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While the current system of care for treating rare but serious infectious diseases—which was developed in response to the 2014–2016 Ebola outbreak—provides an important foundation, a number of issues remain. In particular, a system of care must be able to sustain capacity and capabilities, manage the distribution of needed resources, and meet high demand for services. In this report, RAND researchers consider the need to strengthen the current system of care, discuss potential opportunities, and identify key financial considerations for the sustainability of the system. This research suggests that the United States may benefit from a strengthened or more formalized system of care for rare but serious infectious diseases. The authors identify several opportunities to strengthen the current system of care, including enhancing or building upon the three tiers of acute care facilities that were established during the Ebola outbreak of 2014–2016, developing a brain trust of clinicians and others who can provide advice to health care providers, using mobile teams, and enhancing air and ground systems for safely transferring infected patients. The authors also lay the groundwork for future discussions around key financial considerations to ensure the sustainability of a system of care for rare but serious infectious diseases.

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The coronavirus disease 2019 (COVID-19) pandemic–related recession and resulting job loss raised significant concerns that the U.S. uninsured population could increase, perhaps by millions. However, predictions about coverage loss have not materialized. Because this recession is the first economic downturn since the Affordable Care Act's (ACA's) major coverage provisions took effect in 2014, a possible explanation for the lack of coverage loss is that the ACA's safety-net provisions — such as Medicaid expansion and Advance Premium Tax Credits (APTCs) for marketplace coverage — did their job. However, it is also possible that other responses to the pandemic contributed to the maintenance of insurance levels. For example, more than half of covered workers who lost their jobs as a result of the pandemic retained their employer-sponsored insurance, perhaps because the layoffs were not expected to be permanent. Temporary policies to retain Medicaid enrollees appear to have increased insurance enrollment. Furthermore, some states opened their health care marketplaces for a special enrollment period in 2020, enabling people to newly enroll in insurance in the middle of the year. In 2021, the American Rescue Plan, which temporarily enhanced marketplace tax credits, also led to an enrollment bump. To explore this issue, RAND researchers (1) assess the importance of temporary provisions relative to long-standing policies in stabilizing health insurance enrollment despite heavy job loss and (2) run simulations using New York state as a case study.

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In 2019, California enacted Senate Bill (SB) 542, which created a rebuttable presumption that posttraumatic stress disorder (PTSD) in firefighters and peace officers is a work-related injury and thus compensable under workers' compensation. California has long used presumptions to facilitate workers' compensation claims for many other occupational health conditions in first responders, including cancer, heart trouble, and hernia. SB 542 is intended to encourage care-seeking among first responders and reduce the stigma associated with filing a workers' compensation claim for a mental health condition. The presumption is in effect for injuries occurring between January 1, 2020, and December 31, 2024. The authors of this report evaluate the prevalence of mental health conditions and illnesses among firefighters and peace officers and discuss the implications that this evidence has for policy regarding presumptions established by SB 542. Using a mixed-methods approach, the authors also investigate the frequency of workers' compensation claims involving PTSD, how often these claims are denied, and how first responders experiencing PTSD access mental health care. First responders' mental health and experiences in the workers' compensation system are compared with those of workers in other trauma-exposed occupations. Claims involving PTSD are compared with claims involving other health conditions — such as cancer, heart trouble, and hernias — that are also presumed to be work-related in first responders under California law. The report also contains estimates of the costs to state and local government that might result from presumptive coverage of PTSD in the workers' compensation system, and the authors also discuss stakeholder perspectives on SB 542.

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Like the United States as a whole, Virginia faces a significant shortage of health care workers in nursing, primary care, and behavioral health. If current trends persist, these shortages will increase across Virginia. The authors of this report identify interventions that can help the Virginia Health Workforce Development Authority (VHWDA) address these health care workforce shortages. To accomplish this goal, they applied an analytic framework to existing or potential interventions for retaining, recruiting, and improving the structural efficiency of the nursing, primary care, and behavioral health workforces in Virginia. In this report, they highlight which interventions VHWDA should prioritize based on its desired outcomes and policy goals.