Clinton Counts Cost of Violence in Health Plan

The dispatcher’s voice crackled over the hospital loudspeaker. “Code yellow. Gunshot wound to the head.” Moments later, the paramedics wheeled a young victim in. His hair was bloody and matted. His eyes, rolled upward, were fixed wide open. His mouth was agape. His heart had shut down.

The doctors and nurses scrambled. They pushed a tube down his throat, pounded on his chest and injected him with Adrenalin. They tried to jump start his heart; his arms jerked forward wildly with each electric shock. Meanwhile, the dispatcher was on the loudspeaker again: “Another code yellow. Another gunshot wound will be here in a minute.”

This was a slow night at Washington Hospital Center, home to one of the busiest trauma centers in the murder capital of America. Night after night, the surgeons practice an unusual brand of battlefield medicine; in fact, many of them are military doctors who come here to prepare for battlefield medicine.

But their services do not come cheap, and, because the victims seldom carry insurance or are able to pay their own way, the cost of treatment falls on taxpayers.

For years, medical professionals, health economists and hospital administrators have complained that violence is taking a devastating--and expensive--toll on the nation’s health. Many call it an epidemic, and their frustration is heightened by their belief that violence, like AIDS and lung cancer, can be prevented.

So when President Clinton complained last month in his health care reform speech about “the outrageous cost of violence,” doctors and nurses across the land nodded in agreement.

“It’s about time somebody took some note of it,” said Dr. Howard Champion, the unit chief. “This is a huge public health problem. Here they are scurrying around trying to save money on health-related issues and doing something about this epidemic of violence is a very reasonable candidate.”

The costs of violence are staggering, both in human and economic terms. It is the nation’s 12th leading cause of death and the No. 1 cause of death and disability for people age 15 to 34. Young black men are more likely to be murdered than to die of any other cause. An estimated 4 million women are raped each year, according to the U.S. Centers for Disease Control and Prevention, and 1.5 million children are abused.

As a top adviser to Health and Human Services Secretary Donna Shalala said: “Any time you have that many people dying of anything, it’s a public health issue.”

Depending on who is counting, the United States spends from $5.7 billion to $18 billion a year on medical care for victims of violence--and experts agree those estimates are conservative. By comparison, the nation spent $10 billion last year to treat people infected with the AIDS virus, $11 billion on strokes and $13 billion on diabetes.

“It clearly is a cost area that is expanding,” said Ted Miller, a medical economist for the National Public Services Research Institute in Landover, Md. “If we are not going to have the cost of national health care explode on us, one of the things that we need to do is to control the cost of violence.”

Death--from a strictly financial perspective--is cheap. The biggest costs are driven up by those who survive the violence. They can spend weeks or months in intensive care and rehabilitation, not to mention the long-term costs of lost wages and productivity. Quite often, those racking up medical bills are not covered by insurance.

In Los Angeles County, a one-year study that ended in 1990 estimated that taxpayers spent $53 million to care for gunshot victims alone. At County-USC Medical Center, which conducted the survey, 686 patients were admitted for torso bullet wounds. These patients spent a total of 4,666 days in the hospital. Just 30 had private health insurance. Nearly half had no coverage at all.

In city after city, the story is the same. At Ben Taub Hospital in Houston, officials estimate that 95% of victims of crime-related injury carry no health insurance. Roger Widmeyer, the hospital’s spokesman, recounted an unofficial survey he conducted:

“I just picked a day, like you’d pick a bean out of a hat, and there were 10 gunshots on that day,” he said. “The cheapest one was an $8,033 bill, and that was a robbery victim and he had insurance. The most expensive bill of the remaining nine was $63,700. None of those had any kind of compensation at all. In other words, we ate it.”

And at Washington Hospital Center, officials estimated that $8 million of their $450-million budget goes to free care for violence victims. Hospital Vice President Mark Merrill said that 42% of patients admitted through the trauma unit lack insurance.

A visit to the first-floor intensive care unit seems to prove his point. There, a 31-year-old man rests fitfully under heavy sedation. The victim of a bullet in the spine, he is hooked up to a ventilator. He has been there for three weeks, at an average cost of $3,500 a day. His doctor says that he will be paralyzed for life.

The nurse flips open his chart. In the three boxes for insurance, there are three blanks. And upstairs, there are three more patients like him.

How does the facility pay for this? “We cross-subsidize them,” Merrill explained, somewhat euphemistically, meaning that the hospital jacks up the price of other services--heart surgery, appendectomies and the like--that generally are paid for by insured patients.

Violence has other ripple effects. When emergency departments and intensive care units are tied up with gunshot and stabbing victims, there is less room for the sick. Martin Luther King Jr./Drew Medical Center in Los Angeles, for instance, treats 380 gunshot victims each month--so many that 60% of them are cared for as outpatients because there is no room inside the hospital.

“It’s not unusual for our intensive care units and our recovery room areas to be overloaded by patients who have just received surgery because of gunshot wounds,” said Dr. Reed V. Tuckson, the former Washington health commissioner who is now president of Drew University School of Medicine. Often, less pressing surgeries must be delayed because there are so many gunshot victims, he said.

Should Clinton’s package of universal health care be adopted, hospitals would benefit financially. But the cost of this care simply would be shifted to taxpayers, who would pay for indigent health care. The real answer, Tuckson and others said, lies in prevention.

Public health experts believe that the nation could be spared both the tragedy and the expense of violence if it were treated as a public health problem. This is not a new idea--the CDC founded a violence prevention program a decade ago--but it is one that is just taking hold in Washington.

Some credit Atty. Gen. Janet Reno for bringing the concept to the public’s attention and helping inject it into the health care reform debate. Shedding the traditional law enforcement emphasis on punishment and prisons, Reno has been traveling the nation talking about the “root causes” of violence, visiting hospitals and suggesting that more attention be paid to preventing it when children are very young.

Reno also has teamed up with Shalala on the issue. Next week, a new federal task force on violence, led by top advisers to the two women, will begin a four-month effort to draft the Administration’s strategy for curbing violence.

Dr. Mark Rosenberg, the CDC’s top expert on violence, has been instrumental. “It’s very important to do what the criminal justice sector does, to intervene after violence occurs,” he said. “Our emphasis is on prevention. That’s a real paradigm shift, the notion that we can prevent it not just by incarceration but by changing the behaviors of very young people.”

Clearly, the Administration buys the argument. When she testified before House committees Tuesday, First Lady Hillary Rodham Clinton, who led the White House Task Force on National Health Care Reform, declared: “Violence is a public health problem. . . . We are committed, as you are, to trying to eliminate the level of violence in this country, both as a moral matter but also as a health care imperative.”

But some public health experts and elected officials have complained that, if the Administration is serious about curbing violence, Clinton would have proposed taxes on alcohol and ammunition--which contribute to the problem--as well as taxing cigarettes to help fund his health package.

At a Senate Finance Committee hearing Thursday, Sen. Bill Bradley (D-N.J.) called for an increase in fees on gun dealers, describing it as “a tax directly on the purveyors of violence.” Replied Mrs. Clinton: “I’m all for that.”

With or without fees and taxes, prevention will not be easy. Rosenberg points to other behavioral changes that have improved the nation’s health: Seat belts and air bags have cut down on traffic deaths. Anti-smoking campaigns have helped keep a lid on lung cancer. Lowering cholesterol helps prevent heart disease.

But while there have been “a string of successes” on these fronts, he conceded that there is no tried-and-true method for preventing violence.

In an effort to figure out what works, the CDC has initiated pilot projects to prevent youth violence in Brooklyn, N.Y., Durham, N.C., and Houston. The programs, which cost $1 million a year and will last from three to five years, are designed to offer young people job training, education, recreation and counseling in how to resolve conflicts peacefully.

Private agencies and community groups are following suit. Among them is the California Wellness Foundation--a nonprofit group that announced $12 million in violence prevention grants in July.

At Washington Hospital Center, Champion has helped organize a program for doctors, nurses and other health education professionals to teach young people how to control their anger, and explain how drugs and alcohol contribute to violence.

Yet in Champion’s own unit, the staff is not optimistic. They have seen too many code yellows, too many gunshot wounds in the head, too many “wooden shampoos”-- street slang for a beating with a baseball bat.

“He mentioned violence,” said nurse Ann Ile, referring to Clinton. “But can these people be reformed . . ? Everybody says it’s the guns, it’s the guns, it’s the guns. It’s not the guns. It’s the people.”