Everyone negatively impacted by gun violence hopes it is the shot heard around the world. Yet in the United States, the drumbeat of gun-related deaths and injuries — accidental or not — marches on. How many deaths per day? 100. How many injuries per day? 200. Who’s at greater risk? Those living in households with guns. Those living in the South. Those living in poorer neighborhoods. Where there are more guns, there is more gun-related death and injury.
Public health problems require multi-stakeholder solutions. Sadly, most private payers have generally done little to help curb gun violence. Other than some low-cost member education on gun safety, meaningful and likely impactful efforts are hard to find. Interested in resources about gun safety from federal public payers? You won’t find any. By ignoring this problem, payers miss the mark.
Where have all the payers gone?
The Affordable Care Act (ACA) allows group health plans and insurers offering group or individual coverage to provide benefits for wellness and health-promotion activities, including:
- Smoking cessation
- Weight management
- Stress management
- Physical fitness
- Nutrition
- Heart disease prevention
- Healthy lifestyle support
- Diabetes prevention
But in the name of the protection of Second Amendment gun rights, the ACA explicitly prohibits those who offer programs like these from collecting information about a member’s lawful use, ownership, possession, or storage of a firearm or ammunition. The act also bars payers from requiring members to disclose this information, collecting or storing this information, or using it to determine premium rates or health insurance eligibility.
This is terribly disappointing. How are wellness programs and the Second Amendment in conflict? They are not mutually exclusive. Imagine someone like Lin-Manuel Miranda cleverly looking back at this important historical event in a fast-paced rap song with a driving beat, listing the eight wellness program dos and the one don’t — perhaps with a refrain like “not the guns… no, no, not the guns.”
So, what happened? The gun lobby applied pressure and the legislative process buckled, just as it has done for decades. Who was in the room where it happened? Apparently, then-Senate Majority Leader Harry Reid (a pro-gun Nevada Democrat) inserted this language into the bill after it cleared the Senate Finance Committee before a full Senate vote. How many deaths and injuries that could have been prevented if payers could have had and used this information? Thanks, Harry!
Perhaps payers think the ACA’s Second Amendment restrictions amount to a bulletproof vest, shielding them from flak for not doing more member education and research into triggers of gun violence. And it appears as if payers did not attempt to fight these wellness program restrictions in the courts.
In systems’ crosshairs
Kaiser Permanente’s $2 million investment in gun-injury prevention is a noteworthy exception. The late Bernard Tyson, Kaiser’s former chairman and CEO, said “We know that firearm injury is a leading cause of preventable death in the U.S., and we can leverage our research capabilities combined with our deep clinical experience to help tackle this issue.” Maybe Kaiser’s research capabilities enable it to be a leader. More likely, the philosophy of Kaiser’s executive leadership and it being headquartered in a progressive state with a rich history of taking on thorny issues challenging the nation allow it to take a leadership role.
And perhaps Kaiser, the nation’s largest private integrated delivery system, is embracing gun-injury prevention as a health care provider rather than as a payer. Perhaps Harry Reid, the NRA, and the others in the room where it happened failed to recognize that integrated systems are both payers and providers. Whereas the ACA restricts payers, a unanimous ruling by a federal appeals court in Florida made it clear in 2017 that Second Amendment rights do not override providers’ First Amendment rights to discuss gun safety with their patients. While the ACA restrictions were intentionally broad, they failed to plug the loophole available to providers and health systems.
Kaiser and some other large integrated systems may find it easier to shoot down objections to investments in population health like gun-violence prevention. For example, Intermountain Healthcare’s Zero Suicide program is, among other things, offering gun locks to patients at high risk for suicide, and has a specific, measurable, time-bound objective to reduce suicide rates in Utah by 10% by the end of 2021. Northwell Health’s $1 million investment in its Center for Gun Violence Prevention is yet another example of a health system leading change, and Northwell is planning to integrate information with its electronic health record to target high-risk patients for counseling. Not only can these systems address gun-violence prevention, they want to.
Talk more, and let them know what you’re for
Medical associations have taken a clear stance. Last year, AMA President Patrice Harris said, “Common-sense steps, broadly supported by the American public, must be advanced by policymakers to prevent avoidable deaths and injuries caused by gun violence.” The AMA makes it clear which gun-control policies it supports. The American Academy of Pediatrics, the American Psychiatric Association, and the American College of Surgeons similarly issue strong policy statements supporting gun safety and/or gun violence-prevention laws.
Actions speak louder than words, but words can lead to action. But what does America’s Health Insurance Plans (AHIP), the trade group representing payers, say about gun violence? Nothing. Search for AHIP statements on guns and all you’ll find is mention of how the opioid crisis is deadlier than gun violence. The NRA works hard to be a silencer, but payers don’t have to be silenced.
Payers and their actuaries know that gun-injury prevention makes economic sense, but apparently have not yet concluded how gun-injury prevention makes political sense. Just what are they waiting for? The vast majority of the public and most gun owners support gun-control legislation. The fact that our laws do not reflect the will of the people speaks volumes of how so many lawmakers are still beholden to the NRA. Some payer executives may be concerned that policy statements in support of gun control and gun-violence prevention may offend some board members, team members, clients, and members. But maybe they should also consider how silence can offend many more. Just as companies are eliminating their Facebook advertising for the social media giant’s failure to stop the spread of hate speech on its platform, employers can require payers to take a clear public stance on gun-violence prevention to earn their business or can build related questions into requests for proposals.
Ready, aim, fire
Payers know how to manage effective wellness programs that protect patients’ privacy and confidentiality and that are neither discriminatory nor coercive. And payers have the capability to mine their big data, develop predictive analytics, and implement effective interventions. Payers are uniquely qualified to help prevent gun injury and death.
Now is the time for payers to speak out via policy statements, educate members, offer free gun locks, conduct research, and better prepare for days ahead when they can take a more active role preventing gun violence by targeting at-risk members for counseling and other gun violence-prevention services.
Stop the violence.
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