Workers’ compensation systems were designed around the idea that employees injured on the job would receive guaranteed benefits without having to prove employer fault, while employers would receive protection from unpredictable lawsuits and liability. This framework is often referred to as the “grand bargain” concept and has shaped workers’ compensation law across the country for more than a century.

Workers’ compensation emerged as a compromise between labor and industry during the late nineteenth and early twentieth centuries. Before workers’ compensation laws existed, injured employees typically had to sue employers in court to recover damages, an expensive and uncertain process.

The modern system replaced that litigation model with a no-fault structure, from the Workers Comp College article:

Workers’ compensation entitles workers to benefits if their injury happened in the course and scope of their employment, even if the injury didn’t result from anyone’s negligence. It’s a tradeoff: benefits are available for all work-related injuries, but they’re not as large as they would be if the employer’s negligence had caused the injury.

That tradeoff remains the core policy foundation of workers’ compensation systems nationwide. Predictability is central to the model. For local governments, that predictability matters significantly. Counties employ large numbers of employees, including firefighters, law enforcement officers, emergency medical personnel, detention center officers, and public works employees. Even relatively small changes to compensability standards can create substantial long-term fiscal impacts.

More than a century later, many policymakers and employers still view the system as one of the most significant labor and liability reforms.

From The Iowa Orthopaedic Journal:

Although excessively intricate and burdened by separate implementation schemes for each of the fifty states, workers’ compensation law remains one of the relative success stories of American legislation. Its three critical benefits remain. First, the employer gets tort relief. Second the employee gets a relatively quick, equitable, and predictable no-fault compensation scheme. Finally, the system carries an intrinsic incentive toward rehabilitation of the injured worker.

Why Maryland’s System Looks Different

Maryland, like many states, has adopted “presumptions” for certain occupational diseases affecting public safety employees. A presumption changes the burden of proof. Instead of requiring an employee to fully prove a condition was caused by the job, the law assumes the condition is work-related unless the employer can successfully rebut that presumption. Maryland law currently includes presumptions for various public safety occupations involving conditions such as heart disease, hypertension, lung disease, certain cancers, and more.

Maryland’s primary presumptive statute covers career and volunteer firefighters, rescue squad members, advanced life support personnel, and police officers for specified occupational diseases. For firefighters specifically, Maryland law presumes compensability for a growing list of cancers linked to toxic exposures encountered in the line of duty, including leukemia, prostate cancer, brain cancer, kidney cancer, breast cancer, and others.

Recent state legislation expanded those protections. In 2026, the General Assembly passed HB 347, broadening hypertension-related presumptions for paid fire and rescue employees. This legislation expands existing workers’ compensation presumptions for paid firefighters, EMTs, and paramedics diagnosed with hypertension by presuming not only compensability, but also disablement.

While presumptions are technically rebuttable, successfully rebutting them has become extraordinarily difficult. Maryland courts have interpreted these presumptions in a manner that heavily favors compensability, shifting the burden of proof to employers and making rebuttal difficult in practice.

The Courts’ Role in Expanding Practical Liability

One of the central ideas behind the original workers’ compensation “grand bargain” was to reduce the need for expensive litigation over causation and fault. Yet in modern occupational disease disputes, employers and employees often still require extensive litigation simply to determine compensability.

Employers can theoretically demonstrate that a condition resulted from non-work-related causes, preexisting risk factors, or unrelated exposures. In practice, however, the legal standard has evolved into something much closer to automatic compensability. Employers often cannot defend a workers’ compensation claim merely by arguing there is insufficient scientific evidence connecting an employee’s work to a particular cancer.

From the Unreported Opinion, CLEAR SPRING AMBULANCE CLUB, ET AL. v. ROGER J. REED:

We think the legislature intended that the Morgan type presumption [which requires the opponent to carry the burden of production and persuasion] be applied in adjudicating cases arising under [the statute]. . . . [The presumption] is reflective of a social policy affording preferential treatment to [individuals listed in the statute]. Although the presumption of compensability is a rebuttable one of fact, the legislature manifestly intended that the statute impose a formidable burden on the party against whom it operates. Accordingly, both the burden of production and the burden of persuasion remain fixed on the employer; neither ever shifts to the claimant and the presumption constitutes affirmative evidence on the [claimant’s] behalf throughout the case, notwithstanding the production of contrary evidence by the other side.

Unlike many presumptions in ordinary civil litigation that disappear once an opposing party produces contrary evidence, Maryland courts have held that these workers’ compensation presumptions remain affirmative evidence throughout the case, leaving the burden of persuasion firmly on the employer.

Where the Debate is Heading

The same tensions surrounding cancer and hypertension presumptions are now emerging in debates over mental health injury claims, particularly PTSD coverage for first responders.

PTSD claims illustrate the broader policy tension especially clearly. Historically, workers’ compensation systems focused primarily on physical injuries. Mental health injury claims were often treated more narrowly because of concerns involving causation, proof standards, and the difficulty of distinguishing workplace trauma from broader life stressors.

That approach has changed in recent years, as more have rightly recognized that first responders often face extraordinary psychological trauma as part of their jobs.

This article is part of MACo’s Policy Deep Dive series, where expert policy analysts explore and explain the top county policy issues of the day. A new article is added each week – read all of MACo’s Policy Deep Dives.