Overview
Gun violence has been on the rise in every state in the country, disproportionately plaguing communities of color.1 Connecticut is taking an innovative approach, using Medicaid funding to support the State’s community-based gun violence prevention services. The Governor signed legislation in July 2021 that directs the Connecticut Department of Social Services (DSS) to submit a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) to access federal match to support community violence intervention services. The article below describes the context and approach for this legislation.
Violence Intervention Services Critical Now More Than Ever
Even as the world slowed to a crawl in 2020 and lockdowns hit all 50 states to mitigate the spread of COVID-19, gun violence and shootings remained relentless. 2020 was the deadliest year for gun violence in the past two decades, as the pandemic exacerbated existing challenges of social and economic inequality, isolation and domestic violence. Total gun violence deaths increased over 20 percent in 2020 compared to the prior year, representing 19,420 total deaths due to guns—of which 1,376 were children.2, 3 2021 is on track to surpass 2020’s violence, with already over 14,800 deaths due to gun violence nationwide as of this publication.4 At the same time, Americans have experienced a dramatic increase in gun ownership, with eight of the top 10 highest days ever for firearm background checks since 1998 occurring after the start of the pandemic in early March 2020.5
Hospitals and community-based organizations are uniquely positioned to help address the rise in gun violence and to prevent additional bloodshed and injury. The American Hospital Association (AHA) supports the use of hospital-based violence intervention programs (HVIPs) and launched the Hospitals Against Violence (HAV) initiative in 2016 to encourage hospitals to leverage a public health approach to address gun violence. These hospital and community-based programs aim to intervene with patients as they are treated in hospitals and following their recovery in the community to identify potential reinjury or violence perpetration. This trauma-informed approach continues after patients are treated and can include linkages to community-based services, home visits and follow-up and referral assistance.6 The programs often address social drivers of health—including social inequities, economic and educational opportunities, safe and stable housing—to reduce the risk of future gun violence.
Violence Prevention in Medicaid
The Biden Administration emphasized its commitment to investing in community violence intervention strategies to reduce gun violence, directing CMS to identify how Medicaid and the Children’s Health Insurance Program (CHIP) could be leveraged to support violence prevention. Medicaid is well suited for this initiative, given that nearly two out of three gunshot victims are enrolled in Medicaid or uninsured and state Medicaid agencies are major payers for gun violence injuries and recovery.7 CMS hosted a national, all-state webinar in April 2021 to encourage states to leverage Medicaid authorities to implement HVIPs and other community-based violence intervention opportunities.
There are a number of ways Medicaid programs may support community violence prevention services, including as an optional service under the State Plan, via existing authorized service categories covered by a State Medicaid agency or through federal waivers (e.g., Section 1115 demonstration, Section 1915(b)(3) waiver). For example, Pennsylvania authorizes violence prevention service providers to bill discrete Medicaid approved services under existing billing codes as part of the Healing Hurt People Program at Drexel University in Philadelphia which aims to reduce reinjury and retaliation through a trauma-informed approach for children and youth ages 8 to 30.8 Yet such efforts are nascent, and Medicaid payment for community violence prevention remains rare.
Connecticut’s Innovative Medicaid Initiative
Following the devastating Sandy Hook Elementary School shooting in 2012, Connecticut passed strict gun control laws and has consistently had the lowest rates of gun deaths nationwide.9 However, even in the years prior to the pandemic, gun violence was on the rise with someone killed in Connecticut with a gun every two days.10 The racial inequities seen nationally are also prevalent in Connecticut, with Black men between the ages of 18 and 35 about 39 times more likely to be murdered with a gun compared to white men of the same age.11 The State’s largest cities of Bridgeport, Hartford and New Haven have also reported increases in gun violence during the pandemic, aligned with the nationwide trend, with the State Legislature holding hearings in April 2021 to address the growing concern.12
To address the increased violence, the new legislation requires Connecticut to amend its Medicaid State Plan by July 2022 to include community violence prevention services as a covered Medicaid benefit.13 This will permit community violence prevention services to Medicaid beneficiaries who “(A) Received medical treatment for an injury sustained as a result of an act of community violence, and (B) been referred by a certified or licensed health care provider or social services provider to receive community violence prevention services from a certified violence prevention professional, after such provider determines such beneficiary to be at elevated risk of a violent injury or retaliation resulting from another act of community violence.” The Connecticut Department of Public Health also plans to approve at least one accredited training and certification program for certified violence prevention professionals by January 2022, centered on a trauma-informed approach and inclusive of conflict mediation and retaliation prevention training and case management and advocacy practices.
Connecticut’s current violence prevention services include trained professionals who are on call to arrive at hospitals when a patient arrives with a gunshot wound, including intervention services in the emergency room and follow-up care in the community after release.14 For example, Hartford Communities That Care provides these violence prevention services and connects victims and families with behavioral and physical care, employment training and support services.15
Connecticut plans to submit a SPA to leverage federal Medicaid funding to support community violence prevention services and directly reimburse certified violence prevention professionals. Given that the COVID-19 public health emergency remains in effect, Connecticut will be eligible to receive the 6.2 percentage point bump authorized by the Families First Coronavirus Response Act (FFCRA), reducing the State’s non-federal share to 43.8 percent.16
Conclusion
Nothing precludes other states from following Connecticut’s lead and submitting a SPA—or federal waiver if the state wishes to pursue a pilot program or focus on select populations—to expand and support hospital and community-based violence prevention services. With gun violence in 2021 continuing to rise, Connecticut’s effort to partner with CMS to identify, mitigate and prevent gun violence is likely to be of interest to other states.
1 Black men reflect six percent of the United States population, but over 50 percent of homicide victims due to guns. Women of color are also disproportionately impacted, with Black women three times more likely to be shot and killed by an intimate partner compared to white women.
2 Gun Violence Archive. 2020. August 2021.
3 These numbers reflect homicides, murders and unintentional and defensive gun use; they do not include gun violence due to suicide.
4 Gun Violence Archive. 2021. September 2021.
5 U.S. Federal Bureau of Investigation. National Instant Criminal Background Check System (NICS) Firearm Checks: Top 10 Highest Days/Weeks: November 30, 1998–August 31, 2021.
6 The Health Alliance for Violence Intervention. What Is a Hospital-Based Violence Intervention Program (HVIP)? Available here.
7 CMS. All-State Medicaid & CHIP Call. April 2021. Available here.
8 City of Philadelphia, Office of Violence Prevention. Report on Community-Based Violence Prevention Programs. December 2018. Available here.
9 Connecticut Against Gun Violence. Connecticut’s Gun Laws. Available here.
10 Giffords Law Center to Prevent Gun Violence. The State of Gun Violence in Connecticut. January 2020. Available here.
11 Giffords Law Center to Prevent Gun Violence. The State of Gun Violence in Connecticut. January 2020. Available here.
12 Altimari, D. Gun Violence Surged in Connecticut’s Largest Cities in 2020. Policymakers Say It’s an Epidemic That Needs Renewed Attention. Hartford Courant. April 2021. Available here.
13 Connecticut House Bill 5677. An Act Concerning the Availability of Community Violence Prevention Services Under Medicaid. June 2021. Available here.
14 Haigh, S. Connecticut Looks to Use Medicaid Funds to Address Gun Crime. July 2021. Associated Press. Available here.
15 Bergman, J. New Money for Violence Prevention Workers as State Grapples with Crime Spike. Connecticut Post. July 2021. Available here.
16 HR 6201. Families First Coronavirus Response Act.