Category Archives: Shootings

Fact Check: Are there ‘more gun deaths by far’ in America than any other country? And what is the GOP going to do about IT?

Screen Shot 2019-08-26 at 9.19.29 PMThis is another very long post but gun violence and the solutions need to be center stage going forward. We in health care see the results of gun violence every day in our hospitals, ERs, and offices. Texan Beto O’Rourke joined nine other Democrats on stage in Detroit on Tuesday for the second round of debates in the Democratic presidential primary contest. All of the candidates made questionable statements — take a look at some fact-checking from the night — including O’Rourke, who was asked to respond to a comment about gun violence from Montana Gov. Steve Bullock.

Bullock said that Washington, D.C., “is captured by dark money” and political influence from the likes of the NRA and Koch Industries, making it hard for lawmakers to tackle issues like gun safety.

“That’s the way we’re actually going to make a change on this, Don, is by changing that system,” Bullock said, addressing moderator Don Lemon of CNN. “And most of the things that folks are talking about on this stage we’re not going to address until we kick dark money and the post-Citizens United corporate spending out of these elections.”

Lemon asked O’Rourke to respond to Bullock’s point.

“How else can we explain that we lose nearly 40,000 people in this country to gun violence, a number that no other country comes even close to, that we know what all the solutions are, and yet nothing has changed?” O’Rourke said. “It is because, in this country, money buys influence, access and, increasingly, outcomes.”

We assumed O’Rourke was talking about the number of gun deaths in the United States in the past year, a figure supported by federal data. But is O’Rourke right that no other country comes close to the number of deaths by gun violence in the United States? We took a look.

By Chris Nichols on Tuesday, August 6th, 2019 at 5:32 p.m.

Following the recent mass shootings in Gilroy, California and El Paso, Texas, and just hours before a separate mass shooting in Dayton, Ohio, California Democratic Sen. Dianne Feinstein made a sweeping statement about the number of guns and gun deaths in America.

“There are more guns in this country than people and more per capita than any other country in the world. And there are more gun deaths by far,” Feinstein, a strong advocate for gun control, said on Twitter on Aug. 3, 2019. “I continue to hope that opponents of commonsense gun reform laws will come to their senses and join the effort to save lives.”

Sen. Dianne Feinstein, D-CA, posted this tweet on Aug. 3, 2019.

As of early this week, 22 people were killed in the El Paso shooting, nine in Dayton and three in Gilroy. The suspected gunmen in Dayton and Gilroy also died.

We examined each part of Feinstein’s statement but found we couldn’t place a Truth-O-Meter rating on the first two parts because there’s no official count on the number of guns in America and there are competing estimates on how many exist.

We did place a rating on the last portion about America having “more gun deaths by far” than any other country.

We’ll provide analysis on each piece of Feinstein’s statement below.

Feinstein on guns

First, here’s some background on the senator. In 1994, she authored the Federal Assault Weapons Ban, which was signed by President Bill Clinton. It prohibited the manufacture of 19 specific kinds of military-style, semi-automatic firearms, often called assault weapons.

It also banned the manufacture and sale of gun magazines that hold more than 10 bullets.

The bill expired in 2004 after efforts to extend it failed in Congress.

Its restrictions did not apply to any semi-automatic weapons or magazines made before the ban’s effective date: Sept. 13, 1994.

Feinstein has remained an advocate for gun control. In February of this year, she introduced a bill that would pay for states to create their own extreme-risk protection laws, also known as red flag laws.

Those would allow family members to petition for a court order to “grant law enforcement the authority to temporarily take weapons from dangerous individuals who present a threat to themselves or others,” according to Feinstein’s office.

California, Maryland, and Florida have already enacted similar laws.

“There are more guns in this country than people” 

There are no official count of the number of firearms in the United States, only widely varying estimates, as PolitiFact has reported in the past.

As the Pew Research Center has observed: “Gun ownership is one of the hardest things for researchers to pin down.”

We found estimates as low as 265 million civilian guns in the U.S. in January 2015 — to as high as 393 million in a report last year.

Researchers say estimates can include guns that no longer work, leading to an overcount. Meanwhile, some survey respondents will understate the number of guns they own, leading to an undercount.

With no definitive tally, we decided not to place a rating on this portion of Feinstein’s statement.

“More (guns) per capita than any other country in the world”

This second part of the claim is generally on the right track, whether looking at the high estimates for guns in America or the lower ones. But again it relies on a topic for which there’s no settled data.

Taking the estimate of 393 million civilian firearms, there would be 120.5 guns for every 100 residents in the United States. As The Washington Post reported, that’s twice the per capita rate of the next-highest nation, Yemen, with just 52.8 guns per 100 residents.

Using the lower estimate of 265 million guns in 2015 would still produce about 83 guns for every 100 Americans that year.

While this part of Feinstein’s claim is likely more accurate, the per capita rate doesn’t mean all Americans own guns. Instead, gun ownership is concentrated among a minority of the US population — as surveys from the Pew Research Center and General Social Survey suggest, according to the Post.

“More gun deaths by far” in the United States?

This part of Feinstein’s statement is not supported. We found the United States experiences more firearm injury deaths than other countries of similar socioeconomic standing. But that’s not what Feinstein claimed. She suggested it had “more gun deaths by far” than any other country.

In 2017, Brazil had the most overall gun deaths of any country at 48,493, including homicides, suicides and unintentional gun deaths, according to a June 2018 report by the University of Washington’s Institute for Health Metrics and Evaluation.

The United States had the second most overall gun deaths at 40,229, though it had the highest suicide by a gun total of any nation, at nearly 25,000. Data from the report showed Brazil had the most overall gun deaths at least from 2015 through 2017.

“Yes, Brazil is highest by number” for overall gun deaths, the study’s author, Professor Moshen Naghavi, said by email.

“We believe 2018 and 2019 will be higher,” Naghavi said in a follow-up phone interview, citing decisions made by Brazil’s new president to make firearms more accessible.

Feinstein’s office did not respond to our request for information supporting this portion of her statement.

PolitiFact Texas fact-checked a similar claim last week by former Rep. Beto O’Rourke and rated it Mostly False. O’Rourke said at the Democratic presidential debate in Detroit that “we lose nearly 40,000 people in this country to gun violence, a number that no other country comes even close to.” It cited the University of Washington study and noted that more than a dozen countries had more firearm deaths per capita than the United States in 2016.

Our rating

Sen. Dianne Feinstein claimed, “There are more guns in this country than people and more per capita than any other country in the world. And there are more gun deaths by far.”

We could not place a rating on the first two parts because there are no official count of guns in America, only widely varying estimates.

The last part of her statement, however, is not supported. A recent study showed Brazil, not the United States, had the most overall gun deaths of any country over the last several years. America, however, had the highest total of suicides by firearm of any nation.

In the end, she was wrong that there are “more gun deaths by far” in the United States than any other country in the world.  Here are two charts/tables with data.

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We rate that portion of her claim False.

FALSE – The statement is not accurate.

America’s gun culture in charts

Two mass shootings within 24 hours, leaving 31 people dead, has once again brought the spotlight on gun ownership in the United States.

An attack on a Walmart store in El Paso, Texas on Saturday left 20 dead, while nine died in a shooting in Dayton, Ohio on Sunday.

But where does America stand on the right to bear arms and gun control?

What do young people think about gun control?

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When looking at the period before the Parkland school shooting in 2018, it is interesting to track how young people have felt about gun control.

Support for gun control over the protection of gun rights in America is highest among 18 to 29-year-olds, according to a study by the Pew Research Centre, with a spike after the Orlando nightclub shooting in 2016. The overall trend though suggests a slight decrease in support for gun control over gun rights since 2000.

Pew found that one-third of over-50s said they owned a gun. The rate of gun ownership was lower for younger adults – about 28%. White men are especially likely to own a gun.

How does the US compare with other countries?

I included two charts in the previous discussion and here are two more.

About 40% of Americans say they own a gun or live in a household with one, according to a 2017 survey, and the rate of murder or manslaughter by firearm is the highest in the developed world. There were almost 11,000 deaths as a result of murder or manslaughter involving a firearm in 2017.

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Homicides are taken here to include murder and manslaughter. The FBI separates statistics for what it calls justifiable homicide, which includes the killing of a criminal by a police officer or private citizen in certain circumstances, which are not included.

In about 13% of cases, the FBI does not have data on the weapon used. By removing these cases from the overall total of gun deaths in the US, the proportion of gun-related killings rises to 73% of homicides.

Who owns the world’s guns?

While it is difficult to know exactly how many guns civilians own around the world, by every estimate the US with more than 390 million is far out in front.

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Switzerland and Finland are two of the European countries with the most guns per person – they both have compulsory military service for all men over the age of 18. The Finnish interior ministry says about 60% of gun permits are granted for hunting – a popular pastime in Finland. Cyprus and Yemen also have military service.

How do US gun deaths break down?

There have been more than 110 mass shootings in the US since 1982, according to the investigative magazine Mother Jones.

Up until 2012, a mass shooting was defined as when an attacker had killed four or more victims in an indiscriminate rampage – and since 2013 the figures include attacks with three or more victims. The shootings do not include killings related to other crimes such as armed robbery or gang violence.

The overall number of people killed in mass shootings each year represents only a tiny percentage of the total number.

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Figures from the Centers for Disease Control and Prevention show there were a total of more than 38,600 deaths from guns in 2016 – of which more than 22,900 were suicides. Suicide by firearm accounts for almost half of all suicides in the US, according to the CDC.

A 2016 study published in the American Journal of Public Health found there was a strong relationship between higher levels of gun ownership in a state and higher firearm suicide rates for both men and women.

Attacks in the US become deadlier

The Las Vegas attack in 2017 was the worst in recent US history – and eight of the shootings with the highest number of casualties happened within the past 10 years.

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What types of guns kill Americans?

Military-style assault-style weapons have been blamed for some of the major mass shootings such as the attack in an Orlando nightclub and at the Sandy Hook School in Connecticut.

Dozens of rifles were recovered from the scene of the Las Vegas shooting, police reported.

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A few US states have banned assault-style weapons, which were totally restricted for a decade until 2004.

However, most murders caused by guns involve handguns, according to FBI data.

How much do guns cost to buy?

For those from countries where guns are not widely owned, it can be a surprise to discover that they are relatively cheap to purchase in the US.

Among the arsenal of weapons recovered from the hotel room of Las Vegas shooter, Stephen Paddock were handguns, which can cost from as little $200 (£151) – comparable to a Chromebook laptop.

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Assault-style rifles, also recovered from Paddock’s room, can cost from around $1,500 (£1,132).

In addition to the 23 weapons at the hotel, a further 19 were recovered from Paddock’s home. It is estimated that he may have spent more than $70,000 (£52,800) on firearms and accessories such as tripods, scopes, ammunition, and cartridges.

Who supports gun control?

US public opinion on the banning of handguns has changed dramatically over the last 60 years. Support has shifted over time and now a significant majority opposes a ban on handguns, according to polling by Gallup.

But a majority of Americans say they are dissatisfied with US gun laws and policies, and most of those who are unhappy want stricter legislation.

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Some states have taken steps to ban or strictly regulate ownership of assault weapons. Laws vary by state but California, for example, has banned around 75 types and models of an assault weapon.

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Some controls are widely supported by people across the political divide – such as restricting the sale of guns to people who are mentally ill, or on “watch” lists.

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But Republicans and Democrats are much more divided over other policy proposals, such as whether to allow ordinary citizens increased rights to carry concealed weapons – according to a survey from Pew Research Center.

Who opposes gun control?

The National Rifle Association (NRA) campaigns against all forms of gun control in the US and argues that more guns make the country safer.

It is among the most powerful special interest lobby groups in the US, with a substantial budget to influence members of Congress on gun policy.

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In total, about one in five US gun owners say they are members of the NRA – and it has especially widespread support from Republican-leaning gun owners, according to Pew Research.

In terms of lobbying to influence gun policy, the NRA’s spending jumped from about $3m per year to more than $5m in 2017.

The chart shows only the recorded contributions to lawmakers published by the Senate Office of Public Records.

The NRA spends millions more elsewhere, such as on supporting the election campaigns of political candidates who oppose gun controls.

GOP Waits to See if Trump Will Protect It From the NRA Before Moving on Gun Laws

Sam Brodey Noted that just over a week since mass shootings in El Paso, Texas, and Dayton, Ohio, Senate Republicans are waiting to see if President Trump walks away from the issue again or forces their hand before trying to do anything about potentially expanding background checks for gun purchases.

He’s walked away before. Following the Parkland school massacre last year, the president promised that he was “going to be very strong on background checks,” only to retreat after holding private meetings with National Rifle Association officials at the White House. The NRA, a key ally of Trump’s, has spent big money lobbying against background-checks expansion legislation, and last week reminded him of its staunch opposition.

After the latest shootings, Trump told reporters that there is great “appetite” on the Hill to finally get something done on background checks but his GOP allies in the Senate are holding off, unwilling to burn political capital with the gun lobby and conservative-base voters on the issue if Trump isn’t going to burn some of his.

However, the president’s prior inaction, and the media coverage he incurred for it, may force him to make at least a slightly harder run at background checks this time around, even if only in his messaging and bluster. Two people who’ve spoken to the president in recent days say that he has referenced, during conversations about how he could possibly bend the NRA to his will in this case, his annoyance at media coverage of his post-Parkland about-face that suggested he was all talk and no action on the issue, and easily controlled by the NRA. One of the sources noted that Trump’s aversion to being seen as “controlled” by anyone or any organization makes it much more likely that the president will dwell on the issue for longer than he did last year.

Trump’s influence could well make or break legislation, since Republicans are unlikely to support anything without his blessing but will be just as hesitant to immediately reject a bill he puts his full support behind.

“Many Hill Republicans are waiting to see what Trump will get behind,” said a Senate GOP aide. “He gives them political cover. I don’t think you’re going to see any one bill or one proposal get any momentum until the President publicly endorses it.”

Senate Majority Leader Mitch McConnell (R-KY) said on Thursday that he and the president are actively discussing possible avenues for gun legislation. “He’s anxious to get an outcome and so am I,” said McConnell on a radio show in Kentucky.

The GOP leader stressed that the president was open to a discussion on gun legislation, from background checks to “red flag” bills: “Those are two items that for sure will be front and center as we see what we can come together on and pass.”

A spokesman for McConnell declined to elaborate on the Senate leader’s conversations with the president.

Democrats aren’t holding their breath, given that McConnell won’t call the Senate back from its recess for gun bills and that Trump has backtracked before on the issue after outcry from pro-gun factions of his base.

Democratic aides have been mindful of Sean Hannity’s reaction to the background checks push, since Trump’s position has been known to change based on the broadcasts or private counsel of Hannity and other top Fox personalities.

White House aides are similarly waiting on Trump, and talking up how he’s also been reaching out across the aisle to find a potential solution, even if nobody knows what that would look like yet. “The president has been actively talking to Republicans and Democrats on the matter of background checks, and just being able to have meaningful, measurable reforms that don’t confiscate law-abiding citizens’ firearms without due process, but at the same time keep those firearms out of people who have a propensity toward violence,” Kellyanne Conway, Trump’s White House counselor, said on this week’s Fox News Sunday.

One of those Democratic politicians, Sen. Joe Manchin (D-WV), said in a call with reporters on Wednesday he had spoken to the president twice since the shootings in Dayton and El Paso and that he was “committed to getting something done.”

While “everything is on the table,” Manchin said, Trump’s sign-off on any plan will be key to getting it through the Senate. The proposal introduced by Sen. Pat Toomey (R-PA) and Manchin in the months after the massacre at Sandy Hook elementary made modest adjustments to background check system by extending checks to gun shows and internet sales, but exempted gun transactions between friends and family members. It also provided additional funding to states to put critical information into the National Instant Criminal Background Check System in order to prevent people who should not have guns from obtaining them, and created a commission to study the causes of gun violence.

It’s a bill that’s failed twice, once in 2013 and again after the mass shooting in a San Bernardino office park in 2015. Both times it drew very limited support from Republican senators.

Asked what had changed since the last time the bill failed on the Senate floor, Manchin said, “The political will wasn’t there.”

Manchin said he was told by some colleagues who opposed the bill that they really didn’t object to the substance of the bill but they weren’t convinced the “Obama administration wouldn’t go further [and try] taking more of their guns away from them.”

Manchin said he tried to explain that would be unconstitutional, but to no avail.

Some Trump allies say that this president, given his record and rhetoric, might have just enough credibility among Second Amendment enthusiasts to drag them along, if he so chooses.

“If only Nixon could go to China, then maybe only Trump can address the chasm between gun owners and those who want gun control,” Michael Caputo, a former Trump campaign adviser, told The Daily Beast. “He’s so strong on the Second Amendment he can truly do something to make a change when it comes to these mass shootings.”

Caputo, who in 2013 and 2014 advised Trump on pro-gun voters and the NRA when the celebrity businessman was weighing a run for New York governor, said that even years ago, “We talked about mass shootings and what that means to the United States, and the importance [to voters] of the Second Amendment, and I know the president has been thinking about this issue for a long time: How you balance gun rights versus gun atrocities.”

Trump’s former adviser added, “If the president pursues broader background checks… perhaps it’s because he knows that is something only he can do. He may lose the support of some of the most pro-gun members of his base, but the vast majority of us understand there are some reasonable measures to be taken.”

I will be very interested to see what happens in D.C. when Congress comes back from their vacation. Will they all together come up with realistic guns laws without the concern for the NRA? That includes the President and yes, both parties in both houses!

Firearm-Related Injury and Death in the United States: A Call to Action From the Nation’s Leading Physician and Public Health Professional Organizations; Politics and Solutions!

rifles364I have been so upset with the recent mass shootings and the lack of action to start the real discussion and solutions I thought that I would dedicate a few posts to this subject. The President and Congress had better get something done because the voters are pretty sick and tired of inaction and the GOP being afraid of the NRA. Get over it and do the right thing and come up solutions and more important, stop making it political!!!

Robert McLean, Patricia Harris, John Cullen, etc. of the AMA noted that shortly after the November publication of the American College of Physicians’ policy position paper on reducing firearm injury and death, the National Rifle Association tweeted:

Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.

Within hours, thousands of physicians responded, many using the hashtags #ThisIsOurLane and #ThisIsMyLane, and shared the many reasons why firearm injury and death is most certainly in our lane. Across the United States, physicians have daily, firsthand experience with the devastating consequences of firearm-related injury, disability, and death. We witness the impact of these events not only on our patients, but also on their families and communities. As physicians, we have a special responsibility and obligation to our patients to speak out on prevention of firearm-related injuries and deaths, just as we have spoken out on other critical public health issues. As a country, we must all work together to develop practical solutions to prevent injuries and save lives.

In 2015, several of our organizations joined the American Bar Association in a call to action to address firearm injury as a public health threat. This effort was subsequently endorsed by 52 organizations representing clinicians, consumers, families of firearm injury victims, researchers, public health professionals, and other health advocates. Four years later, firearm-related injury remains a problem of epidemic proportions in the United States, demanding immediate and sustained intervention. Since the 2015 call to action, there have been 18 firearm-related mass murders with 4 or more deaths in the United States, claiming a total of 288 lives and injuring 703 more.

With nearly 40 000 firearm-related deaths in 2017, the United States has reached a 20-year high according to the Centers for Disease Control and Prevention (CDC). We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731 000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths. The authors represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, American Medical Association, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, joins these 6 physician organizations to articulate the principles and recommendations summarized herein. These recommendations stem largely from the individual positions previously approved by our organizations and ongoing collaborative discussion among our leaders.

Background

In 2017, a total of 39 773 people died in the United States as a result of firearm-related injury—23 854 (59.98%) were suicides, 14 542 (36.56%) were homicides, 553 (1.39%) were the result of legal intervention, 486 (1.22%) were subsequent to unintentional discharge of a firearm, and 338 (0.85%) were of undetermined origin. The population-adjusted rates of these deaths are among the highest worldwide and are by far the highest among high-income countries. Firearm-related deaths now exceed motor vehicle–related deaths in the United States. Further, estimates show that the number of nonfatal firearm injuries treated in emergency departments is almost double the number of deaths. Firearm-related injury and death also present substantial economic costs to our nation, with total societal cost estimated to be $229 billion in 2015.

While mass shootings account for a small proportion of the nearly 109 firearm-related deaths that occur daily in the United States, the escalating frequency of mass shootings and their toll on individuals, families, communities, and society make them a hot spot in this public health crisis. Mass shootings create a sense of vulnerability for everyone, that nowhere—no place of worship, no school, no store, no home, no public gathering place, no place of employment—is safe from becoming the venue of a mass shooting. Mass shootings have mental health consequences not only for victims, but for all in affected communities, including emergency responders. Studies also show that mass shootings are associated with increased fear and decreased perceptions of safety in indirectly exposed populations. Preventing the toll of mass firearm violence on the well-being of people in U.S. cities and towns demands the full resources of our health care community and our governments.

Our organizations support a multifaceted public health approach to prevention of firearm injury and death similar to approaches that have successfully reduced the ill effects of tobacco use, motor vehicle accidents, and unintentional poisoning. While we recognize the significant political and philosophical differences about firearm ownership and regulation in the United States, we are committed to reaching out to bridge these differences to improve the health and safety of our patients, their families, and communities, while respecting the U.S. Constitution.

A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation consistent with the U.S. Constitution. Efforts to reduce firearm-related injury and death should focus on identifying individuals at heightened risk for violent acts against themselves or others. All health professionals should be trained to assess and respond to those individuals who may be at heightened risk of harming themselves or others.

Screening, diagnosis, and access to treatment for individuals with mental health and substance use disorders is critical, along with efforts to reduce the stigma of seeking this mental health care. While most individuals with mental health disorders do not pose a risk for harm to themselves or others, improved identification and access to care for persons with mental health disorders may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

In February 2019, 44 major medical and injury prevention organizations and the American Bar Association participated in a Medical Summit on Firearm Injury Prevention. This meeting focused on building consensus on the public health approach to this issue, highlighting the need for research, and developing injury prevention initiatives that the medical community could implement. Here we highlight specific policy recommendations that our 7 organizations believe can reduce firearm-related injury and death in the United States.

Background Checks for Firearm Purchases

Comprehensive criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, private sales, and transfers between individuals with limited exceptions should be required.

Current federal laws require background checks for purchases from retail firearm sellers (Federal Firearms License [FFL] holders); however, purchases from private sellers and transfer of firearms between private individuals do not require background checks. Approximately 40% of firearm transfers take place through means other than a licensed dealer; as a result, an estimated 6.6 million firearms are sold or transferred annually with no background checks. This loophole must be closed. In 2017, of the 25 million individuals who submitted to a background check to purchase or transfer possession of a firearm, 103 985 were prohibited purchasers and were blocked from making a purchase. While it is clear that background checks help to keep firearms out of the hands of individuals at risk of using them to harm themselves or others, the only way to ensure that all prohibited purchasers are prevented from legally acquiring firearms is to make background checks a universal requirement for all firearm purchases or transfers of ownership.

Need for Research on Firearm Injury and Death

Research to understand health-related conditions underpins the modern practice of medicine. In brief, medical research saves lives and improves health. Yet, despite bipartisan agreement that there are no prohibitions on the CDC’s ability to fund such research, research that would inform efforts to reduce firearm-related injury and death has atrophied over the last 2 decades. Consequently, we lack high-quality nationwide data on the incidence and severity of nonfatal firearm injuries. It is critical that the United States adequately fund research to help us understand the causes and effects of intentional and unintentional firearm-related injury and death in order to develop evidence-based interventions and make firearm ownership as safe as possible. Research should be nonpartisan and free of data restrictions to enable robust studies that identify robust solutions. Many of our organizations have affiliated with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), a nonprofit organization of health care professionals and researchers working to provide private funding for research related to firearm injury and its prevention. Both private and public funding are key to building a powerful evidence base on this important issue. Research for firearm injury and its prevention should be federally funded at a level commensurate with its health burden without restriction. To move from atrophy to strength requires not just allowing research, but also naming, appropriating, and directing funding for it and for the establishment of comprehensive data collection platforms to document the epidemiology of this growing public health crisis.

Intimate Partner Violence

Currently, federal laws prohibiting domestic abusers from accessing firearms do not apply to dating partners, even though almost half of intimate partner cases involved current dating partners. Federal law restricts firearm purchases by individuals who have been convicted of a domestic violence misdemeanor or have protective orders against them if they are a current or former spouse; a parent or guardian of the victim; a current or former cohabitant with the victim as a spouse, parent, or guardian; are similarly situated to a spouse, parent, or guardian of the victim; or have a child with the victim. It does not apply to dating partners, stalkers, or individuals who commit violence against another family member. This loophole in the background check system must be closed.

Safe Storage of Firearms

Keeping a firearm locked, keeping it unloaded, storing ammunition locked, and storing it in a separate location have all been associated with a protective effect. A 2018 study found that an estimated 4.6 million U.S. children are living in homes with at least 1 loaded and unlocked firearm. A large number of unintentional firearm fatalities occurred in states where firearm owners were more likely to store their firearms loaded, with the greatest risk in states where loaded firearms were more likely to be stored unlocked. Therefore, our organizations support child access prevention laws that hold accountable firearm owners who negligently store firearms under circumstances where minors could or do gain access to them. These laws are associated with a reduction of suicides and unintentional firearm injuries and fatalities among children.

Mental Health

The great majority of those with a mental illness or substance use disorder are not violent. However, screening, access, and treatment for mental health disorders play a critical role in reducing risk for self-harm and interpersonal violence. This is particularly of concern for adolescents, who are at high risk for suicide as a consequence of their often impulsive behavior. Access to mental health care is critical for all individuals who have a mental health or substance use disorder. This must include early identification, intervention, and treatment of mental health and substance use disorders, including appropriate follow-up. Those who receive adequate treatment from health professionals are less likely to commit acts of violence and individuals with mental illness are more likely to be victims rather than perpetrators of violence. Early identification, intervention, and access to treatment may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

Extreme Risk Protection Orders

Several states have enacted ERPO or ERPO-style laws, and numerous other states are considering them. We support the enactment of these laws as they enable family members and law enforcement agencies to intervene when there are warning signs that an individual is experiencing a temporary crisis that poses an imminent risk to themselves or others while providing due process protections.

Physician Counseling of Patients and “Gag Laws”

Confidential conversations about firearm safety can occur during regular examinations when physicians have the opportunity to educate their patients and answer questions. Such conversations about mitigating health risks are a natural part of the patient–physician relationship. Because of this, our organizations oppose state and federal mandates that interfere with physicians’ right to free speech and the patient–physician relationship, including laws that forbid physicians from discussing a patient’s firearm ownership. Patient education using a public health approach will be required to lower the incidence of firearm injury in the United States. Our organizations are working on programs and strategies that engage firearm owners in devising scientifically sound and culturally competent patient counseling that clinicians can apply broadly.

In the privacy of an examination room, physicians can intervene with patients who are at risk of injuring themselves or others due to firearm access. They can also provide factual information about firearms relevant to their health and the health of their loved ones, answer questions, and advise them on the best course of action to promote health and safety. Providing anticipatory guidance on preventing injuries is something physicians do every day, and it is no different for firearms than for other injury prevention topics. To do so, physicians must be allowed to speak freely to their patients without fear of liability or penalty. They must also be able to document these conversations in the medical record just as they are able and often required to do with other discussions of behaviors that can affect health.

Firearms With Features Designed to Increase Their Rapid and Extended Killing Capacity

The need for reasonable laws and regulations compliant with the Second Amendment regarding high-capacity magazine–fed weapons that facilitate a rapid rate of fire is a point of active debate. Although handguns are the most common type of firearm implicated in firearm-related injury and death, the use of firearms with features designed to increase their rapid and extended killing capacity during mass violence is common. As such, these weapons systems should be the subject of special scrutiny and special regulation. There are various strategies to consider, and our organizations look forward to a greater engagement and partnership with responsible firearm owners to determine how best to achieve this goal.

Conclusion

Physicians are on the front lines of caring for patients affected by intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provide support for families affected by firearm-related injury and death. Physicians are the ones who inform families when their loved ones die as a result of firearm-related injury. Firearm violence directly impacts physicians, their colleagues, and their families. In a recent survey of trauma surgeons, one third of respondents had themselves been injured or had a family member or close friend(s) injured or killed by a firearm. As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society. Our organizations are committed to working with all stakeholders to identify reasonable, evidence-based solutions to stem firearm-related injury and death and will continue to speak out on the need to address the public health threat of firearms.

Understanding gun violence and mass shootings

Columbia University studies showed that public mass shootings, once a rare event, now occur with shocking frequency in the United States. According to the Washington Post, four or more people are killed in this horrific manner every 47 days. The most recent mass shootings, in Dayton, Ohio, and El Paso, Texas, occurred less than a day apart and resulted in the loss of 31 lives.

With each fresh assault, politicians and the public have become more firmly entrenched in their beliefs about the root causes of mass shootings and about possible solutions, from more restrictive gun control laws to better mental health care.

Researchers across Columbia University’s campuses have put these theories to the test in an effort to identify effective strategies for preventing mass shootings and other forms of gun violence.

Mental Illness

Mental illness has long been suspected as a primary cause of gun violence and mass shootings in particular. But only 3% to 5% of violent events are attributable to mental illness, writes Paul Appelbaum, MD, director of the Division of Law, Ethics, and Psychiatry at Columbia University Irving Medical Center, in an opinion article in JAMA Psychiatry. “Much of the increased risk [of violence] in people with mental disorders is attributable to other variables rather than to the disorders themselves. Substance abuse, for example, accounts for a large proportion of the incremental risk.”

Further, Appelbaum writes, “compilations of incidents of mass shootings suggest that people with severe mental disorders may be overrepresented among the perpetrators, but given the possibility of bias in the nonsystematic collection of such data, firm conclusions are impossible at this point.”

Video Games

With little funding to study gun violence, “we tend to fall back on conclusions unsupported by evidence,” says Sonali Rajan, EdD, assistant professor of health education at Columbia University Teachers College in an interview published on the school’s website.

In a study published in PLOS ONE, Rajan and colleagues from NYU Langone found no association between video games and other types of screen time and gun ownership among teens. The researchers analyzed data from the CDC’s Youth Risk Behavior Surveillance System—which surveyed tens of thousands of teens about 55 different behaviors over a period of 10 years—to identify factors associated with carrying a firearm. “Among the 5% to 10% of American teens who report regularly carrying a firearm, there is a much stronger association with substance use, engagement in physical fighting, and exposure to sexual violence than with any poor mental health indicator,” explains Rajan.

Gun Laws

States with more permissive gun laws and greater ownership of firearms had higher rates of mass shootings than states with more restrictions on gun ownership, according to a recent study by Columbia researchers in the British Medical Journal. “Our analyses reveal that U.S. gun laws have become more permissive in past decades, and the divide between permissive states and those with more stringent laws seems to be widening in concert with the growing tragedy of mass shootings in the U.S.,” says senior author Charles Branas, Ph.D., chair of epidemiology at Columbia University Mailman School of Public Health, in an article on the school’s website.

“What happened in Las Vegas saddens me deeply,” Branas says in a previous interview for the Mailman School website. “But this is only the tip of a much larger gun-violence iceberg in the U.S. On the same day, hundreds more people across the U.S. were shot, adding up to somewhere around 100,000 shootings a year.

“We need to think beyond simply guns and people, and start thinking about the environment that is promoting these shootings in the first place,” writes Branas, whose research also has focused on transforming abandoned housing and other signs of urban and rural blight to improve community health and safety.

In other countries, the implementation of laws restricting the purchase of and access to guns in other countries has also been associated with reductions in gun-related deaths, according to a study from researchers at Columbia University Mailman School of Public Health. “While the research did not conclusively prove that restrictions, or relaxation of laws, reduce gun deaths, the results indicate that gun violence tended to decline after countries passed new restrictions on gun purchasing and ownership,” says co-author Sandro Galea, Ph.D., in an interview for the school’s website.

Aftereffects

Recent suicides among survivors of the mass shootings at Sandy Hook Elementary School and Parkland High School show that the effects of such violent events are long-lasting and entrenched.

“The public may be affected [by mass shootings] even if they were not in immediate proximity, because the media reifies the effects of a mass violent incident,” says Jeffrey Lieberman, MD, chair of the Department of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons, in a recent video interview for Medscape.

For survivors of violent events, “reminders such as anniversaries can prolong complicated grief or even reactive grief and trauma,” writes Kathleen Pike, Ph.D., director of the Global Mental Health WHO Collaborating Centre at Columbia University, in an article published on the center’s website. “Community supports matter not only in the immediate aftermath of traumatic events but also for individuals who continue to suffer over time.”

GOP Waits to See if Trump Will Protect It From the NRA Before Moving on Gun Laws

Sam Brodey, Asawin Suebsaeng and Jackie Kucinich reported that just over a week since mass shootings in El Paso, Texas, and Dayton, Ohio, Senate Republicans are waiting to see if President Trump walks away from the issue again or forces their hand before trying to do anything about potentially expanding background checks for gun purchases.

He’s walked away before. Following the Parkland school massacre last year, the president promised that he was “going to be very strong on background checks,” only to retreat after holding private meetings with National Rifle Association officials at the White House. The NRA, a key ally of Trump’s, has spent big money lobbying against background-checks expansion legislation, and last week reminded him of its staunch opposition.

After the latest shootings, Trump told reporters that there is great “appetite” on the Hill to finally get something done on background checks but his GOP allies in the Senate are holding off, unwilling to burn political capital with the gun lobby and conservative-base voters on the issue if Trump isn’t going to burn some of his.

However, the president’s prior inaction, and the media coverage he incurred for it, may force him to make at least a slightly harder run at background checks this time around, even if only in his messaging and bluster. Two people who’ve spoken to the president in recent days say that he has referenced, during conversations about how he could possibly bend the NRA to his will in this case, his annoyance at media coverage of his post-Parkland about-face that suggested he was all talk and no action on the issue, and easily controlled by the NRA. One of the sources noted that Trump’s aversion to being seen as “controlled” by anyone or any organization makes it much more likely that the president will dwell on the issue for longer than he did last year.

Trump’s influence could well make or break legislation, since Republicans are unlikely to support anything without his blessing but will be just as hesitant to immediately reject a bill he puts his full support behind.

“Many Hill Republicans are waiting to see what Trump will get behind,” said a Senate GOP aide. “He gives them political cover. I don’t think you’re going to see any one bill or one proposal get any momentum until the President publicly endorses it.”

Senate Majority Leader Mitch McConnell (R-KY) said on Thursday that he and the president are actively discussing possible avenues for gun legislation. “He’s anxious to get an outcome and so am I,” said McConnell on a radio show in Kentucky.

The GOP leader stressed that the president was open to a discussion on gun legislation, from background checks to “red flag” bills: “Those are two items that for sure will be front and center as we see what we can come together on and pass.”

A spokesman for McConnell declined to elaborate on the Senate leader’s conversations with the president.

Democrats aren’t holding their breath, given that McConnell won’t call the Senate back from its recess for gun bills and that Trump has backtracked before on the issue after outcry from pro-gun factions of his base.

Democratic aides have been mindful of Sean Hannity’s reaction to the background checks push, since Trump’s position has been known to change based on the broadcasts or private counsel of Hannity and other top Fox personalities.

White House aides are similarly waiting on Trump, and talking up how he’s also been reaching out across the aisle to find a potential solution, even if nobody knows what that would look like yet. “The president has been actively talking to Republicans and Democrats on the matter of background checks, and just being able to have meaningful, measurable reforms that don’t confiscate law-abiding citizens’ firearms without due process, but at the same time keep those firearms out of people who have a propensity toward violence,” Kellyanne Conway, Trump’s White House counselor, said on this week’s Fox News Sunday.

One of those Democratic politicians, Sen. Joe Manchin (D-WV), said in a call with reporters on Wednesday he had spoken to the president twice since the shootings in Dayton and El Paso and that he was “committed to getting something done.”

While “everything is on the table,” Manchin said, Trump’s sign-off on any plan will be key to getting it through the Senate. The proposal introduced by Sen. Pat Toomey (R-PA) and Manchin in the months after the massacre at Sandy Hook elementary made modest adjustments to background check system by extending checks to gun shows and internet sales, but exempted gun transactions between friends and family members. It also provided additional funding to states to put critical information into the National Instant Criminal Background Check System in order to prevent people who should not have guns from obtaining them, and created a commission to study the causes of gun violence.

It’s a bill that’s failed twice, once in 2013 and again after the mass shooting in a San Bernardino office park in 2015. Both times it drew very limited support from Republican senators.

Asked what had changed since the last time the bill failed on the Senate floor, Manchin said, “The political will wasn’t there.”

Manchin said he was told by some colleagues who opposed the bill that they really didn’t object to the substance of the bill but they weren’t convinced the “Obama administration wouldn’t go further [and try] taking more of their guns away from them.”

Manchin said he tried to explain that would be unconstitutional, but to no avail.

Some Trump allies say that this president, given his record and rhetoric, might have just enough credibility among Second Amendment enthusiasts to drag them along, if he so chooses.

“If only Nixon could go to China, then maybe only Trump can address the chasm between gun owners and those who want gun control,” Michael Caputo, a former Trump campaign adviser, told The Daily Beast. “He’s so strong on the Second Amendment he can truly do something to make a change when it comes to these mass shootings.”

Caputo, who in 2013 and 2014 advised Trump on pro-gun voters and the NRA when the celebrity businessman was weighing a run for New York governor, said that even years ago, “We talked about mass shootings and what that means to the United States, and the importance [to voters] of the Second Amendment, and I know the president has been thinking about this issue for a long time: How you balance gun rights versus gun atrocities.”

Trump’s former adviser added, “If the president pursues broader background checks… perhaps it’s because he knows that is something only he can do. He may lose the support of some of the most pro-gun members of his base, but the vast majority of us understand there are some reasonable measures to be taken.”

I do have more data comparing the gun violence in the U.S.A. to other countries, which I will save until next week. But the most important point of this post is that those who can make the difference, i.e. the President and Congress have to ignore the NRA and do the right things. I have included a number of options and most important is that we all can not wait for another media circus as they cover the next mass shooting or jus any shooting, especially where the offending weapon is an assault weapon.

Healthcare in 2018. Let’s Review!

48391556_1839791506150500_8003351817255649280_nAs the end of the year approaches I thought that I would try to review some of the progress, if I can find any. Probably the biggest invisible improvements the world sees year to year are essential indicators of overall global public health, like rates of infant mortality, maternal mortality, childhood stunting, and teen pregnancy. These are important, because they represent access the average person alive has to health-care professionals, facilities, medicine, and more. All of these rates have been falling in the past few decades, in some cases dramatically, and every single one fell again in 2018.

The Health of the World In 2018, By The Numbers

Reporter Susan Brink noted that at year’s end, global health numbers offer reason for both hope and despair.

There is one strong positive note. An overriding public health finding is that people are living longer. “If that’s not a bottom line reason for optimism,” says Dr. Ashish Jha, director of the Harvard Global Health Institute and the T.H. Chan School of Public Health, “I don’t know what is.”

And then there are the million-plus cases of cholera in Yemen — deemed “a hideous milestone for the 21st century” by the International Committee of the Red Cross.

Note: Because of the way global numbers are gathered, it’s too soon to report on health statistics from the year now drawing to a close. There are only a few yet available for 2018 — polio cases, for example, and Ebola deaths in Democratic Republic of the Congo.

But there has been a constant stream of numbers released from the years just past. Unless otherwise noted, the numbers below represent the worldwide population.

7 Of Our Most Popular Global Health and Development Stories Of 2018

Life Expectancy

Worldwide life expectancy in 2016 was 72 years, up from 66.5 years in 2000.

The gain of 5.5 years in worldwide life expectancy between 2000 and 2016 was the fastest gain since the 1960s and reversed the declines of the 1990s caused by AIDS in Africa and the fall of the Soviet Union.

But life expectancy has been ticking down in the U.S. for three years: it was 78.9 in 2014; 78.8 in 2015; 78.7 in 2016; and 78.6 in 2017. An increase in deaths from opioids and from suicide is a possible reason for the trend.

Child mortality rates for children under five years of age have fallen from 216 deaths per 1,000 live births in 1950; to 93 deaths per 1,000 live births in 1990; to 40.5 deaths per 1,000 in 2016; and most recently to 39.1 deaths per 1,000 live births in 2017.

Health Care

3.6 million people died in 2016 because they had no access to health care.

5 million people, despite having access to health care, died in 2016 because the quality of care they received was poor.

In 2010, the year that the Affordable Care Act was signed into law, 49.9 million people in the United States, or 16.3 percent of the population under age 65, were without health insurance. In 2017, that number dropped to 28.9 million uninsured, or 10.7 percent of that segment of the population.

Yet also in 2017, the number of uninsured Americans increased by nearly half a million — the first increase since the Affordable Care Act was implemented.

HIV/AIDS

36.9 million people were living with HIV in 2017.

940,000 people died of AIDS-related illnesses in 2017.

35.4 million people have died from AIDS-related illnesses since the epidemic was identified in 1981.

Ebola

11,325 people died of Ebola in the epidemic of 2014-2016 in West Africa.

As of Dec. 23, there have been 347 confirmed deaths so far in the current Ebola outbreak in the Democratic Republic of Congo.

Air Quality

Pollution contributed to the deaths of some 9.9 million people in 2015 by causing diseases such cancer, heart disease and respiratory illnesses. That’s three times more deaths than the death toll from AIDS, tuberculosis and malaria combined.

Murder

Roughly 385,000 people were murdered around the world in 2017.

Hunger

Some 821 million people around the world did not get enough to eat in 2017. resulting in malnutrition, and about 151 million children under five experienced stunted growth due to malnutrition.

An estimated 1.9 billion adults were overweight or obese in 2016. 41 million children under five are overweight or obese.

Cholera

There were 1,207,596 suspected cases of cholera in Yemen between April 2017 and April 2018.

The total estimated number of cholera cases worldwide ranges from 1.4 million to 4 million.

Vaccinations

Global vaccination rates against childhood diseases in 2017: 85 percent. That number has stayed steady for several years.

In 2017, about 100,000 children in the U.S. under two, or 1.3 percent of children that age, had not been vaccinated against serious diseases like measles and whooping cough.

The percentage of unvaccinated U.S. children has quadrupled from 0.3 percent in 2001 — shortly after the circulation of erroneous and disproven reports that vaccines cause autism.

Polio

The number of cases of polio worldwide in 2018 as of Dec. 25 was 29, compared to 22 in 2017. There were an estimated 350,000 cases around the world in 1988.

A mysterious polio-like disease, called acute flaccid myelitis that can paralyze patients, mostly children, appeared in the U.S. in 2014 with 120 confirmed cases from August to December. There were 22 confirmed cases in 2015, 149 confirmed cases in 2016, 35 confirmed cases is 2017 and 182 cases as of Dec. 21, 2018.

Guinea Worm

In 1986, guinea worm disease, an incapacitating disease that creates painful lesions, affected some 3.5 million people in Africa and Asia. As of Oct. 1, 2018, there were 25 reported cases of guinea worm disease worldwide: 1 in Angola; 14 in Chad, and 10 in South Sudan. One obstacle to wiping it out entirely: The worm can circulate in dogs.

Mystery Disease

Number of cases of Disease X: Zero. But that doesn’t mean the World Health Organization isn’t worried about it. They use the term Disease X to refer to a pathogen “pathogen currently unknown to cause human disease” but that has the potential one day to trigger a deadly pandemic.

Healthcare in Congress for 2019: All Hat, No Cattle, Experts Say

News Editor, Joyce Frieden, in her end of the year report, noted that the work Congress does on healthcare next year — and even the year after — will be mostly for show without a lot of concrete results, experts said.

“Probably nothing is going to happen legislatively in the next 2 years around healthcare” in terms of legislation that is actually passed by both the House and Senate and signed by the president, said Chris Sloan, a director at Avalere, a healthcare consulting firm, in a phone interview. “I think the Democrats in the House are going to use this as an opportunity to showcase their policy priorities for 2020 — things like ‘Medicare for All’ or a Medicare buy-in, taking votes on those and nailing down some specifics.”

“You will also see Democrats in the House use their oversight power over [the Department of] Health and Human Services (HHS) — to hold hearings, and give pushback around things the administration is doing around the Affordable Care Act (ACA) like the expansion of association health plans and cuts in funding for marketing and outreach in the [health insurance] exchanges,” he said.

Sloan also expects a lot of activity to occur around drug pricing. “I’m not expecting a major piece of legislation around drug pricing coming out, but it’s a huge issue with a lot of traction on the right and the left… so I’d expect in the House and the Senate [to see] hearings on drug pricing,” he said. “There’s always a chance that the Democratic House and the Republican president will come together on some piece of drug pricing — like transparency reporting — but I think it’s unlikely. So the next 2 years won’t be stagnant for healthcare; there will be a lot of policy development but no major bills.”

Julius Hobson, Jr., JD, senior policy advisor at Polsinelli, a consulting firm here, was a little more optimistic — but only a little. “The first thing on my list is prescription drug pricing,” he said in a phone interview. “If there is an opportunity for Republicans and Democrats to work out something together — provided neither side tries to overreach — that will be the one thing that has the possibility of being enacted.” Possibilities for drug pricing legislation include bills supporting reimportation, pegging U.S. drug prices to those in Europe, or giving HHS the authority to negotiate drug prices under Medicare and Medicaid.

“After that, I can’t find a health issue at the moment that I think the two sides could work on,” Hobson said. “But I think we’ll see more hearings on the oversight of the ACA, especially in the House, as administration officials get dragged in to see what they’re doing.” A House floor vote on a ‘Medicare for All’ bill is also a possibility — although it won’t pass — along with more oversight on veterans’ healthcare, he added.

One area that gets little attention is healthcare costs at the Department of Defense, which is the fastest-growing portion of the budget, said Hobson. “Having been in wars for 17 years, our healthcare costs are going through the roof.” Both President George W. Bush and President Obama pushed for having military members pay more of their costs under the Tricare health insurance program for military families, “but Congress refused to do that.”

Instead of action in Congress, most of the activity on the healthcare front will probably be within the Trump administration, he continued. “There will be more attempts to get things done — things [the administration] can do that Congress is unable to do.” Expect more efforts to come from the Office of Regulatory Reform at the Centers for Medicare & Medicaid Services, “which is consistent with an executive order from last year to come up with lists of regulations they could do away with to make the system less burdensome,” Hobson predicted.

Rodney Whitlock, vice president for health policy at ML Strategies, a consulting firm here, said in a phone interview that he expected some effort to pass a bill related to Texas vs. the United States of America — the court case questioning the constitutionality of the ACA — “and I think there’s something that looks a little more like ACA stabilization in the works… [The question is] what is the difference between the things where they’re trying to make a point versus what might be actually statutorily possible.”

Bob Laszewski, president of Health Policy and Strategy Associates, a consulting firm in Alexandria, Va., agreed with the idea that both parties will be focused on the drug pricing issue. “This seems to be about the only bipartisan interest and it will be interesting to see if there is any real agreement between them,” he said in an email. “Trump’s reference pricing proposal could be an interesting spot — will he find more Democratic allies than Republicans?”

Healthcare-related taxes imposed by the ACA but not yet implemented — including taxes on “Cadillac” health insurance plans and medical devices — are another possible area of cooperation, he said. “These have only been postponed and will have to be dealt with. There does seem to be broad agreement they should not be restarted.” And the pharmaceutical industry will be pushing back against a proposal to have it pay a larger share of drug costs in the Medicare Part D “donut hole,” he added.

Finally, “Democrats will have as their top priority rubbing salt into the Republican wounds on pre-existing conditions and the recent Texas court case,” Laszewski said. “I don’t see any opportunity for bipartisan fixes. With the Supreme Court more than a year away in terms of any final decision, this will be a very dark cloud in 2019.”

Bookended by Obamacare, 2018 was the year of policy change

As Susannah Luthi points out in 2018 tith Congress’ attempt to repeal the Affordable Care Act dead by the end of 2017, any relief the law’s supporters felt were likely short-lived, as 2018 was the year the Trump administration began significantly remolding a law it fundamentally opposes.

Led by HHS Secretary Alex Azar, who took the reins of the $1.2 trillion department last January, the administration charted an overarching strategy to lower drug prices and reduce spending on hospital care. Moreover, by the end of 2018, the entire Affordable Care Act was back in legal peril when a federal judge in Texas struck it down and blocked immediate appeal.

Here’s a look at the major healthcare political issues of 2018, a year when the public political drama slowed down, but activity aiming to overhaul the ACA sped up.

Drug prices

During Azar’s confirmation hearing last January, he faced skeptical Senate Democrats who argued his tenure as a top executive with pharmaceutical giant Eli Lilly & Co. could blunt the Trump administration’s promised plan to lower drug prices.

The skepticism didn’t abate when White House in May unveiled its blueprint. But as the policy bones gained muscle, Azar’s ideas have won over some doubters and drawn manufacturer ire.

“The biggest news item of the year is that the drug blueprint wasn’t hot air and that they’re really trying to do big things,” said Michael Adelberg, a healthcare consultant with the law firm Faegre Baker Daniels. “Like many others, I assumed it was mostly PR, but I think the administration deserves credit for taking this seriously.”

Among the most controversial policies: a mandatory international pricing index model for Part B physician-administered drugs to align prices with those in other countries.

Critics on the left who want Medicare to negotiate directly said the policy falls short. Investment analysts hope the proposal is a tactic to bring manufacturers to the negotiating table.

Critics on the right say it’s price-fixing.

“Proposing to effectively accept the pricing decisions of other countries, while having the chutzpah to brand the policy ‘market-based’ is beyond disappointing,” said Benedic Ippolito of the American Enterprise Institute.

Last month the administration also proposed a significant change to Medicare Part D that sparked outcry: room for price negotiation for drugs in protected classes, where Medicare costs are exceptionally high. Patient groups are fighting back over concerns about access, but the administration says Part D has substantial patient protections in place, and the chronically ill will always be able to get critical medications.

Site-neutral payments

HHS has also took action on site-neutral payments for Medicare, and despite pending litigation, analysts believe the political winds on the issue may have changed.

Last month the administration finalized a rule that will slash payments for office visits at hospital outpatient clinics to match the rate for independent physicians’ offices. In response, two powerful industry groups sued.

But nonpartisan experts have wanted to see this policy move—not only to address rising Medicare expenses but also consolidation and the rising costs that stem from that trend. “In an era of growing consolidation of providers and increasing physician employment by hospitals, site-neutral payments are critical on all dimensions,” said Paul Ginsberg, director of the USC-Brookings Schaeffer Initiative for Health Policy at the Brookings Institution.

Hospitals will keep fighting hard against them, Ginsberg added. But from his vantage point, analysts’ views on the issue have expanded to what’s at stake for the entire healthcare system in terms of this policy, and they are increasingly bipartisan.

“I’ve had the sense that (the administration) has long seen the issue of healthcare competition as something they can work with Democrats on,” he added. “And I think Democrats are much more comfortable using competition than they have been historically. So that’s a political dimension that makes it more promising that this policy could be sustained.”

340B program

The administration also trimmed reimbursement in the 340B drug discount program, which avoided congressional reforms despite Senate hearings and introduction of several House bills.

Hospitals had a key win late this year when HHS jumped ahead of its stated deadline and said it will start capping the prices manufacturers can charge providers for drugs. Regulation over ceiling prices for 340B has been delayed for years and early this fall hospitals sued over the latest postponement.

But litigation over the sweeping cuts to Part B drug reimbursements for 340B hospitals is still pending, and the administration has expanded those cuts to hospital systems’ off-campus facilities.

Affordable Care Act

A proposal to stabilize the individual market with a federal funding boost fell apart early in the year as a band of Republican-led states sued to overturn the law following the effective elimination of the individual mandate penalty for 2019.

Still, Obamacare may survive this attack. Sabrina Corlette, from Georgetown University’s Center on Health Insurance Reforms, said that in 2018 the law proved the doubters wrong. “It revealed remarkable resilience in the face of some pretty dramatic attempts to roll back or undo the law,” she said.

The individual market remains in a holding pattern. Shortly before open enrollment started this year, CMS Administrator Seema Verma touted the fact that premiums dropped for the first time since the law was implemented.

Premiums for benchmark silver plans on the federal individual market exchanges will drop in 2019, marking the first decrease since the Affordable Care Act was implemented, CMS Administrator Seema Verma announced on Thursday.

Verma attributed the 1.5% overall drop to looser regulations, the Trump administration’s market stabilization rule and the seven 1332 State Innovation Waiver approvals that launched reinsurance programs.

Tennessee will see the sharpest premium decline, as average monthly premiums for silver plans fell more than 26%, from more than $600 last year to $449. North Dakota had the greatest increase, with average premiums rising more than 20% from $312 per month to $375. Sixteen of the 39 states using the federal exchange will see declines, two states will have no change and the majority of the remaining states will face marginal, single-digit increases.

Verma dismissed the idea that President Donald Trump’s cut-off last year of the cost-sharing reduction payments hurt the market, although the action was followed by a nearly 40% jump in average premiums as insurers added the cost to benchmark silver plans in a move known as “silver loading.”

Analysts have credited the slim premium increases insurers have announced so far this year as a correction to excessive 2018 rate hikes.

But Verma defended the expansion of short-term, limited duration plans as an affordable option for people who can’t afford Obamacare plans. Potentially, they could appeal to the 20 million Americans who don’t have coverage, she added.

“The prediction was that the offering of short-term plans would have negative impact on the market and increase premiums, but we’re not seeing the impact on the market,” Verma said.

The administrator also announced the administration will be writing new guidance for 1332 waivers to allow states to broaden exchange plan design “to create more affordable options,” but said the new reinsurance programs are a key part of the overall drop in premiums.

Federal exchange states that launch reinsurance programs in 2019 will see decreases in premiums as expected, but prices will not fall to pre-2018 levels. Wisconsin, which had its 1332 waiver approved earlier this year, will see a drop in averages from $464 in 2018 to $440 for 2019. In 2017, average silver plan premiums in the state were just over $300. Maine’s average premiums will decline from $482 in 2018 to $446 in 2019, still more than $100 per month higher than the $316 in 2017.

New Jersey will see the sharpest decrease with its reinsurance waiver. In 2017, average silver premiums were $286 per month, rising to $339 per month this year. With reinsurance, they will settle in at $286 per month in 2019.

Last year, Alaska — which has the highest insurance premiums in the country — saw a drastic decline after implementation of its waiver. Average monthly premiums fell from $759 in 2017 to $595 in 2018. Next year they will drop again to $576.

The CMS hasn’t made enrollment projections for 2019 based on these new numbers, but Verma added that more people may opt for the federal exchanges “when we’re not seeing double-digit rate increases.”

Verma said the administration still wants changes to Obamacare’s exchange rules.

“For millions of people, the law needs to change,” she told reporters. ” While some have publicly been accusing us of sabotage, we have been doing everything we can to mitigate problems of Obamacare.”

The high cost of stabilization continues to trouble many. “ACA markets have stabilized at an unsatisfactory point,” said Douglas Holtz-Eakin, a conservative economist and former director of the Congressional Budget Office.

He said the deep cuts to marketing and other changes “all do matter at the margins” and that the slower enrollments noted this year have borne this out. “You have to decide what the administration’s objective is politically,” he added. “They don’t want to expand enrollment: they want it stabilizing,” but it’s coming at a high cost.

Adelberg said while plans aren’t “hemorrhaging money and going out of business” as they were in the early years, the exchange market still very much depends on subsidies and looks more like a tier of Medicaid.

“The exchange market is starting to look like Medicaid expansion-expansion,” he said.

The CMS has tweaked guidance for Section 1332 state innovation waivers, sparking criticism that the administration opened the door to trimming protections.

Potential actions from the administration take on extra weigh in light of the late-breaking court decision over Obamacare.

But even strong critics of the law doubt the administration would use the murky legal situation to cross statutory lines with waiver approvals in the meantime.

“No one wants to do anything in the interim, and both sides are waiting for the final, final decision,” said conservative policy analyst Chris Jacobs.

Medicaid public option

States this year started a serious push for their own form of the public option through Medicaid and some in Washington have started paying attention.

Minnesota, Nevada and New Mexico are some of the states that have forged ahead with studies on this policy. And with congressional activity on healthcare likely on hold until after the 2020 presidential election, advocates see this year’s progress on the state level with this policy as significant—even if the industry is on the alert about potential revenue hits.
Adelberg said he is tracking the discussion closely and is particularly interested in the option if it’s offered outside the Obamacare exchanges

I have previously stated and I will restate my opinion, that unless civility, maturity, and a dedication to do what is best for the voters, nothing will get done in healthcare in the next 2 years with the Democrats using the failure as one of many talking points to get elected. These will be depressing 2 or more years of frustration. But I will continue my discussion regarding the options for our healthcare system and hopefully offer what I believe is the best form of healthcare delivery for all in our wonderful country.

Happy New Year to All!!

 

 

Thousand Oaks and Our Peculiarly American Affliction. And will the Dems get Gun Control?

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Be shocked by the massacre at a bar. It’s not normal.

Tim Dominguez sits under the freeway after escaping the Borderline Bar and Grill in Thousand Oaks, Calif., where a gunman killed 12 other people Wednesday night.

According to statistics from the Gun Violence Archive, there have been 307 mass shootings in the 312 days of 2018. They are a commonplace occurrence. This is a horrifying thing to say, but it is the truth. We need to say this truth over and over. We need to face this horror without looking away. We live in a country where there are relatively few restrictions on gun ownership and where our cultural tolerance for mass murder appears to be infinite.

Less than a month ago an author visited California State University Channel Islands, not far from where the shooting on Wednesday night took place. A deeply engaged audience greeted her. They had a thoughtful discussion about sexual violence, justice, trauma, and healing. Some of those students might have been at the Borderline Bar and Grill in Thousand Oaks, Calif., Wednesday night, doing what college students are supposed to be doing — dancing and hanging out with friends, having fun. As she read the news Thursday morning, her chest tightened. She read quotes from students from that campus describing the sparks and the smoke they saw. She felt resignation creeping in.

Over the past two years, there has been increased security at his events, armed guards. Sometimes they are there because he had received a threat. Sometimes they are there because she is a black woman with opinions and the threat is already implied. Every time she goes on stage, she looks out into the audience and wonders if there is a man with a gun in the sea of faces. She is not scared of him. She is resigned to the inevitability of him pointing that gun at me, at the crowd, and pulling the trigger. She doesn’t want to be this resigned. She doesn’t want you to be, either.

In an interview, the father of one of the young women who escaped the carnage at the Borderline Bar said his daughter did what he has taught her to do in the event of a mass shooting. It took me a moment to realize what he was saying. We are raising generations of children who are prepared for this kind of crime.

It is a peculiarly American affliction that this epidemic of gun violence doesn’t move us to take any real steps toward curbing gun violence and access to guns.

It is painfully obvious that there is no shooting appalling enough to make American politicians stand up to the National Rifle Association and gun makers. A congressman was shot and critically wounded. Children at Sandy Hook Elementary were murdered. Revelers at the Pulse nightclub were murdered. Concertgoers in Las Vegas were murdered.

Our leaders think and pray their way through the horror. The politicians who rely on N.R.A. donations feign concern and continue taking that money. American voters keep these people in office, perhaps, because it isn’t their loved ones being murdered. Yet. And even if it were, I don’t know that their votes would change. Instead, people treat the Constitution like a fast-food value menu, choosing which amendments are sacrosanct (the First and Second) and which are disposable (any of those giving civil rights to anyone but white men).

The script following these shootings is too familiar — flags at half-staff, hollow words of sympathy — but what chills me is the relatively calm eloquence of the survivors speaking to reporters. How they don’t seem particularly surprised to have survived a mass shooting. That they are able, in the immediate aftermath of trauma, to articulate their experiences. They can do this because they have seen it done.

How do we change this script? How do we convince enough people that we are well past the time for radical action?

We must elect politicians who will ban assault weapons and at the very least enact legislation requiring federal, rigorous background checks for gun owners. But really, that’s not radical. It’s the bare minimum, and by the grace of that kind of legislation in California, the shooter was able to use only a handgun. This massacre where 13 people died could have been much worse.

In late September, I went to a gun range with my brother, who is a gun enthusiast. We spent about an hour shooting guns as he explained the merits of the various weapons. We wore safety goggles, and though it wasn’t my first time shooting a gun, he went over the safety protocols. Before we could even enter the range we watched a safety video. From the moment we entered the facility until the time we left, we were reminded of the danger of these weapons. Each gun was heavy in my hand, hot. Before long, the space around us was thick with the stench of oil and gunpowder. We were shooting at targets, metal, and paper. There was a certain satisfaction when I shot well. I understood the appeal of holding that kind of power in the palm of my hand. I also understood the responsibility of holding a gun. I was awed by it. I was not so enamored that I want to own a gun myself. Yet.

Today I held a 4-month-old baby. He is cute and strong and wide-eyed. He still smells sweet and new. I held him and for a few minutes, I forgot about everything terrible. I forgot about the man with a gun and the 12 other people he killed and the people he injured. I forgot about the man with a gun who walked into a yoga studio and started shooting. I forgot about the man with a gun who walked into a grocery store and started shooting. I forgot about the man with a gun who walked into a synagogue and started shooting. And then I looked at this baby’s tiny face and his wide, gummy smile. I remembered everything terrible. I understood the responsibility of holding a child. I was awed by it. I realized that as horrifying and commonplace and inevitable as mass shootings are, we cannot do nothing. Stare into the horror. Feel it. Feel it so much that you are moved to act.

Deaths From Gun Violence: How The U.S. Compares With The Rest Of The World

Nurith Aizenman reported these statistics about a year ago but I thought that the story and the comparisons were relevant regarding gun violence rates. The timing of that report couldn’t be more apt — or grimmer even today. The statistics were released just as Americans were waking up to the news that a gunman had opened fire the night before at the Borderline Bar and Grill in Thousand Oaks, Calif. He killed 12 people and was found dead at the scene.

The attack came just 11 days after the fatal shooting that claimed 11 lives at Pittsburgh’s Tree of Life synagogue. Eight months before that, a gunman shot 17 people dead at Marjory Stoneman Douglas High School in Parkland, Fla. And just over a year ago a gunman massacred 58 people at a music festival in Las Vegas.

As in previous years, the University of Washington’s latest data indicates that this level of gun violence in a well-off country is a particularly American phenomenon.

When you consider countries with the top indicators of socioeconomic success — income per person and average education level, for instance — the United States is bested by just 18 nations, including Denmark, the Netherlands, Canada, and Japan.

Those countries all also enjoy low rates of gun violence. But the U.S. has the 28th-highest rate in the world: 4.43 deaths due to gun violence per 100,000 people in 2017. That was nine times as high as the rate in Canada, which had 0.47 deaths per 100,000 people — and 29 times as high as in Denmark, which had 0.15 deaths per 100,000.

The numbers come from a massive database maintained by the University’s Institute for Health Metrics and Evaluation, which tracks lives lost in every country, every year, by every possible cause of death. The 2017 figures paint a fairly rosy picture for much of the world, with deaths due to gun violence rare even in many countries that are extremely poor — such as Bangladesh, which saw 0.07 deaths per 100,000 people.

Prosperous Asian countries such as Singapore and Japan boast the absolute lowest rates, though the United Kingdom and Germany are in almost as good shape.

“It is a little surprising that a country like ours should have this level of gun violence,” Ali Mokdad, a professor of global health and epidemiology at the IHME, told NPR in an interview last year. “If you compare us to other well-off countries, we really stand out.”

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To be sure, there are quite a few countries where gun violence is a substantially larger problem than in the United States — particularly in Central America and the Caribbean. Mokdad said a major driver is the large presence of gangs and drug trafficking. “The gangs and drug traffickers fight among themselves to get more territory, and they fight the police,” said Mokdad. And citizens who are not involved are often caught in the crossfire. Another country with widespread gun violence is Venezuela, which has been grappling with political unrest and an economic meltdown.

Screen Shot 2018-11-11 at 12.30.59 PMMokdad said drug trafficking may also be a driving factor in two Asian countries that have unusually high rates of violent gun deaths for their region, the Philippines and Thailand.

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With the casualties due to armed conflicts factored out, even in conflict-ridden regions such as the Middle East, the U.S. rate is worse.

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The U.S. gun violence death rate is also higher than in nearly all countries in sub-Saharan Africa, including many that are among the world’s poorest.

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One more way to consider these data: The institute also estimates what it would expect a country’s rate of gun violence deaths to be based solely on its socioeconomic status. By that measure, the U.S. should be seeing only 0.46 deaths per 100,000 people. Instead, its actual rate of 4.43 deaths per 100,000 is almost 10 times as high.

Dems vow swift action on gun reform next year

Mike Lillis and Scott Wong wrote that the nation’s latest mass shooting has rekindled the fire under Democrats to use their newly won majority to strengthen federal gun laws in the next Congress.

The issue was off the table for eight years of Republican rule, as GOP leaders have sided with the powerful gun lobby against any new gun restrictions.

But House Minority Leader Nancy Pelosi(D-Calif.), who’s seeking to regain the Speaker’s gavel, vowed to move quickly on gun reform next year, citing Wednesday night’s shooting massacre at a California country music bar as the latest reason Congress should step in with new restrictions on the sale and ownership of firearms.

Universal background checks, Pelosi suggested, would be the likely first step.

“It doesn’t cover everything, but it will save many lives,” Pelosi said Thursday night on CNN’s “Cuomo Prime Time” program.

“This will be a priority for us going into the next Congress.”

Rep. Jerrold Nadler (D-N.Y.), likely the incoming chairman of the House Judiciary Committee, said this week that he’ll “immediately get to work” on that legislation next year.

That position marks a shift from almost a decade ago when Democrats last controlled the House and party leaders declined to consider tougher gun laws despite entreaties from some rank-and-file members.

Rep. Mike Quigley (D-Ill.), a gun reformer from Chicago and member of the Judiciary Committee, had requested hearings on background checks in 2010, only to be refused.

The reasons were largely political: House Democrats, at the time, had a more conservative-leaning caucus, boasting more than 50 Blue Dogs in battleground districts the party was fighting to preserve.

After a 10-year ban on assault weapons signed by former President Clinton was widely viewed as a “third rail” that helped secure George W. Bush’s White House victory in 2000, Democrats didn’t want to repeat history.

Since then, the country has seen a long string of prominent mass shootings, including violence targeting a congresswoman in Tucson, Ariz., elementary school students in Newtown, Conn., nightclubbers in Orlando, churchgoers in Charleston, S.C., country music fans in Las Vegas, high schoolers in Parkland, Fla. and Jews praying at a synagogue in Pittsburgh last month.

The most recent tragedy occurred Wednesday night at a bar in Thousand Oaks, Calif., where authorities say a Marine combat veteran killed 12 people before fatally shooting himself.

One of the victims, 27-year-old Telemachus Orfanos, survived last year’s Las Vegas massacre but was killed in the Thousand Oaks shooting.

“I don’t want prayers. I don’t want thoughts. I want gun control, and I hope to God nobody else sends me any more prayers,” Orfanos’s mother, Susan Orfanos, said in an emotional interview with KABC that has been viewed millions of times on social media. “I want gun control. No more guns.”

The rash of devastating episodes shifted public sentiment in strong favor of gun reform, and polls show overwhelming support for measures like expanded background checks among voters of all political stripes.

Three Parts Brands Have Come Together

The Ford Motor Company reported that among the host of Democrats elected to the House on Tuesday in conservative districts, many embraced new restrictions on gun purchases without facing the previously feared backlash at the polls.

“The public has evolved on their belief about this, given the magnitude and disparity of gun violence and mass shootings,” Quigley said Friday by phone.

The Democrats’ plans for gun-reform legislation remain unclear.

Rep. Mike Thompson (D-Calif.), the head of the party’s task force to prevent gun violence, has taken the lead on the background check bill, and will likely do so again next year. There are also dozens of related proposals other lawmakers will surely promote, including bills to ban bump stocks, eliminate assault weapons, spike taxes on guns and ammunition and prohibit high-capacity magazines like the one allegedly used by the shooter in Thousand Oaks.

Quigley is all for pushing bold reforms, including a ban on assault weapons, but is promoting the idea of securing early victories on more popular measures.

“Let’s start where we have some commonality,” he said. “The vast majority of Americans, the majority of gun owners, the majority of NRA [National Rifle Association] members support universal background checks.

“That’s a good place to start.”

That the House will pass some kind of background-checks legislation is clear. But any new gun restrictions face tall odds in the GOP-controlled Senate, where Republicans are near unanimous in their opposition to such reforms.

In 2013, in the wake of the Sandy Hook Elementary School shooting in Newtown, Sens. Pat Toomey (R-Pa.) and Joe Manchin (D-W.Va.) authored legislation to expand background checks for firearms purchased online and at gun shows. It fell six votes short of overcoming a GOP-led filibuster, with only four Republicans — Toomey, and Sens. Susan Collins (Maine), John McCain (Ariz.) and Mark Kirk(Ill.) — supporting the measure.

Kirk lost his reelection bid in 2016 and McCain died this year, leaving just two Senate Republicans who back strengthening background checks. Manchin just won re-election this week and Toomey isn’t up for reelection until 2022.

“Senator Toomey is continuing to work with his colleagues in the Senate to find a path forward to 60 votes for his background check legislation,” said Toomey spokesman Sam Fischer.

Complicating the math for gun reform supporters, Tuesday’s midterms added to the GOP Senate majority, and the incoming Republicans are all gun-rights promoters supported heavily by the firearms lobby.

Asked about the appropriate response to the Thousand Oaks shooting, Sen.-elect Marsha Blackburn(R-Tenn.) was terse.

“What we do is say, how do we make certain that we protect the Second Amendment and protect our citizens?” Blackburn told Fox News on Thursday.

President Trump could be a wild card in the coming gun debate. The president has a long and conflicting history on the topic, from the promotion of an assault-weapons ban years ago to a more recent embrace of the Second Amendment protectionism advocated by the NRA.

Gun-reform advocates, long accustomed to congressional inaction on the issue, say they’ve been encouraged by what they’ve heard from Pelosi and other Democratic leaders so far.

“While so many other factors have not been settled, we believe that House Democrats will move universal background checks in early 2019,” said Robin Lloyd, government affairs director for the Courage to Fight Gun Violence, the gun-reform group led by former Rep. Gabrielle Giffords (D-Ariz.), the congresswoman shot in the head in Tucson in 2011.

Medical professionals to NRA: Guns are our lane. Help us reduce deaths or move over.

 Megan L. Ranney, Heather Sher, and Dara Kass, Opinion contributors, reported that after the American College of Physicians released a paper last week about reducing firearm injuries and deaths in America, the NRA tweeted the statement: “Someone should tell self-important anti-gun doctors to stay in their lane.”

A couple of days later, the Centers for Disease Control published new data indicating that the death toll from gun violence in our nation continues to rise. As the NRA demanded that we doctors stay in our lane, we awoke to learn of the 307th mass shooting in 2018 with another 12 innocent lives lost to an entirely preventable cause of death — gun violence.

Every medical professional practicing in the United States has seen enough gun violence firsthand to deeply understand the toll that this public health epidemic is taking on our children, families, and entire communities.

It is long past time for us to acknowledge the epidemic is real, devastating, and has root causes that can be addressed to assuage the damage. We must all come together to find meaningful solutions to this very American problem.

We bear witness to every gun-related trauma

The physicians, nurses, therapists, medical professionals, and other concerned community members signing this letter are absolutely “in our lane” when we propose solutions to prevent death and disability from gun violence.

As the professionals who manage this epidemic, we bear witness to every trauma and attempt to resuscitate, successful or not.

►We cut open chests and hold hearts in our hands in the hopes of bringing them back to life.

►We do our best to repair the damage from bullets to pulverized organs and splintered bones.

►We care for the survivors of firearm injury for decades after they’ve been paralyzed, lost a limb, or been disabled.

►We deliver mental health care to the siblings and parents of the children who have been shot as well as to the survivors of gun violence.

►We treat the anxiety of teachers and students who are already traumatized by the news of mass shootings who are then are asked to participate in active shooter drills in their own schools.

►We prepare for mass casualty shootings with drills ourselves and practice sorting victims by how life-threatening their injuries are while fervently hoping that a mass shooting never touches our own communities.

►We are asked by families, schools, employers and law enforcement to conduct mental health evaluations and threat assessments of individuals who demonstrate dangerous behaviors with legally-owned firearms — yet we have no protocols to decrease firearm risk when they present to us.

►We support our own medical colleagues as they themselves must recover from the psychological trauma of being first responders to mass shootings.

►We design trauma protocols to reduce the loss of life from even the most horrific gunshot wounds.

►We train civilians to carry and use tourniquets to #StopTheBleed, something that should be necessary on battlefields but not in American grade school classrooms.

►We try our best to conduct research to stop the epidemic of gun violence.

►We hold the hands of gunshot victims taking their final breaths.

►We cry, ourselves, as we tell parents that their child has been shot and that we did our best.

►We escort parents into our treatment rooms to take one last look at their dead child before they have been able to process the news.

►We see firsthand how a single moment ends a life and forever changes the lives of survivors, families, and entire communities.

NRA should help us reduce gun death toll

Our research efforts have been curtailed by NRA lobbying efforts in Congress. We ask that the NRA join forces with us to find solutions.

We invite the NRA to collaborate with us to find workable, effective strategies to diminish the death toll from suicide, homicide, domestic violence and unintentional shootings for the thousands of Americans who will one day find themselves on the wrong side of a barrel of a gun.

We are not anti-gun. We are anti-bullet hole. Let’s work together.

Join us, or move over! This is our lane. We as a society must do something about gun violence NOW!

Also, I live in a region where about 70% of the population owns guns. But the homicide and suicide rate is very, very low. Why? I’m not sure at this time but I along with the majority of our country are tired and scared of the gun-related violence.

The holiday of Thanksgiving reminds us that we ought to be thankful for the blessings and the people in our lives. But what do we do when it seems that everything is going haywire? Maybe somebody recently wronged you. An unexpected expense has thrown off your budget. That new role at your job isn’t as shiny as you thought it would be. Or maybe you’ve been trying to do the right things, live the right way, but situations STILL aren’t working out in your favor.

How do you cope? How do you resist the urge to give up? How do you continue to do good even when you’re not seeing any immediate benefits from “living the right way? And HOW IN THE WORLD can you be thankful for all of this? Sometimes we have to be thankful for what we have and enjoy the day and family and friends.

 

What the New Democratic House majority might actually pass on health care; and It Looks Like VA Healthcare Maybe Improving!

 

 

18670832_1206383419491315_6469395384583311089_nI had prepared two posts for tonight and wanted to hold off on the recent shootings until next week as we digest what the effect really is in our country and the future strategies. Now let’s discuss the effect of the election and in looking at the House Democrats, who have a lot to figure out on their signature issue.

Healthcare carried House Democrats to victory on Election Day. But what now?

Remember my past post reminding the Republicans the importance of healthcare in the midterm elections? We, it looks like it was an important factor in the outcomes of the “wave”. Dylan Scott spent some time looking at his prediction of what the new majority will bring to our health care system. In interviews this fall with half a dozen senior House Democratic aides, health care lobbyists, and progressive wonks, it became clear the party is only in the nascent stages of figuring out its next steps on health care.

The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare.

But Democrats are less certain about an affirmative health care agenda. Most Democrats campaigned on protecting preexisting conditions, but the ACA has already done that. Medicare-for-all is energizing the party’s left wing, but nobody expects a single-payer bill to start moving through the House. Drug prices offer the rare opportunity for bipartisan work with Senate Republicans and the Trump White House, but it is also a difficult problem with few easy policy solutions — certainly not any silver bullet that Democrats could pull out of the box and pass on day one, or even month one, of the next Congress.

Winning a House majority to ensure Obamacare’s safety is an important turning point after so many years in which health care hurt Democrats much more than it helped.

But the path forward for the party on their signature issue is surprisingly undefined.

The likely first item on the Democratic agenda: Obamacare stabilization

Democrats do have some ideas, of course. Democratic aides emphasized the various investigations they could launch into Trump’s health department, not only looking into any efforts by the White House to sabotage Obamacare but also focusing on more obscure issues like Medicare payment rates.

But wonky oversight inquiries probably aren’t the big-ticket item that new Democratic members and their voters are looking for, especially heading into the 2020 presidential election.

After campaigning in defense of Obamacare, warning about Republicans rolling back preexisting conditions protections and the Trump administration’s sabotage of the health care law, a bill to stabilize the Obamacare insurance markets would be the obvious first item for the new Democratic majority’s agenda.

Several sources pointed to a bill by Democratic Reps. Richard Neal (MA), Frank Pallone (NJ), and Bobby Scott (VA) — who have been serving as the top Democrats on leading health care-related committees — as the likely starting point. The plan is designed to build off Obamacare’s infrastructure to expand federal assistance while reversing the recent Republican efforts to undermine the law.

That bill would expand Obamacare’s premium subsidies, both by extending federal assistance to more people in lifting the current eligibility cutoff and by increasing the size of the tax credits people receive. It would also bolster the cost-sharing reduction subsidies that people with lower incomes receive to reduce their out-of-pocket costs while extending eligibility for those subsidies to people with higher incomes.

The Pallone-Neal-Scott bill would reverse the Trump administration’s recent regulations intended to funnel more people to insurance plans that are not required to meet all of Obamacare’s rules for preexisting conditions. It would also pump more money back into enrollment outreach, cut by the Trump administration, and establish a new program to compensate insurers for high-cost patients, with the hope of keeping premiums down.

Two things stick out about this bill: It would be the most robust expansion of Obamacare since the law first passed, and it is just narrow enough that, with a few sweeteners for Senate Republicans, it could conceivably have a chance to pass. Democrats are waiting to see how the GOP majority in the upper chamber reacts to losing the House.

“Undoing sabotage and bringing stabilization to the ACA markets, that’s something we should really be thinking about,” one House Democratic aide told me. “It depends on what kind of mood the Republicans are in. Maybe they’ll say that actually now that the tables are turned, we should probably sit down.”

Senate Republicans and Democrats did come very close to a narrow, bipartisan deal — it wasn’t even as robust as the Pallone-Neal-Scott bill — to stabilize Obamacare in 2017. It fell apart, ostensibly after a tiff over abortion-related provisions, but that near miss would be the reason for any optimism about a bipartisan deal on the divisive health care law.

Then again Senate Republicans might have no interest in an Obamacare compromise after gaining some seats. Democrats would still likely work on stabilization to send a message to voters on health care ahead of the 2020 campaign.

Shoring up Obamacare is a good start, but what next?

In the case, the Pallone-Neal-Scott bill might be a nice starting point — no Democrat really disagrees about whether they should help the law work better in the short term — but it still lacks any truly ambitious provisions. It is just about as narrowly tailored as an Obamacare stabilization bill offered by Democrats could be, a fact that aides and activists will privately concede.

Missing are any of the bolder policy proposals animating the left. Not even a hint of Medicare-for-all single-payer health care, which is or isn’t a surprise, depending on how you look at it.

Medicare-for-all is quickly becoming orthodoxy among many in the party’s progressive grassroots, and a single-payer bill proposed this Congress in the House (similar to the one offered by Bernie Sanders over in the Senate) has 123 sponsors.

But House Democratic leaders probably don’t want to take up such a potentially explosive issue too soon after finally clawing back a modicum of power in Trump’s Washington.

Still, the current stabilization bill doesn’t even include a Medicare or Medicaid buy-in, the rebranded public option that never made it into Obamacare but would allow Americans to voluntarily join one of the major government insurance programs. It is an idea that even the more moderate Democratic members tend to support, and polls have found three-fourths of Americans think a Medicare buy-in is a good idea.

The plain truth is House Democrats haven’t reached a consensus yet about what they want to do to cover more Americans. They agree Obamacare was an important first step, and they agree the status quo is unacceptable. But the exact mechanism for achieving those goals — single-payer, a robust public option, or simply a buffed-up version of Obamacare — is still very much up for debate.

“People will want to do something, but any further action is going to be a consensus-building process,” a senior House Democratic aide told me. “Democrats have lots of different ideas on how to continue working to reduce the uninsured.”

That is all well and good, but few issues are exciting the Democratic grassroots right now like Medicare-for-all. During the midterm campaigns, Democratic candidates and even grassroots leaders were happy to let those words mean whatever voters wanted them to mean. For some people, it meant single-payer; for others; it might mean a Medicare buy-in or something more limited.

The unreservedly progressive members who were just elected to Congress will only wait so long before they start pressing Democratic leaders to take more aggressive steps to pick up one of their top campaign issues. That pressure will only intensify as the 2020 presidential campaign heats up and Democrats debate what kind of platform they should run on as they seek to take back the White House.

For now, Democrats have tried to put off a difficult debate and focus on what unites them. But the debate is still coming.

The riddle of high drug prices still needs to be solved too

Even with Obamacare and preexisting conditions mobilizing Democratic voters this year, prescription drug prices remain a top concern for many Americans. That’s another area where Democrats know they want to act but don’t know yet exactly what they can or should do.

The issue could be an opening for serious dealmaking: Trump himself has attacked big pharma since his presidential campaign. His administration has actually launched some interesting initiatives to rein in drug costs — approving a record number of generic drugs, trying to even the playing field between America and foreign countries — that have some policy wonks intrigued, even if the impact is still to be determined.

Democrats have mostly stuck to slamming Trump for feigning to act on drug prices while cozying up to the drug industry. But it’s a top priority for both parties, and there could be some room for compromise. One progressive policy wonk thought a drug prices bill might actually be the first Democratic priority. It helps that drug prices are a populist issue that the new House majority might really be able to pass a bill on.

But first, Democrats have to figure out what exactly they are for — and what would actually make a difference.

The rallying cry for Democrats on drug prices has been letting Medicare directly negotiate prices with drug manufacturers, a proposal that Trump also embraced as a candidate, though he has since softened as president. The problem is the Congressional Budget Office doesn’t think Medicare negotiations would save any money unless the government is willing to deny seniors coverage for certain medications. But adding such a provision would surely invite attacks that Democrats are depriving people’s grandparents of the medications they need.

There are a lot of levers to pull to try to reduce drug prices: the patent protections that pharma companies receive for new drugs, the mandated discounts when the government buys drugs for Medicare and Medicaid, existing hurdles to getting generic drugs approved, the tax treatment of drug research and development. Lawmakers and the public view pharmacy benefits managers, the mysterious middlemen between health insurers and drugmakers, skeptically.

But none of those are silver bullets to lower prices, and they will certainly invite pushback from the politically potent pharmaceutical lobby, focused on the concerns about how much cracking down on drug companies to discourage them from developing new drugs. Democrats also don’t know yet what specific policies could win support from Senate Republicans or the Trump White House.

“How do you take this gargantuan Chinese menu of things and figure out how things fit together in a way that stem some of the abuses?” is how one Democratic aide summarized the dilemma.

It is a problem bedeviling Democrats on more than just drug prices. Health care was a winner on election night this year, and it has always been a priority for Democrats. Now they just need to figure out what to do.

Because tomorrow is Veterans Day I thought that I would include this article.             After A Year Of Turmoil, New VA Secretary Says ‘Waters Are Calmer’ 

Quil Lawrence in his Twitter post reported on a wide-ranging interview with NPR, Secretary of Veterans Affairs Robert Wilkie said his department is on the mend after a tumultuous 2018.”I do think it is better because the turmoil of the first half of this year is behind us, the waters are calmer. We’re not where we need to be, but we’re heading in that direction,” he said.

Early in Donald Trump’s presidency, the VA was considered an island of stability in an unpredictable administration.

Secretary David Shulkin was a hold-over from the Obama administration, already familiar with the VA’s massive bureaucracy. Bipartisan reforms moved through Congress with relative speed, and Trump could point to a list of legislative accomplishments.

But the president fired Shulkin last March after weeks of intrigue during which VA political appointees plotted openly to oust him. Trump’s first nominee to replace Shulkin, Rear Adm. Ronny L. Jackson, sank under accusations of misconduct (which are still being investigated by the Pentagon).

Numerous high-ranking officials left the department, and records showed that friends of the president outside of government – who weren’t even veterans – had been lobbying Trump at Mar-a-Lago on how to run the VA.

After a stint as acting VA secretary, Robert Wilkie was confirmed by the Senate last July. Since then, Wilkie says he’s been “walking the post,” visiting as many VA facilities as he can. And he’s reached the same conclusion as many of his predecessors.

“I have been incredibly impressed by the caliber of VA employee I’ve encountered everywhere, from Alaska to Massachusetts to Florida,” Wilkie told NPR’s, Steve Inskeep.

“I have no quarrel with the quality of medical care our veterans receive. My biggest problem is actually getting them into the system so that they can receive that care, which means the problems are primarily administrative and bureaucratic,” said Wilkie, himself a veteran of the Navy and a current Air Force reservist, who counts generations of veterans in his family.

“I am the son of a Vietnam soldier. I know what happened when those men and women came home,” Wilkie said. “So that is incredibly important to me.”

Wilkie is navigating an important moment for the VA – while Congress has already passed major reforms, he’s the one who has to implement them. And plenty of political controversy hides in the details.

The VA Mission Act of 2018 was signed into law in June. It’s intended to consolidate about a half-dozen programs The VA uses to buy veterans private healthcare at a cost of billions of dollars, into one streamlined system.

Critics fear that leaning too much on private care will bleed the VA’s own medical centers, and lead to a drop in quality there – and amounts to a starve-the-beast strategy of privatization.

Wilkie says that won’t happen and is not President Trump’s goal, but he has yet to present a budget for expanded private care to the White House and to Congress.

“You’re not going to privatize this institution. I certainly have never talked about that with anyone in this administration,” Wilkie said.

Wilkie also maintains that he has had little contact with the group of outside advisers who meet with the president at Mar-a-Lago, including CEO of Marvel Comics Ike Perlmutter and Florida doctor Bruce Moscowitz. Records show they had extensive communication with the previous VA secretary, sometimes influencing policy decisions.

“I met with them when I was visiting the West Palm Beach VA – my first week as acting (secretary), and have not had any meetings with them ever since that day,” Wilkie said. “I’ll be clear. I make the decisions here at the department, in support of the vision of the president.”

Despite rumors that Wilkie would clear out many of the Trump political appointees who clashed with former secretary Shulkin, he said he didn’t expect more staffing changes.

The one notable departure is Peter O’Rourke, who was acting secretary for two months while Wilkie went through the confirmation process. O’Rourke clashed repeatedly with Congress and the VA’s inspector general. Wilkie himself cited a Wall Street Journal reports that O’Rourke is poised to go and said he’s “on leave.”

“I think there will be an announcement soon about a move to another department in the federal government – I know that he’s looking for something new,” said Wilkie, “He’s on leave.”

Another major new plan that Wilkie must implement is a $10 billion, 10-year plan to make the VA’s medical records compatible with the Pentagon’s.

He once again mentioned his father’s experience as a wounded combat vet.

“He had an 800-page record, and it was the only copy, that he had to carry with him for the rest of his life. He passed away last year,” said Wilkie.

“One of the first decisions I made as the acting secretary was to begin the process of creating a complete electronic healthcare record that begins when that young American enters the military entrance processing station to the time that that soldier, sailor, airman, Marine walks into the VA.”

But that process has actually been underway for a decade – with little to show and about a billion dollars already spent on the effort. The non-partisan Government Accountability Office says it’s in part because neither the Pentagon nor the VA was put in charge of the effort — which is still the case. Wilkie says he has signed an agreement with the Pentagon to jointly run it with clear lines of authority.

“I think we’ll have more announcements later in the year when it comes to one belly-button to push for that office,” he said.

As for staff shortages, another perennial complaint at the VA, Wilkie acknowledged there are 35- to 40,000 vacancies at the agency.

“We suffer from the same shortages that the private sector and other public health services suffer from, particularly in the area of mental health,” he said.

New legislation passed this year gives Wilkie the authority to offer higher pay to medical professionals.

“I’m using it to attract as many people as we can into the system,” said Wilkie

But Wilkie also added that he was shocked, upon taking the post, that it’s not clear how many additional people are needed – because it’s not even clear how many people are working at VA.

“I had two briefings on the same day and two different numbers as to how many people this agency employs.”

Wilkie says he’s in the process of finding out the answer to that question, and many others, as he starts his second 100 days in office.

And to end this post I must include this note. I was raised in the Bronx, New York and are truly embarrassed to acknowledge that the new Congresswoman Cortes-Ortes who was elected, and not sure how when you look at her qualifications and knowledge. But more, she is a socialist and expects everything to be given to all and the government will foot the bill and now listen to this.

Alexandria Ocasio-Cortez, new youngest Congresswoman, says she can’t afford D.C. apartment

Ashley May, a reporter for the USA TODAY noted that the upset primary win in New York by Alexandria Ocasio-Cortez is a huge moment for the Democratic Party because it shows the left-wing base is energized heading into the midterms, according to AP National Politics Reporter Steve Peoples. (June 27) AP

Alexandria Ocasio-Cortez, the youngest woman elected to Congress in the midterm elections, is struggling to pay rent, according to a recent interview.

Ocasio-Cortez, 29, told The New York Times she’s not sure how she will be able to afford an apartment in Washington, D.C., without a salary for three months in an interview published online Wednesday.

She told the Times she has some savings from her job earlier this year as a bartender at a Union Square restaurant, and she’s hoping that will hold her over. Living without a paycheck is something she said her and her partner tried to plan for, but it’s a hardship that’s still “very real.”

“We’re kind of just dealing with the logistics of it day by day, but I’ve really been just kind of squirreling away and then hoping that gets me to January,” she told the Times.

Ocasio-Cortez is a New York activist and Democrat who will represent the 14th Congressional district, which covers the Bronx and Queens.

Thursday, she pointed to her lack of income as a reason why some people are not able to work in politics.

“There are many little ways in which our electoral system isn’t even designed (nor prepared) for working-class people to lead,” she said.

She said she hopes she can change that.

Yes, and now if she plays her cards right she has a job, paying better than any job that she is really qualified for life.

Buck it up Ocasio-Cortez, live outside of DC and take public transportation like most people do!

How did you fund your campaign? I don’t want to hear your sob story and yes I am ashamed that the borough of the Bronx has you for their representative. What a joke! You said that when you got to DC you were going to sign a whole lot of bills and laws to make things better. Do you even know anything about the process and have you ever taken a Civics course. You are in for some big surprises… called reality!

On a better note-Happy Veterans Day and thank you all who have served in our military and those who are still out there helping to make this world a better place to live and protecting our freedoms.

 

Active Shooter Insurance: Sadly, It’s Needed-Or Is It? And the Effect of Gun Violence on Health Care.

42491634_1719865238143128_6077344969692020736_nI knew that we all were in trouble when I received a bulletin from one of my insurance companies. The first article reviewed workplace violence, which as they summarized is a threat that cannot be ignored and that as a difficult a subject that it is, it is important for businesses to consider active shooter/ workplace violence insurance to cover gaps in standard coverage insurance.

According to 2017 data from the Gun Violence Archive (GVA), America is averaging almost one mass shooting a day. GVA considers a mass shooting any incident in which a gunman shoots or kills four or more people in the same time and location. They recorded 345 mass shootings in 2017 and, as of the time of this blog post, 213 in 2018. How depressing and what it says about our society and humanity in general.

Consider this next article:

More hurt, killed in shootings with semiautomatic rifles

More people are wounded and killed in active shooter incidents in which semi-automatic rifles are used, according to a research letter published in the Sept. 11 issue of the Journal of the American Medical Association.

Elzerie de Jager, M.B.B.S., from Brigham and Women’s Hospital in Boston, and colleagues compared the number of persons wounded, killed, and either wounded or killed during active shooter incidents with and without semiautomatic rifles.

Seventy-six of the 248 active shooter incidents involved a rifle; a semiautomatic rifle was involved in 61 incidents (24.6 percent). The researchers found that 898 and 718 persons were wounded and killed, respectively. A higher incidence of

persons wounded (unadjusted mean, 5.48 versus 3.02; incidence rate ratio [IRR], 1.81; 95 percent confidence interval [CI], 1.30 to 2.53), killed (mean, 4.25 versus 44.9 percent; IRR, 0.99; 95 percent CI, 0.60 to 1.61).

“Semiautomatic rifles are designed for easy use, can accept large magazines, and fire high-velocity bullets, enabling active shooters to wound and kill more people per incident,” the authors write.

Gun Violence Threatens the Health of Our Nation

Why am I posting this issue again? Because it does affect the health care of our country with thousands being injured and killed and therefore needs surgical and medical care. Fed up with excuses for why policymakers cannot do anything to stop gun violence, Families USA–along with more than 170 national and state partners–are demanding action. They sent a letter to leaders in Congress urging full repeal of the ban on federally funded research into gun violence.

Last month, 17 people, including 14 students, were killed in a mass shooting at Marjorie Stoneman Douglas High School in Parkland, Florida. While the increased incidents of mass shootings are shocking, they are only the most visible instances of gun violence. Tragically, more than 35,000 people, including nearly 3,000 children, die from gun violence each year in the United States.

Gun violence disproportionately affects children of color

Gun violence knows no barriers. The shooting in Parkland was just the latest in a surge of mass shootings in places as diverse as a country music concert in Las Vegas, an LGBTQ nightclub in Orlando, and an African-American church in Charleston, SC. All people can be affected by this violence but is particularly felt in low-income and racial and ethnic minority communities. African American, Hispanic, and American Indian boys are all significantly more likely to be killed by gun violence than white children.

Families USA recognizes gun violence as a severe threat to the health of our nation. As an organization focused on health care, we have not engaged previously in the vigorous national debate on gun violence. We are entering that debate today because our nation is at a turning point.

While the numbers of people hurt are staggering, we know too little about the causes and effects of gun violence in our community. This is in part due to the “Dickey Amendment” — an effective ban on federally funded research into gun violence. It is past time for that ban to end.

As health care policy experts, we know that effective policy relies on evidence-based research. Despite gun violence is a leading cause of death for children, in 1996 Congress forbade any funding for the Centers for Disease Control and Prevention (CDC) that “may be used to advocate or promote gun control.” The Dickey Amendment, named after its congressional sponsor, has effectively stifled meaningful federal funding for research on the causes and effects gun violence. A recent study published in the Journal of the American Medical Association found that “in relation to mortality rates, gun violence research was the least-researched cause of death.”

Across the country, students are rallying to urge policymakers to take action against gun violence. They are asking adults to enact policies to stem the rising tide of gun violence against children. There are many policies that Congress should enact to protect young people and all Americans against violence, but the healthcare community is united in calling for the end of one policy that is clearly indefensible.

America’s gun culture in 10 charts

Students across the United States will join a national march to call for tighter gun control and to highlight the issue of school safety.

The March for Our Lives was organized by pupils at the Marjory Stoneman Douglas High School in Florida, where a former student is accused of killing 17 people last month.

The shooting, one of the worst in US history, renewed debate about gun laws and the rights of gun owners.

What do young people think about gun control?

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When looking at the period before the Parkland shooting, it is interesting to track how young people have felt about gun control.

Support for gun control over the protection of gun rights in America is highest among 18 to 29-year-olds, according to a study by the Pew Research Centre, with a spike after the Orlando nightclub shooting in 2016. The overall trend though suggests a slight decrease in support for gun control over gun rights since 2000.

Pew found that one-third of over-50s said they owned a gun. The rate of gun ownership was lower for younger adults – about 28%. White men are especially likely to own a gun.

How does the US compare with other countries?

About 40% of Americans say they own a gun or live in a household with one, according to a 2017 survey, and the rate of murder or manslaughter by firearm is the highest in the developed world. There were more than 11,000 deaths as a result of murder or manslaughter involving a firearm in 2016.

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Homicides are taken here to include murder and manslaughter. The FBI separates statistics for what it calls justifiable homicide, which includes the killing of a criminal by a police officer or private citizen in certain circumstances, which are not included.

Who owns the world’s guns?

While it is difficult to know exactly how many guns civilians own around the world, by every estimate the US with around 270 million is far out in front.

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Switzerland and Finland are the European countries with the most guns per person – they both have compulsory military service for all men over the age of 18. Cyprus, Austria, and Yemen also have military service.

How do US gun deaths break down?

There have been more than 90 mass shootings in the US since 1982, according to the investigative magazine Mother Jones.

Up until 2012, a mass shooting was defined as when an attacker had killed four or more victims in an indiscriminate rampage – and since 2013 the figures include attacks with three or more victims. The shootings do not include killings related to other crimes such as armed robbery or gang violence.

The overall number of people killed in mass shootings each year represents only a tiny percentage of the total number.

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There were near twice as many suicides involving firearms in 2015 as there were murders involving guns, and the rate has been increasing in recent years. Suicide by firearm accounts for almost half of all suicides in the US, according to the Centers for Disease Control and Prevention.

AA 2016 study published in the American Journal of Public Health found there was a strong relationship between higher levels of gun ownership in a state and higher firearm suicide rates for both men and women.

Attacks in the US become deadlier

The Las Vegas attack was the worst in recent US history – and five of the shootings with the highest number of casualties happened within the past 10 years.

The Parkland, Florida, the attack is the worst school shooting since Sandy Hook in 2012.

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What types of guns kill Americans?

Military-style assault-style weapons have been blamed for some of the major mass shootings such as the attack in an Orlando nightclub and at the Sandy Hook School in Connecticut.

Dozens of rifles were recovered from the scene of the Las Vegas shooting, Police reported.

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A few US states have banned assault-style weapons, which were totally restricted for a decade until 2004.

However, most murders caused by guns involve handguns, according to FBI data.

How much do guns cost to buy?

For those from countries where guns are not widely owned, it can be a surprise to discover that they are relatively cheap to purchase in the US.

Among the arsenal of weapons recovered from the hotel room of Las Vegas shooter, Stephen Paddock were handguns, which can cost from as little $200 (£151) – comparable to a Chromebook laptop.

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Assault-style rifles also recovered from Paddock’s room, can cost around $1,500 (£1,132).

In addition to the 23 weapons at the hotel, a further 19 were recovered from Paddock’s home. It is estimated that he may have spent more than $70,000 (£52,800) on firearms and accessories such as tripods, scopes, ammunition, and cartridges.

Who supports gun control?

US public opinion on the banning of handguns has changed dramatically over the last 60 years. Support has shifted over time and now a significant majority opposes a ban on handguns, according to polling by Gallup.

But a majority of Americans say they are dissatisfied with US gun laws and policies, and most of those who are unhappy want stricter legislation.

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Some controls are widely supported by people across the political divide – such as restricting the sale of guns to people who are mentally ill, or on “watch” lists.

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But Republicans and Democrats are much more divided over other policy proposals, such as whether to allow ordinary citizens increased rights to carry concealed weapons – according to a survey from Pew Research Center.

In his latest comment on the shootings, President Donald Trump said he would be “talking about gun laws as times goes by”. The White House said now is not the time to be debating gun control.

His predecessor, Barack Obama, struggled to get any new gun control laws onto the statute books, because of Republican opposition.

Who opposes gun control?

The National Rifle Association (NRA) campaigns against all forms of gun control in the US and argues that more guns make the country safer.

It is among the most powerful special interest lobby groups in the US, with a substantial budget to influence members of Congress on gun policy.

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In total, about one in five US gun owners say they are members of the NRA – and it has especially widespread support from Republican-leaning gun owners, according to Pew Research.

In terms of lobbying, the NRA officially spends about $3m per year to influence gun policy.

The chart shows only the recorded contributions to lawmakers published by the Senate Office of Public Records.

The NRA spends millions more elsewhere, such as on supporting the election campaigns of political candidates who oppose gun controls.

I’m not sure the correct answer to all these shootings but something has to be done. I’m not sure how we read the minds of those with mental issues but we need to find ways to evaluate and give them help and treat them and keep guns away from them, especially automatic weapons.

Back to our discussion on single payer systems and Medicare for All next week.