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Voting presents a challenge to military personnel and overseas citizens. Mail absentee ballots are often unreliable, and many citizens are unaware of their full range of voting options. Following implementation of a new internet-based ballot delivery system, we assessed the impact of the different email messages used to introduce it. Our findings show that communications with a concise subject line, source credibility, and that feature a citizen's reference groups encourage system usage. These communications also promote greater usage and turnout among citizens located in nations experiencing conflict, in allied nations, and abroad. Our findings have implications for scholars and political practitioners.

As seen in Chapter 4, the ability of voting legislation to influence aggregate outcomes is somewhat limited. Although there appears to be improvement in Uniform and Overseas Citizens Absentee Voting Act (UOCAVA) ballot return rates and UOCAVA ballot acceptance rates after the implementation of the Military and Overseas Voter Empowerment (MOVE) Act, military and overseas voter turnout remains low. However, public policy influences not only aggregate macro-level outcomes, but also micro-level individual variables. In contrast to Chapter 4, this chapter looks at the impact of public policy on the individual voter. How have voters responded to changes in the voting process? Are voters more satisfied with the process than in previous years? In this chapter, I use data from the Overseas Vote Foundation (OVF) 2008 and 2010 postelection voter surveys (whose methodology is described in detail in Chapter 2) to examine whether the implementation of electronic transmission methods in the MOVE Act impacted the individual’s perception of the voting process.

Previous chapters have firmly establishedthat military and overseas voters have traditionally experienced considerable trouble completing the voting process, which is reflected, for example, in the low ballot return rates described in Chapter 4. These difficulties have been primarily attributed to the voting time line; that is, because of their geographical distance from their local election officials (LEOs) as well as a reliance on traditional postal methods, voters were often unable to receive a blank ballot and/or return a voted ballot by the appropriate deadline. In short, it simply took too long to vote. As described in Chapter 3, since 2000, a series of legislative fixes at the state level and the passage of the Military and Overseas Voter Empowerment (MOVE) Act in 2009 at the federal level have been implemented in order to reduce the hurdles individuals face when voting, for example, extending the time line for voting to a mandatory 45 days.

As described in Chapter 3, the historical development of military and overseas voting policy is best characterized as a series of legislation created in response to a galvanizing event, such as war, a presidential election, or pressure from outside groups. Very few of these policies were developed in the context of data-driven reform, but were rather supported (or not) based on partisan preferences. The American Political Science Association (APSA) report of 1952 and the Federal Voting Assistance Act of 1955 represent an important exception, and a turning point in the development of public policy. However, it would take another 55 years before enough data were available to enable truly data-driven reform, and in 2009, Congress passed the Military and Overseas Voter Empowerment (MOVE) Act in the wake of the statistics and data accessible after the 2008 presidential election.

Following their role in the disputed Florida recount, military and overseas voters emerged in importance in 2000. In the summer of 2008, then Senator Obama gave an important speech in Berlin, once again shining a light on this voting bloc. By that time, military and overseas voters had a long-established history of voting rights struggles, but still encountered numerous problems while voting, and remained a largely understudied portion of the voting population. Reflecting upon the amount of change in military and overseas voting between the summer of 2008 and the summer of 2014, the differences are remarkable.

OBJECTIVES: To determine the effects of a policy of using acupuncture, compared with a policy of avoiding acupuncture, on headache in primary care patients with chronic headache disorders. The effects of acupuncture on medication use, quality of life, resource use and days off sick in this population and the cost-effectiveness of acupuncture were also examined. DESIGN: Randomised, controlled trial. SETTING: General practices in England and Wales. PARTICIPANTS: The study included 401 patients with chronic headache disorder, predominantly migraine. INTERVENTIONS: Patients were randomly allocated to receive up to 12 acupuncture treatments over 3 months or to a control intervention offering usual care. MAIN OUTCOME MEASURES: Outcome measures included headache score; assessment of Short Form 36 (SF-36) health status and use of medication at baseline, 3 months and 12 months; assessment of use of resources every 3 months; and assessment of incremental cost per quality-adjusted life-year (QALY) gained. RESULTS: Headache score at 12 months, the primary end-point, was lower in the acupuncture group than in controls. The adjusted difference between means was 4.6. This result was robust to sensitivity analysis incorporating imputation for missing data. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year. SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy and change in health. Compared with controls, patients randomised to acupuncture used 15% less medication, made 25% fewer visits to GPs and took 15% fewer days off sick. Total costs during the 1-year period of the study were on average higher for the acupuncture group than for controls because of the acupuncture practitioners' costs. The mean health gain from acupuncture during the year of the trial was 0.021 QALYs, leading to a base-case estimate of GBP9180 per QALY gained. This result was robust to sensitivity analysis. Cost per QALY dropped substantially when the analysis incorporated likely QALY differences for the years after the trial. CONCLUSIONS: The study suggests that acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. It is relatively cost-effective compared with a number of other interventions provided by the NHS. Further studies could examine the duration of acupuncture effects beyond 1 year and the relative benefit to patients with migraine with compared to tension-type headache. Trials are also warranted examining the effectiveness and cost-effectiveness of acupuncture in patients with headache receiving more aggressive pharmacological management.

Objective To determine the effects of a policy of “use acupuncture” on headache, health status, days off sick, and use of resources in patients with chronic headache compared with a policy of “avoid acupuncture.”Design Randomised, controlled trial.Setting General practices in England and Wales.Participants 401 patients with chronic headache, predominantly migraine.Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months or to a control intervention offering usual care.Main outcome measures Headache score, SF-36 health status, and use of medication were assessed at baseline, three, and 12 months. Use of resources was assessed every three months.Results Headache score at 12 months, the primary end point, was lower in the acupuncture group (16.2, SD 13.7, n = 161, 34% reduction from baseline) than in controls (22.3, SD 17.0, n = 140, 16% reduction from baseline). The adjusted difference between means is 4.6 (95% confidence interval 2.2 to 7.0; P = 0.0002). This result is robust to sensitivity analysis incorporating imputation for missing data. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year (8 to 38). SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy, and change in health. Compared with controls, patients randomised to acupuncture used 15% less medication (P = 0.02), made 25% fewer visits to general practitioners (P = 0.10), and took 15% fewer days off sick (P = 0.2).Conclusions Acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. Expansion of NHS acupuncture services should be considered.