On a Sunday afternoon in June of 2006, a young man we'll call Michael Robinson was shot six times on a street in his West Oakland neighborhood. Paramedics rushed the bleeding seventeen-year-old to Highland Hospital's trauma center, where a medical team treated his wounded legs, arms, and abdomen. Although they stopped his bleeding quickly, and the bullets just missed his major organs, Robinson still needed multiple surgeries. Like approximately 95 percent of the patients treated for violent injuries at Highland Hospital, he had no health insurance.
By the time Robinson left the hospital nine days later, he had racked up a $75,000 bill. In addition to the three emergency medical technicians who kept him alive on the way to the hospital, he required a team of nearly twenty staff members, including a respiratory therapist, an anesthesiologist, two nurses, four surgeons, and several lab and radiology technicians.
Following his stay, Robinson received a bill for his hospital care, but he couldn't pay it. Instead, California taxpayers covered most of it through MediCal, the state's health insurance program for low-income residents. That is often the case with medical bills accrued by the victims of violence, a majority of whom are less than thirty years old and have low incomes.
"Usually MediCal will cover all or most of it," said Nic Bekaert, Highland Hospital's community injury prevention coordinator, who helps such patients figure out how to cover their jaw-dropping bills and avoid falling into debt. "But a lot of them do carry around these bills for whatever reason. Typically they don't do much about it, so it goes through collections and stays with them for a while."
Patients who aren't eligible for MediCal or can't receive help from California's victim compensation program are expected to pay for their care out of pocket. But that rarely happens. Instead, trauma centers like Highland end up eating the costs of such care. And the last few years have been undeniably expensive for Highland's trauma center and emergency room.
As Oakland's murder rate spiked in the past three years, it has been accompanied by a corresponding increase in violent injuries, car crashes, and other nonviolent trauma, which often tend to mirror violence trends. In 2007, Highland's trauma center treated 2,337 patients, more than 40 percent of whom were victims of violence. Treating them alone cost the hospital about $33 million, Bekaert said, and that may be a lowball figure, because Highland typically underbills its patients. It also doesn't include the millions more spent treating the scores of less severe violent injuries that bypassed trauma and were handled directly in the emergency room. Nearly half of those trauma patients had been shot, the rest stabbed or assaulted.
As callous as it may seem to be equating lives with dollars, the financial costs of gun violence are clearly staggering. The last comprehensive national report was released in 1999 by the Journal of the American Medical Association. Using records and costs from 1994, it reported that 134,445 gunshot injuries produced $2.3 billion in lifetime medical costs, of which $1.1 billion was paid by taxpayers. When financial considerations such as lost productivity are factored into the equation, the Brady Campaign to Prevent Gun Violence has estimated that taxpayers shoulder about 85 percent of the costs of gun violence.
Indeed, the increased rates of violence in some cities, along with the rising costs of health care, pose a major financial challenge to public hospitals. Andres Soto, Alameda County's violence prevention coordinator, noted that the King/Drew Medical Center in Los Angeles closed down its trauma center in 2004 partly due to the costs of treating gunshot victims from the city's South Central neighborhood.
Shootings and violent crime have an enormous price tag by any measure. But while the price of treating victims — not to mention the associated law enforcement and incarceration costs — continually skyrocket, advocates complain that violence-prevention efforts are consistently underfunded. "I don't know what moves people," said Dr. Rachel Steinhert, an emergency physician at Contra Costa Regional Medical Center. "To me, it seems crazy that there isn't more of a movement. It's clearly preventable ... I'm not sure if the public cares."
If society isn't motivated to invest in violence-prevention out of concern for the well-being of crime victims, advocates hope that perhaps it can be motivated to do so by understanding the explosive costs of treating the victims of violence.
Highland Hospital's trauma center is much smaller than one might expect given the volume, and high drama, of patients who come through here. Located just off the main lobby of the massive county institution, the trauma ward is next to the emergency room and consists of two modest-sized rooms. Both were empty on a recent afternoon, when the calm of the place made it hard to imagine a flurry of medical personnel frantically trying to keep a wounded teenager alive.
Paramedics typically decide if a patient's condition is serious enough to merit trauma activation. Less life-threatening cases, violence-related or otherwise, are generally taken to the emergency room, which treats about 40,000 patients annually. If, for instance, someone is grazed by a bullet but not in need of immediate intervention, they'll go to the ER, a generally less costly destination.
Trauma itself is a relatively new form of medicine. Federal law requires access to local trauma centers, and any injury deemed a trauma by paramedics must be treated there. As Northern Alameda County's only such center, all trauma injuries in the region go through Highland regardless of the patient's economic status. Among the 2,337 people treated last year, violent injury accounted for 40 percent of visits, followed by car crashes, and then falls. "We're the end of the line," said Bekaert, a hint of pride in his voice. "If you get seriously injured, you go to Highland. If it's anything else, you want to go anywhere else."
Trauma doctors say the average cost of treating a gunshot wound is $40,000, although some professionals assert that the tab is more than double that, Bekaert said. Individual patients' bills ranged from $1,000 to $1.5 million last year, he added.
"You can easily see how the manpower and resources quickly add up," said Dr. Gregory Victorino, Highland's chief trauma surgeon. But in the heat of trying to save a life, such financial factors are irrelevant, he added. "Resources and time don't enter into my mind," said Victorino, one of nine Highland trauma surgeons. "Initially, it doesn't matter why they're here. We're just trying to take care of them the best we can and save their life."
The resources, medical talent, and heroics poured into saving a life are at times staggering — particularly considering the simplicity of the actions that usually inflict the damage.
Even a patient with no pulse upon arrival at the hospital can rack up a costly bill. Until all medical conditions defining death are met, he will continue to receive CPR in the trauma room. "The trauma team cannot make a determination of whether a patient is Do Not Resuscitate, so they do everything they can to save the patient's life, regardless of any other information they have," Bekaert said. "Naturally, there is no determination of an intervention being too costly to proceed. Everything is done, no questions asked."