LAWMAKERS

Lawmakers have a variety of tools at their disposal to advocate for policy changes that will improve public health outcomes related to violence.

American Rescue Plan Act

The American Rescue Plan Act (ARP) was passed and signed into law in 2021 as a federal relief package to assist with the recovery from the COVID-19 pandemic. The bill allocated a record $1.9 trillion to cities, counties, and states in order to address financial hardships related to the pandemic. In addition to covering costs such as tests and medications, local governments were given broad authority to use this money to address societal challenges that were exacerbated by the pandemic’s disruption. Importantly, guidance from the federal government explicitly stated that this funding could be used to address the spikes in community violence that were seen nationwide.

As of 2023, dozens of communities across the country have allocated roughly $2 billion in ARP funds towards community violence intervention (CVI). This funding provides an important opportunity for CVI programs because lawmakers at three levels of government—cities, counties, and states—have the ability to independently make these investments, which must be allocated by the end of 2024 and spent by the end of 2026.

The Alliance for Safety and Justice provides additional information about ARP funding for CVI in their issue brief, “The Promise of the American Rescue Plan.”

Medicaid

Medicaid is a public health insurance program that provides important support to victims of violent injury. Initially created alongside Medicare in 1965, Medicaid was designed for low-income pregnant women, children, and people with disabilities. The Affordable Care Act (ACA) expanded the program’s eligibility to anyone with an income less than 138 percent of the federal poverty limit—approximately $16,500 annually for a single adult.

Before the ACA’s Medicaid expansion, victims of gunshot and stab wounds were disproportionately uninsured. After the program’s expansion, many of these previously uninsured patients gained access to health insurance, which helps pay for medical care, including mental health services and substance abuse treatment. Importantly, Medicaid is the nation’s largest payer for health costs associated with gunshot wounds.

Medicaid is designed as a partnership between state governments and the federal government. This allows states a great deal of flexibility in administering patient benefits and other aspects of the program, such as rules for signing up and options for prescription drugs. The biggest source of variability among states is in patient eligibility, in part due to a 2012 Supreme Court decision that made the ACA’s Medicaid expansion optional for states. As of April 2023, 40 states and the District of Columbia have adopted the expansion, while 10 have not (the Kaiser Family Foundation website provides an updated count).

Medicaid provides ample opportunities for lawmakers to advocate for violently injured patients and their providers. In states that have not yet expanded Medicaid eligibility, this is the most pressing area of need for patients and providers as without insurance, patients have limited options for accessing medical care or mental health and substance abuse treatment. In states that have already expanded Medicaid, state flexibility in program administration offers additional opportunities for advocacy. For example, Medicaid allows states to issue direct reimbursements for the services of violence prevention professionals, which can be accomplished administratively and without requiring the passage of a new law. One state that has taken advantage of this option is Pennsylvania, which elected to reimburse Philadelphia hospitals for the work of their violence peer counselors. In other states, lawmakers have proposed legislation that creates a pathway for reimbursement of violence prevention professionals. As of the start of 2023, five states—Connecticut, Illinois, Oregon, California, and Maryland—have elected to provide violence prevention benefits as part of their Medicaid programs.

Opportunities for advocacy also exist at the federal level. For example, the Center for Medicare and Medicaid Innovation could create a “violent injury” demonstration project to obtain additional data on programs while still providing needed services. Both federal and state lawmakers can advocate for legislation to carry out these measures in support of HVIP services.

Victims of Crime Act

Passed in 1984, the Victims of Crime Act (VOCA) is a federal law that uses non-criminal justice measures to assist victims of crime. One such measure is the Crime Victims Fund, which offers financial compensation to victims of crime. Lawmakers at the state level can and have used VOCA as a tool to support HVIPs and remove barriers for patient access in hospitals.

Using VOCA to support HVIPs

The federal Crime Victims Fund is a special mandatory spending account funded by fines, fees, and penalties imposed on people found guilty of federal offenses rather than federal tax revenue. The Crime Victims Fund provides two distinct and important sources of potential funding for HVIPs and their clients: VOCA assistance grants and VOCA compensation.

A VOCA assistance grant is a “formula” grant, meaning that states are each allotted a certain amount of funding based on a formula that factors in population size. VOCA assistance grants support organizations that provide direct services to victims of crime, such as crisis intervention and counseling. VOCA assistance grants are funded by federal dollars but are managed by state administrative agencies (SAA), which are different in each state. In South Carolina, for example, the SAA is the Office of the Attorney General, while in Tennessee, it is the Office of Criminal Justice Programs.

The amount of funding available to organizations via VOCA assistance grants has increased substantially in recent years. In 2015, Congress raised the VOCA assistance grant spending cap from $700 million to $2.36 billion, effectively quadrupling available funding. Although subsequent years saw a dip in total funding levels, Congress passed the “VOCA Fix to Sustain the Crime Victims Fund Act of 2021” which is widely anticipated to replenish the fund. This recent influx of funds creates an opportunity for HVIPs as SAAs are looking for additional programs to fund with VOCA assistance grants. As programs that provide direct services to victims of violent crime, HVIPs qualify to receive VOCA assistance dollars. One program that has taken advantage of this is Project Ujima, an HVIP based in Milwaukee, Wisconsin, which has received regular and substantial funding from its SAA—the Wisconsin Department of Justice’s Office of Crime Victim Services—for a number of years.

Lawmakers around the country can work with HVIPs and their SAA to secure VOCA assistance grant funding. A full directory of SAA’s, along with contact information is available here.

Using VOCA to remove barriers for patient access

VOCA compensation dollars—which are distributed by the Department of Justice’s Office of Victims of Crime (OVC) to states that administer victim compensation programs—are available to individual victims of violence for crime-related expenses and services, including lost wages and the cost of medical, dental, and mental health care. The receipt of victim compensation funds is contingent upon a number of factors, including the victim’s cooperation with law enforcement officials. Restrictions on how VOCA funds can be used are determined by both federal and state guidelines, and there is substantial variability between states on what is permissible.

Despite the availability of victim compensation funds, a relatively small proportion of victims of crime—especially those who are young, male, racial or ethnic minorities, and victims of physical assault—apply for compensation or access assistance programs. This is due to a number of factors, including lack of knowledge about victims’ compensation benefits and eligibility, challenges to completing the application process, and hesitancy about involvement with law enforcement officials. Additionally, victims of violence often face bureaucratic challenges that may disqualify them, such as prior criminal charges or subjective assessments of police cooperation. Lawmakers can reexamine these criteria to help streamline the application process.

Legislation that Directly Funds HVIPs

There are several strong examples of state and federal legislation that directly funds HVIPs.                                                                                                                                                                        

State legislation to directly support hospital-based violence intervention programs

  • In 2018, Maryland passed HB 432, which created a fund that provides grants to local governments and nonprofits to support and evaluate evidence-based violence intervention programs, including HVIPs.

  • During New Jersey’s 2018-2019 legislative session, the acting governor signed into law a package of gun violence intervention bills (S3301, S3312, and S3323) that aim to prevent gun violence in several ways—by establishing HVIPs in the Department of Health, by requiring Level One and Level Two trauma centers to provide HVIPs upon available funding, and by requiring the Victims of Crime Compensation Office victim counseling service to partner with trauma centers to refer certain victims to violence and intervention programs.

  • In 2021, New York enacted legislation (S.7763 and A.5505) through the state’s budget process that requires Victim of Crime Act Funds to be allocated to support hospital-based violence intervention programs.

State legislation to Create Medicaid Violence Prevention Benefits

All of the bills listed below create reimbursement pathways for violence prevention benefits within Medicaid.

  • Connecticut HB5677 (2021)

  • Illinois SB2017 (2021)

  • Oregon HB5677 (2022)

  • California AB1929 (2022)

  • Maryland SB350 and HB1005 (2022)

Federal legislation that directly funds HVIPs

  • 2021-2022 Break the Cycle of Violence Act S.2275/H.R.4118 — Proposed by Senator Cory Booker (D-NJ) and Representative Steven Horsford (D-NV-4), this bill would authorize a $5 billion investment in CVI strategies through new grant programs to support violence intervention initiatives.

  • 2021-2022 Bipartisan Solution to Cyclical Violence Act (H.R. 1260/S.2422) — Representative C.A. Dutch Ruppersberger (D-MD-2) and Senator Benjamin Cardin introduced bills to amend the Public Health Service Act to establish a grant program supporting trauma centers with violence intervention and violence prevention programs. The bill passed the House of Representatives and was reintroduced during the 118th Congress.