Firearm injuries, whether fatal or nonfatal, contribute to a sizeable national economic burden. In 2020, the estimated cost related to firearm injuries and deaths in the U.S. was $493.2 billion.¹ By providing detailed cost patterns on nonfatal firearm injuries, we aim to equip policymakers, providers, and healthcare systems with data on the healthcare costs associated with these injuries. This paper quantifies the recent incidence of firearm injuries among commercially insured populations, updates Milliman’s earlier commercial claims analysis with more recent 2020–2022 data,² and traces the six-month healthcare cost journey that follows a nonfatal firearm injury event (FIE).

Firearm injury statistics in the United States

Firearm injuries and deaths remain a significant public health issue, where nearly 47,000 firearm-related deaths occurred in the United States in 2023,³ and for every firearm death, there are two firearm injuries.¹ Although the incidence of firearm-related deaths has been on the rise over the past two decades,⁴ decreases in firearm-related death rates have been observed in recent years.⁵

The incidence of firearm injuries is greatest among younger age groups, where annual rates of FIEs requiring emergency medical services were consistently highest among people age 15 to 24 years.⁶ Furthermore, firearm-related deaths continue to be the leading cause of death among children and adolescents under 20 years of age. In 2017, firearm injuries surpassed motor vehicle accidents as the leading cause of death in the U.S. among people under age 25.⁷

In 2022, we published a study examining healthcare costs preceding and following nonfatal FIEs among commercially insured individuals using insurance claims data from 2017 to 2019 (Healthcare cost journey for survivors of firearm injuries), where an FIE is defined as an initial firearm injury encounter in the inpatient setting or emergency department.² This paper reflects an update to our prior commercial study with more recent data.

Findings

Firearm injuries in the commercially insured population

We identified nearly 14,000 individuals with claims for an initial FIE occurring from 2020 through 2022 in our commercial study population (see Methodology). Among commercially insured adults, the annual rate of firearm injuries in our dataset was 8.6 per 100,000 in 2022, and the rate among children was half of the rate among adults (4.3 per 100,000).

Of the nearly 14,000 individuals with claims for an initial FIE, about half had a firearm injury resulting in either an inpatient or emergency department or observation (ED/Obs) encounter (i.e., an FIE) and had six months of health insurance coverage in the periods before and after the injury (our study population). Given that we required continuous eligibility for six months following the FIE to assess healthcare costs, the FIEs included in our commercial cost journey analysis were assumed to be nonfatal. Males were five times more likely to experience an FIE than females (84% of FIEs occurred among males, and 16% occurred among females). Individuals age 18 to 29 are more likely to experience an FIE than any other age group, where 43% of individuals experiencing an FIE were in this age group.

Direct healthcare costs for survivors of firearm injury events in the commercial population

Within our study population, the average cost* of an FIE was $40,125 (Figure 1). When comparing individuals admitted for their FIE to those with an ED/Obs visit, the costs incurred for the FIE were 15 times higher for the inpatient group ($94,079 versus $6,262 - see Figures 2 and 3).

In both cohorts, costs remained elevated in the six months after the FIE, where costs in the six months following the FIE were statistically significantly greater (p<0.05) than in the six months prior to the FIE (baseline). Costs following the FIE were 4.0 times greater for those admitted for an FIE and 2.0 times for those with an ED/Obs FIE (Figure 4).

The service categories with the largest increases following the FIE were inpatient and outpatient surgery, physical therapy/occupational therapy/speech therapy (PT/OT/ST), and home healthcare services (Figure 5). Individuals who were admitted for their FIE experienced the greatest increase in PT/OT/ST service costs (over 40 times the baseline cost) compared to those with an ED/Obs FIE (five times the baseline cost).

Discussion

Treating a nonfatal firearm injury is costly, and these costs persist in the six months following the injury. Firearm injury rates were highest among younger males, which is consistent with other sources on firearm injury rates.^1,6 In our analysis of costs related to FIEs, the relationship between post-injury and pre-injury costs was consistent with our prior analysis for the years 2017 through 2019,² where costs increased substantially in the six months following the FIE across all service categories measured. These observations are within the range of other studies examining changes in costs in the year following a firearm injury among survivors.^8,9,10 Along with increases in costs, survivors of firearm injuries also experience increases in healthcare utilization and diagnoses of mental health conditions post-injury.⁸ One study found a 1.23 times greater risk of utilizing psychotherapy and a 1.40 times greater risk of utilizing substance use treatment in the 12 months following the injury among children and adolescents experiencing a firearm injury relative to matched controls.¹¹

These findings add to existing research on the burden of firearm injuries on the healthcare system. Potential future research topics include:

1. Understanding FIE rates and costs by clinical severity, race and ethnicity, and other socioeconomic factors. Trends in firearm injuries have demonstrated clear disparities in injury and mortality rates by race, ethnicity, age, and urbanicity.^1,6,12.
2. Studying the longitudinal burden of firearm injuries to provide a comprehensive view of direct and indirect costs. The impact of firearm injuries can also extend to caregivers and family members of firearm injury survivors, with significant increases in behavioral health service use observed.¹³ Additionally, employers may be interested in costs related to disability, absenteeism, and lost productivity for both survivors and their family members.
3. Comparing the long-term costs and indirect effects of firearm injuries on survivors and their families to those of other injury types can help put the impact of firearm injuries into context.

Further research on the impact of firearm injuries for survivors, caregivers, and families can shed light on the broader social and financial consequences of these events.

Data sources and methodology

Data sources

Milliman Consolidated Health Cost Guidelines Sources Database (CHSD)

The data on commercially insured individuals was obtained from Milliman’s Consolidated Health Cost Guidelines™ Sources Database (CHSD). The Milliman CHSD contains proprietary historical claims experience from several of Milliman’s Health Cost Guidelines (HCG) data contributors. The database contains annual enrollment and paid medical and pharmacy claims for over 70 million commercially insured individuals covered by the benefit plans of large employers, health plans, and governmental and public organizations nationwide. We used data years 2020 to 2022 for this analysis.

Methodology

We identified individuals with firearm-related initial encounters using ICD-10-CM diagnosis codes in the 2020 to 2022 CHSD dataset for commercially insured individuals. FIEs were identified as the first inpatient or ED/Obs claim for an initial firearm-related encounter ICD-10-CM diagnosis code (code list available upon request).

Firearm injury rates were calculated as the number of individuals experiencing an initial firearm injury per 100,000. The denominator was the total number of eligible members with at least one month of medical coverage in Milliman’s CHSD for the given study year.

Individuals included in the cost journey analysis were required to have at least six months of continuous enrollment both before and after the FIE. Individuals were stratified into four age groups (under 18, 18 to 29, 30 to 49, and 50 to 64), sex (male or female), and site-of-service for their FIE (admitted for an inpatient stay for their FIE or ED/Obs visit only). Allowed total costs were trended to January 1, 2023, at an annual rate of 5.0%. To account for the impact of high-cost and low-cost outliers, we separately truncated the population at the 5th and 95th percentile of total allowed costs (all costs from the six months pre-FIE to six months post-FIE) by FIE site-of-service (Figure 6). Individuals with total allowed costs below the 5th percentile and above the 95th percentile were excluded from the FIE analysis. We compared costs before and after the FIE (excluding FIE costs) using paired t-tests and determined statistical significance at alpha=0.05 for all FIEs and separately for the inpatient and ED/Obs cohorts.

Caveats and limitations

We used administrative claims data for this study, reflecting healthcare services paid by a commercial insurer, which only include firearm injuries coded on a claim with an initial encounter diagnosis code. Our study does not capture firearm injuries that do not result in an encounter with the healthcare system or lack complete coding specific to firearm-related initial encounters. Our analysis of FIEs also excludes all firearm injuries that resulted in death or loss of coverage either during initial treatment of the firearm injury or in the six months following the event. Also, results from this analysis have not been geographically or demographically adjusted and reflect the observed populations and geographies represented in the source data.

Our study period includes the COVID-19 pandemic, and it has been documented that firearm injuries increased during this period.¹⁴ We did not compare the incidence rates of firearm injuries across our three-year study period, nor did we adjust for any COVID-related complications or other influences the pandemic may have had on healthcare expenditures during our study period.

Milliman has developed models to estimate the cost values included in this report. The intent of the models was to estimate the healthcare costs associated with initial nonfatal firearm injuries. We have reviewed the models, including their inputs, calculations, and outputs, for consistency, reasonableness, and appropriateness to the intended purpose and in compliance with generally accepted actuarial practice and relevant Actuarial Standards of Practice (ASOPs, particularly ASOP 56, Modeling). The models rely on data and information as input to the models. The commercial results presented in this report are based on an insured sample population. Results could vary across different populations for a variety of reasons, potentially including differences in socioeconomic status, population health status, reimbursement levels, delivery systems, random variation, or other factors. The models, including all input, calculations, and output, may not be appropriate for any other purpose.

The American Academy of Actuaries requires its members to identify their credentials in their work product. Harsha Mirchandani is a member of the American Academy of Actuaries and meets its relevant qualification requirements.

¹ Miller, G. F., Barnett, S. B. L., Florence, C. S., McDavid Harrison, K., Dahlberg, L. L., & Mercy, J. A. (2024). Costs of fatal and nonfatal firearm injuries in the U.S., 2019 and 2020. American Journal of Preventive Medicine, 66(2), 195–204. https://doi.org/10.1016/j.amepre.2023.09.026.

² Tomicki, S., Mirchandani, H., & Johnson, R. (2022, 11 July). Healthcare cost journey for survivors of firearm injuries. Milliman, Inc. Retrieved October 3, 2025, from https://www.milliman.com/en/insight/healthcare-cost-for-survivors-of-firearm-injuries.

³ National Center for Health Statistics. (2025, September 17). FastStats: All Injuries. U.S. Centers for Disease Control and Prevention. Retrieved October 3, 2025, from https://www.cdc.gov/nchs/fastats/injury.htm.

⁴ Rees, C. A., Monuteaux, M. C., Steidley, I., Mannix, R., Lee, L. K., Barrett, J. T., & Fleegler, E. W. (2022). Trends and disparities in firearm fatalities in the United States, 1990-2021. JAMA Network Open, 5(11), e2244221. https://doi.org/10.1001/jamanetworkopen.2022.44221.

⁵ Gramlich, J. (2025, March 5). What the data says about gun deaths in the U.S. Pew Research Center. Retrieved October 3, 2025, from https://www.pewresearch.org/short-reads/2025/03/05/what-the-data-says-about-gun-deaths-in-the-us/.

⁶ Rowh, A., Zwald, M., Fowler, K., Jack, S., Siordia, C., & Walters, J. (2024). Emergency medical services encounters for firearm injuries — 858 counties, United States, January 2019–September 2023. Morbidity and Mortality Weekly Report, 73(24), 551–557. https://dx.doi.org/10.15585/mmwr.mm7324a3.

⁷ Lee, L. K., Douglas, K., & Hemenway, D. (2022). Crossing lines — a change in the leading cause of death among U.S. children. The New England Journal of Medicine, 386(16),1485–1487. https://doi.org/10.1056/NEJMp2200169.

⁸ Song, Z., Zubizarreta, J. R., Giuriato, M., Paulos, E., & Koh, K. A. (2022). Changes in health care spending, use, and clinical outcomes after nonfatal firearm injuries among survivors and family members: A cohort study. Annals of Internal Medicine, 175(6), 795–803. https://doi.org/10.7326/M21-2812.

⁹ Gastineau, K. A. B., Oddo, E. R., Maldonado, L. G., Simpson, A. N., Hink, A. B., & Andrews, A. L. (2024). Health care utilization after nonfatal firearm injuries. Pediatrics, 153(1), e2022059648. https://doi.org/10.1542/peds.2022-059648.

¹⁰ Ranney ML, Herges C, Metcalfe L, Schuur JD, Hain P, Rowhani-Rahbar A. Increases in Actual Health Care Costs and Claims After Firearm Injury. Ann Intern Med. 2020 Dec 15;173(12):949-955. https://pubmed.ncbi.nlm.nih.gov/32986488/.

¹¹ Oddo, E. R., Simpson, A. N., Maldonado, L., Hink, A. B., & Andrews, A. L. (2023). Mental health care utilization among children and adolescents with a firearm injury. JAMA Surgery, 158(1), 29–34. https://doi.org/10.1001/jamasurg.2022.5299.

¹² Kaufman, E. J., Song, J., Xiong, R., Seamon, M. J., & Delgado, M. K. (2024). Fatal and nonfatal firearm injury rates by race and ethnicity in the United States, 2019 to 2020. Annals of Internal Medicine, 177(9), 1157–1169. https://doi.org/10.7326/M23-2251.

¹³ Song, Z., Zubizarreta, J. R., Giuriato, M., Koh, K. A., & Sacks, C. A. (2023). Firearm injuries in children and adolescents: Health and economic consequences among survivors and family members. Health Affairs, 42(11), 1541–1550. https://doi.org/10.1377/hlthaff.2023.00587 .

¹⁴ Zwald, M. L., Van Dyke, M. E., Chen, M. S., Radhakrishnan, L., Holland, K. M., Simon, T. R., Dahlberg, L. L., et al. (2023). Emergency department visits for firearm injuries before and during the COVID-19 pandemic – United States, January 2019–December 2022. Morbidity and Mortality Weekly Report, 72(13), 333–337. https://doi.org/10.15585/mmwr.mm7213a2 .