HMN 2025: How Safety-net hospitals carry the highest cost of gun injuries, analysis finds

The initial hospital treatment of firearm injuries cost the U.S. health care system an estimated $7.7 billion between 2016 and 2021, with the largest share falling on urban trauma center hospitals that serve the highest proportion of Medicaid patients, reports a new study led by Northwestern Medicine.

The study analyzed emergency department and inpatient visits for firearm injuries between 2016 and 2021. Annual costs held steady at about $1.2 billion through 2019, then jumped to $1.6 billion in 2021, a 33% increase that coincided with a rise in firearm injuries during the COVID-19 pandemic.

More than half of all firearm injury costs were billed to Medicaid. Yet, Medicaid reimbursement often falls short of actual treatment costs, leaving safety-net hospitals, which serve vulnerable, lower-income patient populations, on the front lines of the gun violence epidemic to absorb substantial losses. The study authors warn that recent Medicaid funding cuts adopted by Congress could further strain these hospitals.

The findings are published in JAMA Health Forum.

“Gun injuries are a source of financial strain on hospitals, particularly large safety-net trauma center hospitals that often operate on thin margins,” said study corresponding author Alexander Lundberg, assistant professor of emergency medicine at Northwestern University Feinberg School of Medicine.

“Because in many states Medicaid reimbursement is typically below the true cost of care, trauma center hospitals are already absorbing significant losses,” added study co-author Dr. Anne Stey, assistant professor of surgery at Northwestern University Feinberg School of Medicine and a Northwestern Medicine trauma surgeon.

“Medicaid funding cuts could further financially destabilize trauma centers. Some could close, or stop being trauma centers that provide the high-level and life-saving trauma care that all American families need after car accidents, falls and bike accidents.”

Overall, the largest share of costs went toward treating patients who were Black, men and from low-income areas.

How the study was conducted

To get a national picture of the health care costs of firearm injuries, the scientists analyzed hospital records from six states: Arkansas, Florida, Maryland, Massachusetts, New York and Wisconsin. The team chose these states because they collect high-quality data on both inpatient hospitalizations and emergency visits.

The team analyzed every hospital visit in those states for a new firearm injury from 2016 to 2021 and then used these patterns to generate national estimates.

To find out where in the health system the costs are most concentrated, the team broke down the data by patient demographics, hospital size and health insurance coverage, among other factors.

Among the key findings, the annual cost of treatment for pediatric patients grew 54% from 2019 to 2021. Medicaid was also the primary payer for 52% of all hospital costs, followed by private insurance (20%), self-pay or uninsured patients (16%) and Medicare (6%).

Beyond the hospital bill

The Northwestern team notes that their estimate likely understates the complete financial toll of firearm injuries. Their analysis included only the initial hospital stay or emergency visit and did not capture other significant health care costs related to firearm injuries, such as ambulance or air transport, rehabilitation, follow-up visits and return to hospital.

The study also does not account for indirect costs to American families such as lost wages of patients and their caregivers, long-term disability or the emotional and economic burden on communities.

Lundberg and colleagues say their findings highlight the need to strengthen financial support for trauma center hospitals to sustain trauma care in their communities most affected by gun violence.

The authors also call for more investment in injury-prevention programs and safe-firearm storage education to prevent unauthorized firearm access.

The content is provided for information purposes only.