by Clark Merrefield, The Journalist’s Resource
Mass shootings in the U.S. often attract national media coverage. They’re horrific, they upend the lives of numerous victims and families, and they’ve become increasingly common over the past two decades.
Less covered nationally, but deserving of more media attention, is the everyday toll of gun violence — particularly injuries, which incur tens of billions of dollars in hospital costs and lost work time every year.
To offer a sense of the economic costs of firearm injuries, we looked into recent academic papers on the topic. Here are some quick takeaways from the research:
- There are more than 100,000 firearm injuries in the U.S. each year, according to federal estimates, but there is no national database that counts firearm injuries.
- The cost of emergency department visits and inpatient admissions related to firearm injury totals almost $3 billion per year.
- Work-loss costs, calculated in terms of lost wages and other factors, are roughly $50 billion yearly, according to academic research and other estimates, which also figure the value of lost quality of life at more than $200 billion per year in the U.S.
- Young adults — young men in their 20s in particular — have the highest firearm injury rates. One reason for the billions of dollars in economic costs from firearm injuries is that younger people have more of their lives left to live. Think of it like this: The average lifespan in the U.S. is 78 years. Many people retire in their mid-60s. Someone shot and debilitated at age 55 will miss out on the opportunity for roughly a decade of work. But someone shot and debilitated at age 25 will miss out on about 40 years of potential work, and experience decades of diminished quality of life.
- People who are uninsured, use public insurance or decide to pay hospital bills out of pocket represent a huge portion of firearm injury medical costs. About 41% of firearm injury patients who arrive at an emergency department pay for care themselves. Those publicly insured or uninsured account for $44 million, or 67%, of readmission costs after an initial hospital intake for firearm injury.
- Handgun injuries are the most expensive in terms of overall medical costs — more than $183 million yearly among those admitted to a hospital and $19,175 per hospital admission.
- Roughly half of hospitalizations for firearm injury are among Black patients. Black and Hispanic people are more likely to suffer a firearm injury due to assault than people of other races and ethnicities. White patients are most likely to suffer a firearm injury due to self-harm or accident.
- Thousands of children each year suffer firearm injuries and are admitted to a hospital, with annual hospitalization costs totaling nearly $100 million.
How Many People are Hurt by Firearms? We Don’t Exactly Know
There are no standard, national data sources that tally mass shootings or firearm injuries.
The FBI tracks active shooter incidents, in which one or more shooters kill or try to kill people in a populated area, but not mass shootings. Mother Jones keeps a current count of mass shootings using the federal definition of a mass killing — a killing in a public place in which three or more people are killed, not including the perpetrator.
There were 10 mass shooting events in the U.S. in 2019, two in 2020, and there have been three this year, the Mother Jones database shows. There were 28 active shooter incidents in 2019, the most recent year FBI data is available.
Journalists also turn to the nonpartisan Gun Violence Archive for information on mass shootings. The archive uses a broad definition of mass shooting — its only criterion is that a perpetrator shoots or kills four or more people during an incident. The archive counts 417 mass shootings in 2019, 611 in 2020 and 132 in 2021, as of April 7. In all, 39,707 people died from injuries caused by firearm discharge in 2019, the most recent year available from the U.S. Centers for Disease Control and Prevention. About one-third — 14,414 — were homicides, while about 60% — 23,941 — were deaths by suicide.
There are twice-to-three times as many firearm injuries as there are firearm deaths each year, according to various estimates. Firearm injuries generally refer to wounds or penetrating injuries sustained from a projectile, such as a bullet or slug, fired from a handgun, shotgun or other firearm. Most survivors of firearm injuries do not harm themselves, according to research highlighted below.
Researchers often use data on hospital emergency department visits and admissions to study firearm injuries. Those data fail to capture some firearm injuries — someone with a minor injury from a firearm discharge may not seek emergency care, for example.
Still, emergency department sample data is widely used in academic literature. The data aren’t perfect — there are potential unknown coding errors and some entries lack key data fields, such as the type of firearm used — but they offer the best available insight on firearm injuries in the U.S.
And, if someone needs immediate medical attention for a firearm injury, that’s the kind of physical trauma likely to amplify economic consequences.
One source for firearm injury data is the National Center for Injury Prevention and Control at the U.S. Centers for Disease Control and Prevention. From 2013 to 2019, people with nonfatal firearm injuries visited emergency departments an estimated 752,351 times, according to the center.
That figure was calculated based on a sample of 16,902 such cases and comes with a large standard error. Generally, standard errors decrease with more sample data. The total number of emergency department visits due to firearm injury is likely between 319,471 and 1,185,231 for 2013 to 2019, according to the injury center. That includes unintentional firearm injuries as well as those resulting from assault, self-harm and law enforcement encounters. There’s not enough sample data for the injury center to estimate recent timeframes shorter than 2013 to 2019, or rates for individual years.
Those CDC numbers are based on the National Electronic Injury Surveillance System, part of the U.S. Consumer Product Safety Commission. The injury surveillance system collects patient visit data from a sample of 100 hospitals with emergency departments across the country.
Another source of firearm injury data, more common in academic research, is the Nationwide Emergency Department Sample from the U.S. Agency for Healthcare Research and Quality. It’s the largest source of emergency department data in the U.S., estimating characteristics of 145 million such visits each year. One way researchers use this data is to estimate the costs of health care related to treating injuries caused by firearm discharge.
The emergency department dataset isn’t free — at least, not in its entirety. Each year of data from 2016 to 2018 costs $1,000, though the price drops for more distant years going back to 2006. The dataset is one of several that are part of the Healthcare Cost and Utilization Project. Journalists and the public can run individual queries of the data for free through HCUPNet. National, regional and some county-level data are available this way. If you’re a journalist with a more complicated request than the online portal can fulfill, reach out to Karen Carp or Shelby Venson-Smith at the agency for help.
Healthcare Costs for Firearm Injuries are a Multi-billion Dollar Burden
The authors of an October 2017 paper in Health Affairs use the health care research agency’s national sample to identify a weighted total of 704,916 patients from 2006 to 2014 who arrived at an emergency department alive with a firearm-related injury. Those data don’t include details on patients’ race or ethnicity. Weighting is common in statistical analysis. Researchers do it when their data sample doesn’t perfectly match the larger population they want to study. Weighting adjusts for populations that are overrepresented or underrepresented in the sample, so that the sample more closely resembles the overall population.
“Emergency Department Visits for Firearm-Related Injuries in the United States, 2006–14,” Faiz Gani, Joseph Sakran and Joseph Canner. Health Affairs, October 2017.
On average, each emergency department visit costs $5,254, with costs for inpatients jumping to $95,887, the authors of the Health Affairs paper find. In total, the authors estimate yearly healthcare costs of $2.8 billion for firearm-related injuries. That includes emergency department visits and inpatient admissions.
An inpatient is a patient a doctor formally admits to a hospital to stay for a length of time.
Some 37.2% of patients in the study treated in an emergency department were admitted to the hospital, while 8.3% died. Nearly half of patients arrived at an emergency department following an assault, with 5.3% due to self-harm.
About 70% had minor or moderate injuries, while 30% had injuries that were serious or severe. People aged 18 to 29 years made up half the sample, and men were nine times as likely as women to arrive at an emergency department with a firearm-related injury. Though it’s not the main focus of the paper, the authors use the CDC data to estimate work-loss costs of $44.5 billion per year due to firearm injuries.
About 41% of patients pay hospital costs themselves. The authors write that “uninsured or self-pay patients lack negotiating power and thus leverage with payers, either they bear the entire financial burden of their injuries in the form of out-of-pocket spending, or these costs remain unrecovered — thereby adding to the uncompensated care provided by hospitals, physicians, and health care systems.”
Fewer Federal Dollars = Less Research
The Health Affairs authors note funding for research on gun violence dried up after a mid-1990s law banned federal research to advocate or promote gun control: “For every hundred articles published on sepsis, only about four are published on gun violence,” they write.
The 1996 provision, written by former Republican Congressman Jay Dickey of Arkansas, didn’t outright ban research on guns but made such research politically unpalatable.
“Precisely what was or was not permitted under the clause was unclear,” write two doctors, Arthur Kellermann and Frederick Rivara, in a February 2013 JAMA Viewpoint article. “But no federal employee was willing to risk his or her career or the agency’s funding to find out.”
From 1998 to 2012, scientific publications on gun violence fell 64% and federal funding for firearm injury research plummeted 96%, according to public health journalist Ted Alcorn, writing in JAMA in January 2017.
But firearm research backed by federal dollars is on its way. A March 2018 Congressional spending bill clarified that the Dickey Amendment did not forbid the federal government from funding research on the causes of firearm violence.
In late 2019, Congress approved $25 million to conduct research on gun violence, to be split evenly between the CDC and the National Institutes of Health. By September 2020, the NIH had awarded $8.5 million in funding for nine investigations, with the CDC putting $8 million toward 16 research projects related to firearm injury and mortality.
A Closer Look at Inpatient Costs
A July 2017 paper in Injury Epidemiology takes a closer look at inpatient costs related to injuries from firearm discharge, using 2003 to 2013 data from the National Inpatient Sample, a companion to the emergency department sample. The inpatient sample includes information from 20% of all hospitals, according to the authors. The inpatient data also include information on the race and ethnicity of firearm injury patients. The authors analyze a weighted total of 336,785 admissions during the decade studied.
“Cost of hospitalization for firearm injuries by firearm type, intent, and payer in the United States,” Corrine Peek-Asa, Brandon Butcher and Joseph Cavanaugh. Injury Epidemiology, July 2017.
Most people admitted to a hospital with firearm-related injuries — 80% — were aged 15 to 44. Men were much more commonly hospitalized than women — 18.2 men per 100,000 people in the U.S., compared with 2.1 women per 100,000. Roughly half of hospitalizations for firearm injury were among Black patients — 39.7 per 100,000.
Black and Hispanic patients were more likely to suffer a firearm injury due to assault, while white patients were most likely to be unintentionally injured by a firearm discharge, or because of self-harm.
The roughly 30,000 hospitalizations for firearm-related injuries each year total $622 million in average admission costs, the authors find. In 60% of cases, the type of firearm used was unknown.
For admissions where the firearm type was known, handgun discharge accounted for 70% of injuries and $183 million in annual hospital stay costs, followed by shotgun injuries at about $50 million.
The hospital admission data do not describe firing mechanisms, such as automatic or semi-automatic.
Associated Press style, which The Journalist’s Resource follows, notes that the terms “assault rifle” and “assault weapons” should be avoided. They are “highly politicized terms that generally refer to AR- or AK-style rifles designed for the civilian market, but convey little meaning about the actual functions of the weapon,” according to the style guide. “Avoid the terms preferred by advocates and gun manufacturers, such as military-style rifles or modern sporting rifles.”
Tracking Patients Over Time
While the Health Affairs and Injury Epidemiology papers are instructive as to overall health care costs for firearm-related injuries, the national data they use are a snapshot. Researchers can’t track the outcomes of patients in those samples across time.
“This lack of longitudinal, patient-level data limits our ability to examine the health care-level effect of firearm injury outside of the initial, acute injury and to make a coherent argument for why insurers and states should consider firearm injury prevention a worthwhile investment,” write the authors of a December 2020 paper in the Annals of Internal Medicine. The authors use a before-and-after study to see how health care costs changed for firearm injury patients with Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas. They analyze data from plan members who sustained a firearm injury from 2015 to 2017.
“Increases in Actual Health Care Costs and Claims After Firearm Injury,” Megan Ranney, et. al. Annals of Internal Medicine, December 2020.
Comparing the six months before and after the injury, costs spiked from $3,984 per member to $17,806 for those released from an emergency department.
For those hospitalized, healthcare costs went from $4,118 before a firearm injury to $92,151 after the injury. Out-of-pocket costs for patients — even with insurance — increased 133%, to $2,526, for each patient discharged and 644%, to $3,020, for those hospitalized.
“The burden of firearm injury on the health care system is large and quantifiable,” the authors conclude.
A Closer Look at Readmission Costs
Just because a patient is admitted to a hospital for a firearm injury and later discharged doesn’t mean their healthcare for the injury is over. A number of those discharged are later admitted to another hospital, potentially accounting “for a significant hidden burden in terms of rate and cost of hospitalization after a firearm injury,” write the authors of a May 2018 paper in the Annals of Surgery, the first national study to explore readmission to a different hospital following a firearm injury.
“Hidden Costs of Hospitalization After Firearm Injury,” Rishi Rattan, et. al. Annals of Surgery, May 2018.
Using 2013 and 2014 data from the Nationwide Readmissions Database, a sample set of about half of all U.S. hospitalizations, the researchers analyzed 45,462 patients admitted for a firearm injury. Of those, 7.6% were readmitted within 30 days. Among readmissions, 16.8% went to a different hospital.
The authors observe higher rates of readmission for patients publicly insured or uninsured, those with a self-inflicted firearm injury, those over age 65 and those who had major surgery. About 20% were readmitted for infection.
Patients were more likely to be readmitted to a different hospital if they had been originally treated at a for-profit hospital. Those readmitted to a different hospital also tended to be younger and less severely injured. The authors calculate an additional $65.5 million per year in readmission costs overall. Patients publicly insured or uninsured account for $44 million of the yearly readmission costs, the authors find.
Pediatric Hospital Admissions
Studies on firearm injury costs often include patients of any age, but a May 2020 paper in the Journal of Pediatric Surgery takes a specific look at patients under age 18. The authors use the readmissions database to identify 13,596 children admitted for a firearm injury from 2010 to 2014. “While guns cause significant morbidity, disability, and premature mortality in children, they also have a substantial economic impact,” the authors write.
“Human and Economic Costs of Pediatric Firearm Injury,” Hallie Quiroz, et. al. Journal of Pediatric Surgery, May 2020.
Of the 12,799 children who survived their initial admission and were discharged, 6% were readmitted within 30 days and 12% of readmissions were to a different hospital.
Total cost of hospitalization for children injured by firearm discharge: $382 million, nearly $96 million per year studied. The authors attribute $40 million of the total to readmissions. They assume one or more parents or guardians will need to take time off work to care for a child injured by a firearm, adding $38 million in lost productivity.
Opportunity Costs: Work Loss and Quality of Life
Health economists think of lost productivity in terms of opportunity costs. Dollar amounts are often derived from average wages for the age and sex of the person injured by a firearm discharge, the severity of the injury and other factors. The inability to work for a period of time is an opportunity cost — in other words, someone injured by a firearm temporarily or permanently loses the opportunity to work.
And work doesn’t necessarily mean traditional paid employment. Economists often calculate the value of unpaid household work and caregiving costs for the injured when tallying firearm injury costs. Society incurs the highest amount of lost productivity when people die from firearm injuries, particularly those who are younger, because they will have lost a higher number of potentially productive years.
The nonprofit, nonpartisan Pacific Institute for Research and Evaluation is one go-to source for information on the economic costs of gun injuries and deaths. Academic researchers use their data, and so does the CDC, though the agency only offers national cost estimates related to gun injuries from 2010.
Ted Miller, a senior researcher at the Pacific Institute who helped develop the cost formula the CDC uses, worked with Everytown for Gun Safety on their February 2021 report about the economic costs of firearm violence. The report is the most recent, comprehensive analysis of the national costs of firearm injuries and fatalities. Media outlets have covered or cited the report numerous times since it was published.
Everytown is a nonprofit organization that advocates for gun control and is largely financed by former New York City Mayor Michael Bloomberg. The total annual cost of gun violence was $280 billion in 2018, according to the report.
Miller and Everytown attribute $51.2 billion to work loss, with the bulk of the total costs — $214.2 billion — coming in the form of quality-of-life losses.
Quality-of-life encompasses the “intangible costs that quantify — based on jury awards and victim settlements — the pain, suffering, and lost overall well-being that a person and their family experience due to gun death and injury,” according to the report.
The National Suicide Prevention Lifeline is a hotline for individuals in crisis or for those looking to help someone else. To speak with a certified listener, call 1-800-273-8255.
Plus, explore our coverage of how journalists perpetuate the myth that suicides rise during winter holidays, how news coverage of celebrity suicides often falls short of expert guidelines and 7 things journalists should know when reporting on guns.
Clark Merrefield is the senior economics editor at The Journalist’s Resource where he has worked since 2019.