Guns and Taxes

by | August 19, 2021

This year is shaping up to be another horrific one for gun violence. With over 27,000 deaths from firearms in the US reported as of August 12th, fatalities will likely exceed last year’s 43,559 deaths. Gun violence is so commonplace that only large-scale carnage in the form of mass shootings makes the news nowadays. The United States leads every single highly developed nation in gun fatalities. It has the second highest number of gun deaths globally, topped only by Brazil. Make no mistake, this is the cost of our domestic policy regarding firearms and the permissiveness of gun acquisition.

I am a general and trauma surgeon, and, unfortunately, I see my fair share of patients injured by guns. I remember standing over a schoolgirl shot by a classmate who had brought his father’s gun with him in his backpack; it discharged when he dropped his bag on the ground, tearing a hole through her 8-year-old body. I remember her scared yet curiously inquisitive eyes staring up at me as I offered what reassurance I could muster in that moment, before bundling her off to the operating room. I remember sliding my scalpel across the delicate skin of her abdomen, the red welling up through my incision as we quickly stuffed packing sponges to staunch the blood. I remember distinctly thinking how not ok this all was, how unnecessary and tragic, how preventable. 

Over the course of my career, I have seen wounds in the elderly and in the very young, but the vast majority are working age adults. While some are lucky and walk out of the hospital within hours or days as the result of flesh wounds, many suffer much longer-term consequences: shattered bones and severed nerves, spinal cord damage, bowel injuries requiring them to defecate into a bag. These injuries have monumental social and psychological costs. They also have real financial costs for patients, hospitals, insurance programs, and state and federal governments.

I don’t think about costs or billing when caring for injured patients, and I suspect most trauma surgeons don’t spend much time during clinical care thinking about these issues either. But as a society we must. Hospitals cannot run on charity alone and the costs involved are substantial. They also tend to fall most heavily on poorer hospitals that do not have much margin for unreimbursed expenditure. These safety net hospitals in both urban and rural areas are financially strained by uncompensated care.

We as a country have made policy choices that have allowed the spread of weapons among our population, yet we have not fully accounted for the costs and financial impacts of these decisions. Simply paying for hospitalizations for patients injured by firearms has cost the US health system over $9 billion over the last decade. This cost is spread across three major payer groups: federal and state governments through Medicare and Medicaid programs, private insurance, and patients themselves who are uninsured or underinsured. Government sponsored programs, particularly Medicaid, contribute approximately 45% to these costs; private insurance pays for just over 20% of hospitalization costs. Over 30% of the costs of hospitalization are the responsibility of individual patients or are written off as charity care. With an average hospitalization costing upwards of $32,000 per incident, the cost burden for anyone, much less an uninsured patient, is catastrophic.

These numbers belie the true costs of firearm injuries. While some 40,000 US residents die, at least 85,000 are injured (hospital costs mostly accrue to these individuals, as the dead tend not to rack up large medical bills) and hospital payments do not account for ongoing medical expenses, lost wages, long-term care, lost opportunity, and broken lives, to say nothing of the physical and psychological trauma of injury and of the legal and police actions. A full accounting of such costs has been estimated at over $17 billion a year. There are important financial implications of our policy choices regarding firearms. 

Unsurprisingly, states that are most permissive in their gun policies are also the states with the highest per capita medical costs for hospitalizations from firearm injuries. Ironically, these states are also the ones that are least likely to have expanded insurance coverage under the Affordable Care Act or participated in insurance collectives to improve financial security for health care. Financial costs of firearm injuries are thus uncoupled from policy choices at the state level, meaning that those least able to bear the cost are most likely to bear the brunt of firearm injuries, an exceptionally anti-poor approach.

This is particularly true in southern states. Of the overall costs of hospitalizations for firearm injuries, the southern region, which hosts 37% of the US population, is responsible for 42% of the medical costs. Government insurance programs cover 34% of the costs in this region, while self-pay costs account for 28%. In contrast, the Northeast, which hosts 18% of the US population, is responsible for only 14% of the hospitalization costs for firearm injuries, and government programs cover 56% of the costs; self-paying patients are responsible for 18% of total costs. Of particular note, there are no differences in costs per hospitalization, indicating that these costs are driven by the volume of injuries and not by their severity or differences in billing or treatment. States with lax gun laws have a high burden of firearm injuries, account for a large proportion of the costs of treating these injured patients and shift the burden of paying for these medical costs onto the injured themselves through their failure to expand insurance programs under the Affordable Care Act. Under the mantle of free choice and personal responsibility, these deliberately anti-poor policies are impoverishing and unjust: over 70% of patients hospitalized with firearm injuries are in the bottom half of income earners.

Our policies are, of course, informed by our legal system and the fundamental rights afforded to us as Americans. First off is the right to bear arms enshrined in Article 2 of the Bill of Rights. While current court readings of the Second Amendment downplay the “well-regulated militia” clause, the actual right to bear arms is not contested. What continues to be debated, however, are the regulations around firearm purchase, procurement, and safety, with a specific focus on the concept that all rights come with responsibilities.  

There is, however, another responsibility of the federal government, one of setting taxes. Taxes on goods, in particular “luxury” and “sin” taxes, are the government’s mechanism to prompt consumers to make specific purchasing choices. As Adam Smith noted in The Wealth of Nations, “Sugar, rum, and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.” There is no reason why states should not try to cover the costs of permissive gun policies that lead to high medical and social expenditure through taxes specifically designed to close such funding gaps. 

There are other potential mechanisms to address the epidemic of firearm violence in the US, some of them more practical than others. While prohibition has worked in other countries such as the UK and Australia, which have seen precipitous declines in firearm injuries following stringent laws and widespread buy-back programs, such a policy is unconstitutional in the US, as currently interpreted, and may not be entirely desirable even if it were achievable. Background checks, waiting periods, permits, formalized training programs, and safe storage strategies are all extremely important for improving firearm safety; many are innocuous and used to be fundamental National Rifle Association (NRA) priorities. Waiting periods may be particularly useful for reducing suicide risk, the major cause of firearm deaths in the US. None of these strategies, however, bend the cost curve when it comes to paying for injuries.

Costs could potentially be recovered through two additional mechanisms: insurance premiums and tort law. 

Smokers pay higher medical insurance premiums – it is not unreasonable for gun owners to pay higher insurance premiums given the additional risks posed by a firearm in the home. Supplemental gun owner insurance might work in a similar way as auto insurance. As a doctor I have malpractice insurance; might gun owners have similar insurance? Still, neither insurance policy approach solves the issue of the poor, uninsured, or underinsured receiving catastrophic medical bills, or enables hospitals to recoup the costs of care for wounded patients. 

Within tort law, the Protection of Lawful Commerce in Arms Act provides broad protection to gun manufacturers from liability, even though the technology exists to improve the safety of firearms through smart sensors and improved engineering. Many states have additional blanket immunity laws to protect gun manufacturers—no other manufacturer has such a protected carve out from lawsuit risk.  

Direct taxation is the most immediate solution to covering costs of firearm injuries. Taxes might be levied at the point of sale, or further upstream at the point of manufacturing. Taxes can be further gradated based on certain types of products – semi-automatic and high-calibre weapons, bump stocks, specialty ammunition – that pose more immediate risks in urban environments or populous areas.

Taxes have been used to drive behaviors in the past. While such policies may not change the interest in, or market for, firearms, they could help cover the costs of care and prevent further societal ills that come from medical impoverishment. 

Hospitals cannot simply close. Care cannot simply stop if someone cannot pay the bills. We all pay these costs in the form of hospital subsidies to keep critical facilities up and running. The costs are hidden in plain sight. 

Gun costs are an enormous issue. Honest accounting is essential. It is long overdue. Few topics are more likely to lead to heated debate than guns and taxes. But it is a debate we need to have if we are to fix what is truly broken.

About the Author

Thomas G Weiser is an Associate Professor of Surgery in the Department of Surgery at Stanford University. He practices general, trauma, and emergency surgery and surgical critical care at Stanford Healthcare, an American College of Surgeons accredited Level I Trauma Center. Tom is also a Senior Clinical Lecturer at the University of Edinburgh.

In addition to his clinical work, Tom is a health services researcher focusing on quality care and strategies for improving the safety and reliability of complex care delivery. From 2006-2009 he worked with the World Health Organization’s Safe Surgery Saves Lives program where he helped create, evaluate, and implement the WHO Surgical Safety Checklist, a critical safety tool for surgical teams. He helped author the surgical volume of the Disease Control Priorities Project, a World Bank initiative that identified a cost-effective suite of emergency and essential operations. Tom also assisted the Lancet Commission on Global Surgery with data analysis that informed its key message highlighting the important role of surgery in a strong and well-functioning health system.

He is the Consulting Medical Officer for Lifebox, a charity devoted to improving surgical and anesthetic safety worldwide.

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