Josh Hatcher remembers the date: 11 April 2021. He was picking up a friend at a Bay Area Rapid Transit station in Oakland, California, and a ride-share car was holding up traffic. He and the driver got into an argument and both men got out of the car. Hatcher’s friend warned him that the driver might have a gun and that they should go. But as he moved to get back in the car, shots rang out. Five of them hit Hatcher – a father of three – in the back, close to his heart.
When he woke up in the hospital, a frontline worker named Carlos met him there. Carlos, an Oakland native who shared common ground with Hatcher, was working with the Oakland non-profit Youth Alive. Programs like Youth Alive meet survivors of gunshot or stab wounds in the hospital, and fast – when the need is greatest. It’s at this moment that survivors are at their most vulnerable. They’re recovering from wounds, questioning their safety and facing a higher risk of re-injury and perpetuation of violence through retaliation.
These hospital-based violence intervention programs (HVIPs) dispatch “intervention specialists” like Carlos to their bedsides to offer support, redirect them away from retaliation and connect them with the services they need to rebuild their lives: counseling, finding safer housing, getting insurance, enrolling in school, navigating bureaucratic paperwork or simply helping with rides to doctor’s appointments or the store.
And it’s effective, advocates say. Forty per cent of those who survive a violent injury will become victims again within five years, according to Gabriel Garcia, policy and advocacy director for Youth Alive. “But with our services,” he said, “that gets cut down to 2%.”
“When you’re going through stuff like that, you do worry about retaliation,” Hatcher said. “That’s just natural. I stayed very positive. I made sure I kept myself surrounded by positive people. I prayed. I did all the necessary things to keep me grounded so that I wouldn’t continue to put myself in situations where maybe I’d get shot again or somebody else could get hurt.”
It’s a strategy that’s gaining traction. In August, Gavin Newsom, the California governor, signed Assembly bill 1929 into law, allowing violence prevention services provided by qualified professionals to be covered by Medi-Cal, the state’s Medicaid program. While the implementation is still in its infancy, the bill passed with bipartisan support in the California state senate, which voted unanimously in favor of the legislation. It’s a move that also recasts gun violence as a public health concern, not just a criminal justice one.
As policy and advocacy director, Garcia was deeply involved in the process, which accelerated after the Biden-Harris administration gave states the green light in 2021 to invest in violence prevention services as a Medicaid benefit. Since then, Oregon, Connecticut, Illinois and Maryland have passed similar laws, according to Kyle Fischer, an emergency physician and the policy director for the Health Alliance for Violence Intervention (HAVI), the national network that represents HVIPs and offers training to certify their workers. A similar bill is also pending in New York.
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Youth Alive, whose methods are now used around the country, first developed the hospital-based approach to gun violence more than 30 years ago in Oakland. At the time, Oakland had one of the highest rates of violent crime among US cities, according to the FBI’s Uniform Crime Reporting Program, which disproportionately affected young Black and Latino men aged 18-35. But before the nationwide surge in gun violence, Oakland also witnessed annual declines, which many attributed in part to the success of violence prevention programs.
Effective programs share a common premise, according to a report from the non-profit Giffords Law Center to Prevent Gun Violence: small, identifiable pockets of a city’s population are responsible for – and victims of – the majority of its gun violence. Strategically intervening within this group can cut gun homicide rates by as much as half in as little as two years.
Funds to power these programs are outweighed by the cost of violence, both in human and economic terms. Researchers estimate that gun violence costs America $557bn annually. Each fatality costs taxpayers an average of $274,000, while a non-fatal injury averages $25,000.
At the HAVI, Fischer has been advocating for Medicaid reimbursement for more than a decade.
In his career as an emergency physician, he saw that there weren’t enough resources to provide the long-term physical, psychological and social care survivors needed after their short-term care. While most people understand that veterans need mental health services to treat PTSD, many don’t consider the continuing needs of survivors of community violence, he said: “The human brain does not differentiate between a gunshot wound in Oakland and a gunshot wound in Afghanistan.”
For Hatcher, that started with Carlos. They’d go out to eat every week. Carlos helped him focus on his faith through his recovery and he set up Hatcher with a therapist who helped him better understand how to defuse emotional situations. Without this new support network, he said he would have been more frustrated that he couldn’t get the help he needed.
“I didn’t realize, with me being a victim of gun violence, still how positive and peaceful I was compared to people who were victims of gun violence,” Hatcher said. “It put a negative or just a bad spirit over them, to where they didn’t really want to be happy no more, to be positive.”
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Youth Alive’s hospital-based model will qualify for reimbursement, Garcia said, but accessing Medi-Cal comes with a great deal of administrative work. Community-based organizations will have to apply for reimbursement on a client-by-client basis, and that burden can divert resources from the lifesaving work that happens on the ground.
Still, there’s optimism that these funds can be a gamechanger.
“The promise of this model is that there is money there for every client that we serve,” Garcia said. “That’s the ideal. But all of this comes down to implementation, and that’s the stage that we’re at right now.”
Typically, Fischer said, funding for most violence prevention programs has been a mix of grants, donations, city funding, in-kind contributions from hospitals and more. Access to reliable funding means that these organizations can adapt and expand more easily when the need for their services grows, such as when gun violence increased during the pandemic.
Medicaid funds can also offer some stability and certainty, he said, possibly shielding a city’s violence prevention programs from the downstream effects of different political priorities when, for example, a new mayor takes office.
But Fischer said he’s also clear with all of the HAVI’s member programs – this isn’t a panacea. Rather, it’s a helpful building block to diversify funding and allow for more flexibility.
Figuring out all the nuts and bolts of how the funding will work will take time. In the meantime, the HAVI is convening a large group of violence prevention organizations across the state, including Youth Alive, to determine what next steps look like.
“We’re working really, really hard to get that right,” Fischer said. “What we are aiming to do is making sure that in every county in California where there is a survivor of violence that needs violence prevention services – those county health plans are working with the local violence intervention programs so that they’re being reimbursed in a fair, equitable and strong way that minimizes the bureaucracy.”
These organizations are also working to help both lawmakers and the general public begin to see community violence as a public health concern.
Fernando Rejon, the executive director of Urban Peace Institute (UPI) – which has trained more than 4,700 violence intervention workers, community members and law enforcement officers as a part of its mission to reduce violence in Los Angeles – said community safety cannot be addressed by police alone, who address violence after it’s already happened.
“It’s really calling for a broader understanding of what safety is,” Rejon said. “And understanding public health approaches is really helpful to broaden out from an arrest-only, mass incarceration strategy. That costs a lot of money and wastes a lot of dollars, but it also traumatizes and incarcerates generations of mostly people of color that do not have the same advantages as those who do not grow up in those communities or are not people of color.”
UPI released its LA Peace Plan in October, which aims to create a department of community safety on par with the LAPD. When law enforcement responds to a gang-related homicide, Rejon said, the likelihood of retaliation falls to about 24%. When an intervention worker responds from a community-based, public-health perspective, the likelihood drops below 1%.
“People understand public health more now than they did at maybe any time in the history of the world because of what we’ve been through and are still going through,” Rejon said. “[The pandemic was] the fastest I’ve ever seen LA county get dollars out. They were under emergency orders, and, well, couldn’t we be under emergency orders to address young people dying in the streets?”
Hatcher knows the urgency better than most. He’s doing his best to help people understand how gun violence affects people in marginalized communities facing poverty, trauma and limited access to mental health services.
He’s still connected to Youth Alive, where Garcia arranged for him to speak with Congresswoman Barbara Lee, who represents Oakland, last summer about his experience as a survivor. He shared with her that it made him want to be a leader in his community.
He’s involved in feeding the unhoused, in peace walks and community cleanups, and in putting together free basketball clinics called Buckets, Not Bullets. In his own family, he has a teenage daughter and young twins and it’s important to him that he models a peaceful mindset.
“I’m not the only person in the world that’s been shot before. I have to understand that there’s a greater purpose in me still being alive,” Hatcher said. “Being there for my family, being there for people who need me. My work on this earth is not done. I have a lot to learn and a lot to provide.”
