What will 2013 bring?

The homicide rate in the United States is seven times higher than that in other industrialized nations, a phenomenon largely explained by the widespread and easy availability of guns. There were 12 000 gun related homicides in 2008. By comparison, in the UK in 2008-09, there were 39 firearm related deaths (www.economist.com/blogs/lexington/2012/12/gun-control). Mass shootings occur several times every year in the US, and they are often followed by weak and short lived calls for stricter gun control. The tragic events in Newtown, Connecticut last month, however, were different. Most of the victims were young children, and the shooting took place at an elementary school. Public opinion has shifted, and there have been more persistent calls for changes in the gun ownership laws, especially limiting access to some types of guns and ammunition.

A complete ban on guns in the US is unlikely because the supreme court interprets the Second Amendment to the Constitution as protecting an individual’s right to own guns, and a rich gun lobby, led by the National Rifle Association, contributes to the campaign coffers of many powerful lawmakers. But, as argued by Katherine A Vittes and her colleagues at the Johns Hopkins Bloomberg School of Public Health, in an editorial on bmj.com (doi:10.1136/bmj.e8672), several sensible policy changes may decrease gun violence without infringing most citizens’ rights to own guns. These measures involve expanding current restrictions and regulations. For example, they would require a background check for everyone buying a gun, including from private sellers; extending firearm prohibitions to anyone convicted of any violent crime and those who abuse alcohol and drugs; and limiting sales to those over the age of 21. Because these measures do not ban gun sales, they may be more palatable to legislators.

While fiscal issues will likely dominate the debate in the coming months, the implementation of some provisions of the Affordable Care Act will probably offer numerous other contentious issues in the year ahead. By October 2013, when most Americans will have to select their insurance plans for next year, states must have health insurance exchanges where individuals will be able to find non-employment-based insurance plans at competitive rates. The law says that these exchanges can be run by the state government, state-federal partnerships, or, if states opt out, by the federal government. Many Republican governors (who decry federal intervention in state affairs) paradoxically chose to let the federal government run their exchanges. Ed Susman, in a feature on bmj.com (doi:10.1136/bmj.e8616) discusses some of the reasons for this anomalous situation, and explains how the exchanges will work.