ACA limits what happens after patient guns discussion

Scenario The Affordable Care Act allows physicians to talk to their patients about guns, but the act limits data collection about gun ownership.

Reply Physicians have an obligation to address the social determinants of disease and injury with their patients and families. Moreover, as leaders in a civil society, we have obligations to discuss and address these determinants with other leaders of our communities.

Multiple social factors affect the distribution and burden of disease and injury and vary across communities and states. In the case of acute injury, social determinants include safety belt use, helmet use, at-risk alcohol use and abuse, unsecured medications, unsecured guns in the homes of children and teenagers, and unsecured backyard pools.

It is accepted practice for physicians and other health professionals to inquire about these risks and work with patients and their families to effectively reduce them to prevent acute injury and death. Framing anticipatory guidance is critical to bring about behavior changes that result in safe and healthy home environments.

On Jan. 16, in response to the killing of 20 elementary school children and six of their teachers in Newtown, Conn., President Obama recommended legislative action for reducing gun violence and announced executive actions that he will take on his own. Among the executive actions was clarifying that the Affordable Care Act does not prohibit physicians discussing gun safety in the home with their patients and families. This clarification was necessary because the ACA indeed has much to say about what information can be collected or reported by physicians during programs about wellness and health risks.

The ACA contains language about what physicians, health insurers and health systems can and cannot ask in addressing social determinants of health in the context of wellness and health promotion programs. I wish to dissect that language so that physicians and health care leaders can have a better understanding of what can take place between medical professionals and their patients and families and what is prohibited under the ACA language for inclusion in wellness and illness and injury prevention programs.

The primary thrust of the gun rights language of the ACA is contained in the amended Section 2717, as subsection (c) PROTECTION OF SECOND AMENDMENT GUN RIGHTS. Subparts (1) – (3) read as follows:

(1) WELLNESS AND PREVENTION PROGRAMS: A wellness and health promotion activity implemented under subsection(a)(1)(D) [this section details reporting requirements for groups that implement wellness and health promotion activities] may not require the disclosure or collection of any information relating to:

(A) the presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property of an individual; or

(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.

(2) LIMITATION ON DATA COLLECTION: None of the authorities provided to the secretary under the Patient Protection and Affordable Care Act or an amendment made by that act shall be construed to authorize or may be used for the collection of any information relating to:

(A) the lawful ownership or possession of a firearm or ammunition;

(B) the lawful use of a firearm or ammunition; or

(C) the lawful storage of a firearm or ammunition.

(3) LIMITATION ON DATABASES OR DATA BANKS: None of the authorities provided to the secretary under the Patient Protection and Affordable Care Act or an amendment made by that act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.

This language does not explicitly prohibit the physician or other medical professional from discussing acute injury prevention with patients and their families. The language does, however, prohibit physician groups and health care organizations from developing and maintaining a database of information on patients and families and their respective lawful firearm ownership.

Subpart (4) prohibits health insurers from increasing or decreasing premiums based on an individual's lawful ownership, possession, use or storage of a firearm or ammunition.

Finally, subpart (5) states:

LIMITATION ON DATA COLLECTION REQUIREMENTS FOR INDIVIDUALS: No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that act relating to:

(A) the lawful ownership or possession of a firearm or ammunition; or

(B) the lawful use, possession, or storage of a firearm or ammunition.

A patient or patient's family member is not required to disclose lawful firearm ownership, use, possession or storage under “any data collection activity” authorized under the ACA. This does not affect the patient-physician relationship or the physician's obligations to inquire about and discuss acute injury prevention, including unsecured guns in the homes of children and teenagers.

In this gun rights amendment, the ACA aims to prevent any database development that contains information on patients and their families who lawfully possess guns and ammunition. The ACA further protects individuals and households by prohibiting health insurers from adjusting insurance premiums based on their lawful gun and ammunition ownership.

The gun rights language in the ACA does not preclude health care professionals from inquiring into or providing anticipatory guidance about social determinants of the patient's health, which include use or presence of unsecured guns in the home.

Obama's Jan. 16 recommendations to the Legislature and his executive actions encourage physicians to talk to patients about gun safety.

The American Medical Association supports what its president, Jeremy A. Lazarus, MD, called “unfettered medical discussion” about safety risks including those posed by guns in the home.

— Stephen Hargarten, MD, MPH, professor and chair of emergency medicine; director, Injury Research Center, Medical College of Wisconsin