The High Cost of Gun Violence 

There's nothing cheap about getting shot. Just ask the people who see the carnage at Highland Hospital's trauma center.

On a Sunday afternoon in June of 2006, a young man we'll call Michael Robinson was shot six times on a street in his West Oakland neighborhood. Paramedics rushed the bleeding seventeen-year-old to Highland Hospital's trauma center, where a medical team treated his wounded legs, arms, and abdomen. Although they stopped his bleeding quickly, and the bullets just missed his major organs, Robinson still needed multiple surgeries. Like approximately 95 percent of the patients treated for violent injuries at Highland Hospital, he had no health insurance.

By the time Robinson left the hospital nine days later, he had racked up a $75,000 bill. In addition to the three emergency medical technicians who kept him alive on the way to the hospital, he required a team of nearly twenty staff members, including a respiratory therapist, an anesthesiologist, two nurses, four surgeons, and several lab and radiology technicians.

Following his stay, Robinson received a bill for his hospital care, but he couldn't pay it. Instead, California taxpayers covered most of it through MediCal, the state's health insurance program for low-income residents. That is often the case with medical bills accrued by the victims of violence, a majority of whom are less than thirty years old and have low incomes.

"Usually MediCal will cover all or most of it," said Nic Bekaert, Highland Hospital's community injury prevention coordinator, who helps such patients figure out how to cover their jaw-dropping bills and avoid falling into debt. "But a lot of them do carry around these bills for whatever reason. Typically they don't do much about it, so it goes through collections and stays with them for a while."

Patients who aren't eligible for MediCal or can't receive help from California's victim compensation program are expected to pay for their care out of pocket. But that rarely happens. Instead, trauma centers like Highland end up eating the costs of such care. And the last few years have been undeniably expensive for Highland's trauma center and emergency room.

As Oakland's murder rate spiked in the past three years, it has been accompanied by a corresponding increase in violent injuries, car crashes, and other nonviolent trauma, which often tend to mirror violence trends. In 2007, Highland's trauma center treated 2,337 patients, more than 40 percent of whom were victims of violence. Treating them alone cost the hospital about $33 million, Bekaert said, and that may be a lowball figure, because Highland typically underbills its patients. It also doesn't include the millions more spent treating the scores of less severe violent injuries that bypassed trauma and were handled directly in the emergency room. Nearly half of those trauma patients had been shot, the rest stabbed or assaulted.

As callous as it may seem to be equating lives with dollars, the financial costs of gun violence are clearly staggering. The last comprehensive national report was released in 1999 by the Journal of the American Medical Association. Using records and costs from 1994, it reported that 134,445 gunshot injuries produced $2.3 billion in lifetime medical costs, of which $1.1 billion was paid by taxpayers. When financial considerations such as lost productivity are factored into the equation, the Brady Campaign to Prevent Gun Violence has estimated that taxpayers shoulder about 85 percent of the costs of gun violence.

Indeed, the increased rates of violence in some cities, along with the rising costs of health care, pose a major financial challenge to public hospitals. Andres Soto, Alameda County's violence prevention coordinator, noted that the King/Drew Medical Center in Los Angeles closed down its trauma center in 2004 partly due to the costs of treating gunshot victims from the city's South Central neighborhood.

Shootings and violent crime have an enormous price tag by any measure. But while the price of treating victims — not to mention the associated law enforcement and incarceration costs — continually skyrocket, advocates complain that violence-prevention efforts are consistently underfunded. "I don't know what moves people," said Dr. Rachel Steinhert, an emergency physician at Contra Costa Regional Medical Center. "To me, it seems crazy that there isn't more of a movement. It's clearly preventable ... I'm not sure if the public cares."

If society isn't motivated to invest in violence-prevention out of concern for the well-being of crime victims, advocates hope that perhaps it can be motivated to do so by understanding the explosive costs of treating the victims of violence.

Highland Hospital's trauma center is much smaller than one might expect given the volume, and high drama, of patients who come through here. Located just off the main lobby of the massive county institution, the trauma ward is next to the emergency room and consists of two modest-sized rooms. Both were empty on a recent afternoon, when the calm of the place made it hard to imagine a flurry of medical personnel frantically trying to keep a wounded teenager alive.

Paramedics typically decide if a patient's condition is serious enough to merit trauma activation. Less life-threatening cases, violence-related or otherwise, are generally taken to the emergency room, which treats about 40,000 patients annually. If, for instance, someone is grazed by a bullet but not in need of immediate intervention, they'll go to the ER, a generally less costly destination.

Trauma itself is a relatively new form of medicine. Federal law requires access to local trauma centers, and any injury deemed a trauma by paramedics must be treated there. As Northern Alameda County's only such center, all trauma injuries in the region go through Highland regardless of the patient's economic status. Among the 2,337 people treated last year, violent injury accounted for 40 percent of visits, followed by car crashes, and then falls. "We're the end of the line," said Bekaert, a hint of pride in his voice. "If you get seriously injured, you go to Highland. If it's anything else, you want to go anywhere else."

Trauma doctors say the average cost of treating a gunshot wound is $40,000, although some professionals assert that the tab is more than double that, Bekaert said. Individual patients' bills ranged from $1,000 to $1.5 million last year, he added.

"You can easily see how the manpower and resources quickly add up," said Dr. Gregory Victorino, Highland's chief trauma surgeon. But in the heat of trying to save a life, such financial factors are irrelevant, he added. "Resources and time don't enter into my mind," said Victorino, one of nine Highland trauma surgeons. "Initially, it doesn't matter why they're here. We're just trying to take care of them the best we can and save their life."

The resources, medical talent, and heroics poured into saving a life are at times staggering — particularly considering the simplicity of the actions that usually inflict the damage.

Even a patient with no pulse upon arrival at the hospital can rack up a costly bill. Until all medical conditions defining death are met, he will continue to receive CPR in the trauma room. "The trauma team cannot make a determination of whether a patient is Do Not Resuscitate, so they do everything they can to save the patient's life, regardless of any other information they have," Bekaert said. "Naturally, there is no determination of an intervention being too costly to proceed. Everything is done, no questions asked."

Bekaert remembered the case of one fifteen-year-old boy who came in with a gunshot wound to his neck. "They did everything they could, including cracking his chest open with essentially a hammer and chisel ... and hand-pumping his heart," Bekaert said. "Miraculously, after losing his entire blood volume and several trips to the operating room, he survived. Unfortunately, they didn't know his spinal cord was severed, rendering him not only quadriplegic but with 'locked-in syndrome' [in which a patient can only blink]. However, had they known this would be the outcome earlier, they still would have done everything they could to save him."

As the manager of Highland's youth violence-prevention program, Bekaert knows at any given time who's in the ER and the trauma center. His days are often spent running laps around the hospital's sterile halls meeting new, blood-stained patients. During a rare, brief respite, he retreated to his tiny office in a deserted back hallway and took a moment to describe the hospital's $1.5 million patient.

The 25-year-old gunshot victim, who was part of the contingent that Bekaert refers to as the "high rollers," received multiple surgeries and was in Highland for 193 days. Some of the costs contributing to his bill included approximately $12,000 for use of the trauma room, $6,000 for single use of the operating room, $1,500 a day for ventilator use, and $9,000 a day for the intensive care unit room.

"Add to that meds, procedures, equipment, labs, transfusions, x-rays, and CAT scans, which all vary from a few bucks to several thousand," Bekaert said. The potential need for medications, ongoing nursing, and post-traumatic stress therapy also should be factored in, he noted. "Some drugs, for example, vary from pennies to $10,000 a single dose." If the patient were a quadriplegic the rest of his life, Bekaert suggested, "over his lifetime, we're talking many millions of dollars for just one person."

As an advocate for his patients, Bekaert says it's often a major challenge finding the funding to pay their bills and avoid sending them back out on the streets prematurely. It's a process of constant jockeying with both the hospital and public insurance funders. He added that Highland's doctors often feel pressure to keep the turnover flowing.

"No one wants to pay for these kids," he said. "We still operate under these concepts of the deserving poor and the undeserving poor. It's one thing if you're a poor child and minding your own business and get shot, but if you've got tattoos and a possible gang affiliation, somehow you're less worthy as a human being."

Dr. Victorino often worries about what will happen to patients once they get back out on the street. His greatest fear is that he will see them again on the operating table. Since January alone, 170 youths aged twenty and younger have been admitted to Highland's trauma center or emergency room for violent injuries. Eighteen — more than 10 percent — were repeat patients and five have come back more than twice. One kid, who was treated by the trauma team for a gunshot wound at the end of April, was shot on the street five days later and pronounced dead at the scene.

Dr. Steinhart, the ER physician at Contra Costa Regional Medical Center, notes that gun violence disproportionately affects young people. She cited one recent study that showed if you can just get some of these kids through their mid-twenties, they're not that violent anymore.

Homicide is the leading cause of death in Oakland for males aged fifteen to 24. According to Highland's Trauma Log, 470 youths ages fourteen to twenty were treated for violent injuries at the hospital last year. The number went down a bit from 2006, the city's bloodiest year in over a decade, but was almost double 2003's rate. Of those treated by the trauma team, more than 70 percent had gunshot wounds and 45 percent were under eighteen. The large majority were black males from Oakland.

"We're completely numb to the reality of this situation," said Bekaert, who's worked in and around the hospital for the past nine years. "The term used is epidemic. It's of absolutely epic and unimaginable proportions. Usually, when something that epic occurs in society, the public is up in arms and something gets done. But really, we've been living with this crisis for so long, it's become socially acceptable — part of the fabric."

In light of the explosive medical expenses, Bekaert and many colleagues insist that violence-prevention programs are a very wise investment, both financially and humanely. A former employee of the Oakland nonprofit Youth Alive, he still works closely with the organization's Caught in the Crossfire program, which uses peer-based intervention to prevent the common occurrence of violently injured youth retaliating against their assailants. When a young patient is admitted to the hospital, Bekaert makes a referral and a caseworker from the program shows up within an hour at the bedside.

Such was the case with Michael Robinson, the seventeen-year-old with the $75,000 tab. Soon after a phone call from Bekaert, Emilio Mena of Caught in the Crossfire introduced himself to the stitched-up young man in his small room at Highland. Like the program's other caseworkers — known as Intervention Specialists — Mena, a former gangbanger, is a product of the streets and has experienced his own share of violence. The program is completely voluntary, but once it's made clear that there's no connection to the law, most patients gladly accept the services. Mena frequently checked in with Robinson after he left the hospital, getting him on MediCal and helping him finish up school. Robinson also got hooked up fixing air conditioners in another local hospital, a job he still holds.

On average, the program, which also operates in Los Angeles, provides services to approximately 120 Oakland youths per year. Since its inception in 1994, it's worked with more than 1,000 violently injured youths. Among them, 98 percent avoided violent reinjury and not a single participant has retaliated, according to the program's web site. A 2007 study in the Journal of the American College of Surgeons compared youth in Caught in the Crossfire with violently injured youth not in the program and found that one year after the injury, participants were 70 percent less likely to be arrested than their peers.

The cost of the program per youth is around $3,500, which isn't too bad compared to the $40,000 average cost of treating a gunshot wound or the nearly $100,000 annual cost of keeping someone behind bars in the California Youth Authority.

For Bekaert, the bottom line is that public funding is finite and resources could be focused on other medical needs if the rate of violence dramatically dropped. "That's money that could go elsewhere," he said. "If you prevent that, that's money well spent."

Dr. Victorino notes the absurdity of the situation, a public-health crisis that many medical professionals have deemed a disease, yet which is so seemingly preventable compared to, say, cancer. "I think the hospital provides a wonderful service for people in the community," he said. "But on a particular Friday or Saturday night I say, 'God, when is this going to stop, when are we going to do something? ... We need a trauma center, but we don't need to be taking care of all these kids.

"I knew what I was getting into when I did my training here eight years ago. ... But I look at these young fifteen- and sixteen-year-olds. This is something that we as a society should be able to prevent. This is a waste of human life."


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