy performance information and media coverage of January 2024 to October 2025. It is possible to identify three urgent issues identified in the analysis: allowing processes longer than one year to postpone the construction discourages private funding; lack of federal-state coordination leads to unspent funds and redundant effort; deployment serves the wealthy urban population most, and 94 percent of the rural counties do not have sufficient coverage of critical infrastructure, with low-income populations the most in need of community-provided charging. These delays are a result of inefficiencies in governance as opposed to technical constraints. This paper adds a Triple Vulnerability Framework that shows the interacting influence of environmental stress factors on institutions and social injustice as a determinant of infrastructure resilience. Among other suggestions, it indicates compulsory resilience auditing on federally funded projects, real time charger checking mechanisms, and documents financing structures to orient funds towards experiences that lack adequate services. These reforms are essential to enable the transition to electric vehicles to create equal transportation and energy disparities instead of bringing about equitable decarbonization.

This study evaluated the economic viability and resilience of anaerobic digestion (AD) systems on United States (U.S.) dairy, revealing substantial vulnerabilities to policy and market shocks. While optimal Renewable Natural Gas (RNG) systems demonstrated a 54.0% success probability and positive mean Net Present Value (NPV) ($392,000) under baseline volatility, their viability is catastrophically degraded by federal policy shocks, causing the success probability to plummet to 1.4%. Conversely, Combined Heat and Power (CHP) systems showed a lower baseline success rate (32.6%) and negative mean NPV ($−156,000) but exhibit more gradual vulnerability. These findings were derived from an integrated analytical framework combining deterministic optimization, Monte Carlo simulation, and a novel multidimensional resilience assessment. Deterministic analysis confirmed that revenue diversification is essential for viability, with optimal RNG and CHP configurations achieving breakeven at 655 and 1165 cows, respectively. Our novel Composite Resilience Index (CRI) revealed a counterintuitive finding: despite RNG’s superior baseline profitability, CHP systems achieve a higher overall resilience score (52.3 vs. 47.7) due to better stability and shock resistance. These results highlight the critical importance of incorporating uncertainty and resilience considerations beyond traditional NPV analysis for renewable energy investment decisions.

Academic institutions face increasing challenges in grant writing due to evolving federal and state policies that restrict the use of specific language. Manual review processes are labor-intensive and may delay submissions, highlighting the need for scalable, secure solutions that ensure compliance without compromising scientific integrity. This study aimed to develop a secure, artificial intelligence-powered tool that assists researchers in writing grants consistent with evolving state and federal policy requirements. GrantCheck (University of Massachusetts Chan Medical School) was built on a private Amazon Web Services virtual private cloud, integrating a rule-based natural language processing engine with large language models accessed via Amazon Bedrock. A hybrid pipeline detects flagged terms and generates alternative phrasing, with validation steps to prevent hallucinations. A secure web-based front end enables document upload and report retrieval. Usability was assessed using the System Usability Scale. GrantCheck achieved high performance in detecting and recommending alternatives for sensitive terms, with a precision of 1.00, recall of 0.73, and an F1-score of 0.84-outperforming general-purpose models including GPT-4o (OpenAI; F1=0.43), Deepseek R1 (High-Flyer; F1=0.40), Llama 3.1 (Meta AI; F1=0.27), Gemini 2.5 Flash (Google; F1=0.58), and even Gemini 2.5 Pro (Google; F1=0.72). Usability testing among 25 faculty and staff yielded a mean System Usability Scale score of 85.9 (SD 13.4), indicating high user satisfaction and strong workflow integration. GrantCheck demonstrates the feasibility of deploying institutionally hosted, artificial intelligence-driven systems to support compliant and researcher-friendly grant writing. Beyond administrative efficiency, such systems can indirectly safeguard public health research continuity by minimizing grant delays and funding losses caused by language-related policy changes. By maintaining compliance without suppressing scientific rigor or inclusivity, GrantCheck helps protect the pipeline of research that advances biomedical discovery, health equity, and patient outcomes. This capability is particularly relevant for proposals in sensitive domains-such as social determinants of health, behavioral medicine, and community-based research-that are most vulnerable to evolving policy restrictions. As a proof-of-concept development study, our implementation is tailored to one institution's policy environment and security infrastructure, and findings should be interpreted as preliminary rather than universally generalizable.

Cosmetic botulinum neurotoxin (BoNT) can be used to temporarily diminish facial wrinkles (1); however, injection for this purpose occasionally results in localized paralytic effects, even when BoNT that is approved by the Food and Drug Administration (FDA) and purchased from authorized sources is administered by licensed and trained medical professionals. Rarely, improperly procured or administered BoNT can lead to severe illness. During May-June 2025, hospital clinicians and health departments in New York, Texas, and Wisconsin each alerted CDC about a person in their jurisdiction who experienced severe illness after self-injecting cosmetic BoNT that was purchased online.* None of the three patients met their state's requirements for purchasing or administering BoNT; no link was reported among the patients. This report describes the patients' characteristics, treatment, and outcomes. This activity was reviewed by CDC, deemed not research, and conducted consistent with applicable federal law and CDC policy.†.

Research methodology This case was developed using secondary sources, including online news outlets, academic databases and academic textbooks. Case overview/synopsis In early 2025, amid sweeping federal policy changes under President Trump’s second term, Melanie Storey, the newly appointed President and Chief Executive of the National Association of student Financial Aid Administrators (NASFAA), faced a complex leadership challenge. The administration’s executive orders, including efforts to dismantle the U.S. Department of Education and transfer oversight of the $1.7 trillion student loan portfolio to the Small Business Administration, created uncertainty for millions of student loan borrowers and financial aid professionals. The resulting disruption, including widespread federal staff layoffs and technical failures in financial aid systems, intensified concerns about access to student loans and repayment options. As the leader of NASFAA, Storey had to navigate these turbulent changes while ensuring that her constituents had the guidance and resources needed to adapt. To succeed, she needed to apply change management principles to craft an effective multi-stakeholder communication strategy and highlight quick wins to maintain stakeholder confidence. This case challenges students to think strategically about how leaders can manage change amid uncertainty, engage stakeholders and build momentum for long-term solutions in a high-stakes policy environment. Complexity academic level This case is designed for upper-level undergraduate strategic communication students, particularly those in courses that dedicate time to leadership and change management communications. It should be taught after students have been introduced to concepts related to stakeholder theory and strategic communication planning so that they can integrate those foundational concepts in the activity and discussion.

School meals are a cornerstone of the United States’ nutrition safety net for children from low-income families, providing nearly 30 million lunches daily. However, recent U.S. policy actions may limit access to school meals for children who need them most. The One Big Beautiful Bill Act changed eligibility requirements to limit participation in the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. School-age children enrolled in SNAP and Medicaid are automatically enrolled in school meal programs. Limiting participation in SNAP and Medicaid has the potential to significantly impact children’s ability to receive nutritious school meals at low or no cost, will make it harder for schools to participate in community eligibility provision, and will increase the administrative burden on school staff and parents.

The 1974 Supreme Court decision Lau v. Nichols established a legal and moral foundation for linguistic equity in American public education. However, the legacy of Lau is still up for debate fifty years later. Through the entwined histories of bilingual education, federal enforcement, and ideological shift, this paper re-examines the ruling. It charts the evolution of dual-language immersion models from transitional bilingual programs, showing how local politics and federal policy have alternately increased and limited linguistic rights. The paper makes the case that Lau’s original vision has been altered by cycles of progress and backlash, reflecting larger conflicts between assimilation and pluralism, rights and resources, equity and gentrification. It does this by drawing on theories of language ideology and raciolinguistics. This analysis shows that language justice in the US depends on institutional and civic commitment as well as legal precedent by placing Lau within the political economy of education reform.

Abstract Background United States wilderness areas face increasing challenges from altered fire regimes and climate change, and land managers face ever more complex decisions about fire use. While federal policies permit various fire management strategies in wilderness, including prescribed fire, managers predominantly rely on suppression despite broad support to restore and sustain fire's natural role in these landscapes. Consequently, wilderness fire regimes continue to diverge from historical norms. To better understand wilderness fire management, we used surveys and interviews with wilderness and fire managers to assess current fire management strategies, how they differ in wilderness versus non-wilderness areas, and the rationales behind wilderness fire management decisions. Results Respondents identified public perception, resource availability, and administrative hurdles as primary barriers to prescribed fire and managed wildfire. Notably, these constraints stem more from implementation challenges than from wilderness policy restrictions. Though prescribed fire is rarely used in wilderness, research participants expressed strong support for its expanded application. Conclusions Adequate plans, policies, and practices must accompany wilderness fire management ideals. Addressing risk aversion among decision-makers and building public trust will also benefit wilderness fire management. While allowing natural ignitions to burn in wilderness might be viewed as ideal, many wilderness areas may require active management through prescribed fire to restore historical conditions before natural fire regimes could safely resume. Our research demonstrates the need for wilderness fire management that balances sustaining wilderness qualities with the realities of historical fire regimes that were shaped in part by Indigenous people and challenges posed by legacies of fire exclusion compounded by a changing climate.

ABSTRACT Despite intensified sanctions efforts, illegal deforestation in Mato Grosso, Brazil, remains widespread. This study analyzes over 820,000 hectares embargoed for environmental violations between 2008 and 2021, revealing that most embargoed areas continue to be used for farming (agricultural and cattle production), undermining the effectiveness of command-and-control measures. The persistence of economic exploitation, even after re-embargoes, highlights systemic weaknesses in enforcement and market compliance. Factors such as supply chain fraud, legislative leniency, and political pressure contribute to ongoing deforestation. The study emphasizes the need for continuous monitoring and integration of law enforcement with market-based instruments, including rural credit restrictions and traceability tools. It also calls for alignment between federal and regional policies to avoid legal uncertainty. Our findings underscore the urgency of strengthening mechanisms for law enforcement and advancing the implementation of economic and market-based instruments capable of curbing illegal deforestation.

In 2018, Illinois implemented House Bill 40 (HB40) which required Medicaid (means-tested public insurance) coverage of abortion care for Illinois residents. Medicaid coverage of abortion increases financial accessibility, which oftentimes leads to earlier access to care for covered patients. The ability of residents to use Medicaid may have increased the availability of financial assistance for non-residents. However, whether Medicaid coverage is associated with any changes in abortion access among out-of-state patients – who cannot use Medicaid for abortion coverage – is unknown. To explore if Medicaid coverage of abortion is associated with changes in abortion access for out-of-state patients, we analyzed de-identified records of abortion visits among non-Illinois residents presenting for abortion care across 12 Illinois health centers. We used logistic regression to assess if presenting early for an abortion (≤11 weeks gestation) was associated with implementation of HB40 (2017 vs 2018–2019). Although out-of-state residents were more likely to present early if they received abortion care in the post-HB40 period than pre-HB40 (81% at ≤11 weeks in 2018–2019 vs 78% in 2017), multivariable regression shows that HB40 was not associated with early abortion access when controlling for other patient characteristics. Out-of-state patients had higher odds of presenting ≤11 weeks of gestation during the study period if they were a resident of a state bordering Illinois (OR 1.89, 95% CI 1.55-2.30, p < 0.001) or were over the age of 24 (OR 1.50, 95% CI 1.35-1.66; p < 0.001). Given the significant rise in out-of-state patients after the Dobbs decision, future research should explore how large increases in patient volume over time have impacted abortion care in Illinois and other states, and assess how federal and state-level legal or policy changes influence abortion access for out-of-state patients.