About a month ago, on September 26, President Joe Biden and the White House announced a bevy of executive actions intended to help prevent gun violence. We covered those in brief a few weeks ago, but in this issue of The Trajectory, we’re zooming in on one particular public health effort that could have a broad effect on safer storage and violence prevention — potentially reducing both suicides and community gun violence.
The White House announced that the federal agency that oversees Medicaid, the insurance program for low-income Americans, is developing a plan that will allow state Medicaid agencies to reimburse health care providers for screening patients for gun injury risk, counseling them on safer storage practices, and sharing violence prevention resources.
Why that matters: Like anything else, it’s hard to scale an initiative without dollars to back it. If these services can get that funding, it may prompt a kind of waterfall effect, where Medicaid makes it easier for doctors to offer a service, hospitals opt in, and then it becomes more widely implemented, potentially by private health insurers.
“The communities Medicaid is designed to serve, many of them are the same communities that are suffering from gun violence,” Greg Jackson, a deputy director of the White House Office of Gun Violence Prevention, said last week during a briefing. “For so many of these communities, the number one health threat is the threat of gun violence, and now we’re able to offer real resources and solutions for them.”
To get a better understanding of what this effort could mean at hospitals across the country, I spoke with Dr. Chethan Sathya, a pediatric trauma surgeon at Cohen Children’s Medical Center in New York City. Aside from his work there, he’s also a gun violence prevention researcher and the director of the Center for Gun Violence Prevention at Northwell Health, New York state’s largest hospital system.
As part of a research project funded by the National Institutes of Health, Sathya has overseen a first-of-its-kind protocol to universally screen patients at Northwell’s emergency departments for firearm injury risk — a massive undertaking that has involved coordinating with hundreds of providers across three large trauma centers. As the federal government gears up to provide a stable stream of funding for this type of care, his federally funded project will likely be a blueprint for other hospitals to follow.
Our conversation has been edited for length and clarity.
What’s most significant about this effort?
Medicaid is administered partly by the federal government and partly by states. This is a big move toward pushing the Centers for Medicare and Medicaid Services (CMS) — which oversees Medicaid — to start reimbursing more firearm injury prevention activities within health care.
They’ve already moved forward with reimbursing hospital-based violence intervention efforts.
The major piece of this executive action is that they expanded that to include safe storage counseling and screening for firearm injury risk. This is the first time CMS has been directed to explore reimbursing these activities, which could be transformational.
How could safe storage counseling and screening for firearm risk help prevent gun injuries and deaths?
Gun violence covers a wide spectrum, from firearm suicides to mass shootings in schools, to community interpersonal violence and unintentional injuries at home, like when a child or someone else gets ahold of a gun that’s not secured safely.
Each type of gun violence is different in its root causes and potential solutions. That’s really important to understand, because we need a range of interventions to address the entire epidemic. If we don’t approach it with nuance, we’ll apply solutions meant for one type of firearm injury to another, which won’t be effective.
Specifically, safe storage counseling has been shown in studies to promote safety practices — such as keeping firearms locked, unloaded, and storing ammunition separately — which reduces unintentional injuries at home, public mass shootings (because many shooters get guns from their parents), and suicides. There’s no question that safe storage has a significant impact on those three areas.
When it comes to community and interpersonal violence, the root causes are more tied to structural inequities like lack of housing, employment, and education — in addition to guns. I would argue that safe storage policies and counseling are less likely to affect that type of gun violence. That’s where hospital-based and community violence intervention efforts have made a real difference in some cities.
This is clearly a health care issue. Gun violence is the leading cause of death among kids and a major public health crisis in this country. There is a lot of value in reframing it as a health care conversation, rather than a political one, which helps destigmatize the issue. Health care has really transcended that polarization when it comes to a lot of other topics. Doctors have done this with other stigmatized topics like substance use, HIV, and tobacco. When these became part of health care conversations, they were reframed around safety. At the end of the day, that’s what this is about — safer communities and safety for your family.
What is it about bringing this conversation into the health care setting that takes the politics out of it?
In today’s society, it’s become really difficult to have tough conversations, whether around the family dinner table or with friends, because we’re living in such a polarized environment. But despite what you might see — with public health workers not being as trusted and misinformation spreading — that patient-doctor relationship has been preserved.
We see that patients and families, regardless of their political views, still trust those relationships. It doesn’t mean they’ll always follow your advice, but they are at least willing to listen. And right now, there are many new gun owners in this country who may not fully understand the risks.
We already talk to families about other safety issues, like wearing helmets, dog safety, drowning prevention, smoking, and vaping. This conversation about firearm safety fits right into that.
So this conversation isn’t about vilifying anyone or coming at it from a judgmental angle. It’s about empathizing with why people have guns while also empathizing with the fact that they want to keep their families safe. That’s where the solutions come into play with the advice we give. The guidance we provide is centered on that — helping them achieve safety.
We already talk to families about other safety issues, like wearing helmets, dog safety, drowning prevention, smoking, and vaping. This conversation about firearm safety fits right into that. And when it’s framed that way, families are much more receptive.
That’s because families want to keep their loved ones safe. They want less violence in their communities. No one wants mass shootings. No one wants loved ones to die or shoot somebody. This executive action promotes those conversations in a way that centers on family safety, rather than politics, for the first time.
What is the significance of Medicaid being involved here?
When it comes to hospitals, we need to understand that there are funded and non-funded mandates. If health care workers and hospitals are asked to take on extra work, like firearm safety screening, without any funding, it’s hard to scale those programs. This is true for any initiative, like substance use screening, for example.
Medicaid funding provides a revenue stream that incentivizes both providers and hospitals to perform screenings, recognizing it as a reimbursable part of preventive care and value-based care. Hospitals and providers are reimbursed based on the value and prevention-focused care they offer, and firearm risk screening should be no different.
There’s already a major push to address social determinants of health by helping patients with housing, food security, mental health, and substance use screening. This is similar because it’s also preventative care, and that’s the role Medicaid funding plays.
Medicaid is administered at the state level. Is this optional, and is there a risk that some states won’t take advantage of it?
Yes, that’s absolutely correct. There is a risk that some states won’t move forward with this. [But] if you look at what happened with Medicaid reimbursement for violence prevention, only a handful of states took action at first, but more states are joining in every year. It’s just a matter of time before this becomes more widely implemented.
If there’s a mechanism for states to get reimbursement or increased funding for screening, you might be surprised how many will start moving forward, especially when hospitals begin advocating for it as a way to gain Medicaid reimbursement.
Looking ahead, there’s also the possibility that this Medicaid initiative could influence commercial payers to include firearm screening as part of value-based preventive care, bundled with other social health interventions. These are stepping stones toward broader implementation.
When that happens, hospitals across the country will start adopting these practices, and states will want to be part of it. That’s the ultimate goal, though we still have some time before we get there.
You’ve pioneered universal screening at Northwell. How have your patients, their families, and caregivers responded to these conversations, and what have you learned from doing that?
We’ve conducted 70,000 screens, and the response has been overwhelmingly positive. Northwell is a large health system serving Long Island, Westchester, and all five boroughs of New York City. So we see a wide variety of people across the political spectrum. Despite that, 99.5 percent of these conversations have been positive. There’s been no loss of trust, and the conversations haven’t harmed the therapeutic relationship with patients and families. They view it as a safety conversation.
People are proud of the work we’re doing. That wasn’t the case when we started four years ago — there was hesitation, even from health care workers. But now, our team members have really embraced this, the community talks about it, and patients expect to be asked these questions when they come to the hospital. In fact, when they aren’t asked, they actually question why not.
In terms of effectiveness, we’re actively measuring outcomes. About 15 to 20 percent of patients screen positive for either violence risk or firearm access risk, which is quite high. We then provide interventions, including gun locks or connecting patients to violence intervention resources.
We’re conducting an efficacy trial to measure whether these interventions lead to behavior changes, such as safe firearm storage or utilizing violence prevention resources. Anecdotally, it seems to be working, and the preliminary data suggests there is behavior change, but we’re still actively in the process of fully measuring outcomes.
When you say you screen for firearm access risk and firearm violence risk, what does that mean? Is it just asking if someone has a gun at home, or is it more specific?
There’s often a narrow focus on firearm access when we talk about gun violence screening. One of our questions is simply, “Do you have access to a firearm within or outside of the household?” If the answer is yes, we then provide firearm safety counseling, offer gun locks, and collaborate with gun owners and the community to promote safety. But in many communities, limiting the screening to firearm access alone doesn’t capture the whole picture. For instance, it wouldn’t make sense to give a gun lock to a 13-year-old living in a community where their main concern is being shot in their neighborhood.
So we expanded our screening to include questions that assess violence risk as well. For example, we ask, “In the last six months, how many times have you heard gunshots?” or “Have you had a gun pulled on you?” There’s a series of other questions that help us assess someone’s risk of being involved in violence.
If someone screens positive for violence risk, instead of giving gun safety counseling and locks, we provide violence prevention resources to prevent the gunshot before it happens.
Can you explain how this is different from the hospital-based violence intervention program (HVIP) model?
The typical HVIP model, which is great and makes sense in resource-limited situations, steps in after someone has been shot. A credible messenger, often someone who has experienced gun violence themselves, meets the patient in the emergency department. They work with the patient, whether a child or adult, to help manage the situation and prevent further conflict. These messengers often partner with community violence intervention groups to offer opportunities that keep kids out of gangs or other dangerous situations, breaking the cycle of violence.
We know that people who get shot, especially in interpersonal violence, are very likely to be shot again. HVIP programs have been very effective in reducing that risk.
If your child is playing with a loaded gun, it’s only a matter of time before something happens. Those conversations can prevent a tragedy, and it happens more often than you’d think.
What we’re doing with screening is taking it a step earlier. If someone screens positive for violence risk, we already know they have a high chance of being shot. So instead of waiting for them to be shot and then stepping in, we can offer services that might prevent the shooting in the first place.
That’s the main difference — it’s more about primary prevention, addressing the risk before the violence occurs, rather than secondary prevention, which happens after someone has already been harmed.
Can you talk a bit about your experience working in pediatrics and how these conversations may help prevent gun injuries in children?
When it comes to gun violence, which really refers to firearm injury and mortality in the U.S., it’s still the leading cause of death among children. There are so many mothers and parents we’ve talked to who didn’t fully understand the risks of having a loaded firearm in the house. We hear it all the time — they’ve changed the way they store their firearms just because of a simple conversation.
We often assume everyone knows what we mean by “safe storage,” but many people don’t. We’ve had situations where parents only realized their kids were playing with guns in the house because we brought it up during screening. That’s a near-miss event, right? If your child is playing with a loaded gun, it’s only a matter of time before something happens. Those conversations can prevent a tragedy, and it happens more often than you’d think.
On the violence side, many kids live in communities where they fear being shot. Through this program, we’ve been able to offer mentorship opportunities, work with community violence intervention groups, provide employment opportunities, and more.
One case stands out — a 12-year-old girl died after being shot in the chest, and we couldn’t save her. Her brother became close with us and shadowed our team at the hospital. Before that, he said he felt hopeless, like he had no other option, along with his friends, but to follow the same path. But now he’s on his way to becoming a nurse, and those four friends are all interested in healthcare as well. That kind of transformation can really make a difference, giving kids a path forward and changing their lives. It’s another example of how these conversations and interventions can move the needle on gun violence.
