(CNN) There were a million things running through James Slaugh's mind as he was rushed to a nearby hospital after the deadly rampage in Club Q, in Colorado Springs, last month.
Among them: what kind of bills he would be facing.
"My first night in the ER, that was in the back of my mind: 'I'm being whisked away to a hospital, and I'm not sure how much this is going to cost," he said. "You just went through a shooting, you just got shot, but that's where my brain went to."
A shooter killed five people at the club on November 19. More than a dozen others were injured, including Slaugh, his sister, Charlene, and his boyfriend, Jancarlos, who were enjoying a Saturday night out. Slaugh was shot in the shoulder -- a wound he later learned shattered the bone in his upper arm, and his boyfriend was shot in the leg. Slaugh's sister had "more than a dozen holes caused by an undetermined number of gunshots," their brother, Mark Slaugh, said.
Mark Slaugh spent most of that night frantically calling and texting to make sure his siblings were still alive. Since then, he's grappled with the family's mounting hospital bills, and helping fill out paperwork detailing the family's needs in hopes they will receive reimbursements from local victim funds.
"That was the reality setting in 10, 11 days after the incident had occurred," Mark Slaugh said. "Hospital stays are very expensive, surgeries are very expensive."
The bills they've received so far are concerning: Jancarlos, who is not insured, spent one night in the emergency room, where doctors stitched the part of his leg that a bullet tore through. That carried a price tag of more than $20,000. James Slaugh, who has insurance, was billed $130,000, he told CNN, and doesn't know how much of that he will have to pay out of pocket -- and just how much Charlene's multiple surgeries and weekslong treatments will amount to, though she's also insured.
Their brother worries the GoFundMe page they've created, which has raised more than $38,000, won't be nearly enough. "We know there's going to be an uphill battle," he said.
"We don't have generational wealth to rely on. It's going to be a struggle."
So far in 2022, there have been at least 623 mass shootings nationwide, according to the Gun Violence Archive. Though there's no national database tracking the financial aftermath of mass shootings and it's hard to estimate the total cost that can follow survivors for decades, one study published in the JAMA Network Open in May 2022 found that the average of initial hospital charges for patients injured during a mass shooting between 2012 and 2019 was more than $64,900 per person.
But those who survive the carnage are faced with not just hospital bills but the lifelong costs of an altered lifestyle: many are unable to return to work because of disabilities and may need follow-up surgeries, rehabilitation for months or years, mental health treatment and home care.
It's a costly recovery that no one can ever prepare for -- but one that is becoming a reality for a growing number of Americans as mass shootings pervade everyday life.
Barrett Hudson, 31, was also inside Club Q when shots rang out on November 19. Hudson, who had just moved to Colorado Springs from North Carolina, was shot five times in the back and twice in his arms. He underwent several procedures before surgeons eventually decided to leave three bullets lodged in his body, including one that was close to his spine, Hudson said.
"The surgeries are awful," he told CNN from his Charlotte home, where he returned so his dad and close friends are able to take care of him. Another friend set up a GoFundMe page for Hudson, who is insured, to help cover any out-of-pocket expenses connected to his "long-term physical therapy and rehabilitation."
Amid a hazy past few weeks that have felt like a nightmare, Hudson said he hasn't been able to think about medical and recovery costs. All he knows: there's "tons of doctor's appointments" coming up, physical therapy, and a list of psychiatrists that doctors in Colorado and North Carolina recommended.
A 2021 report from the US Government Accountability Office found that in 2016 and 2017, initial hospital costs for gun injury care -- not specific to mass shootings -- topped $1 billion each year.
But that's just the tip of the iceberg: survivors of gun violence often need follow-up surgeries and treatments. And those injured in mass shootings specifically -- where weapons have been larger and more powerful than in other incidents of gun violence -- are even more likely to have long-term care costs and long-lasting disabilities.
"Many of these traumatic injuries require ongoing care, sometimes for years in the future, requiring further surgeries," said Dr. Michael Cheatham, the chief surgical quality officer at Orlando Health's Orlando Regional Medical Center. Cheatham worked on the night a gunman opened fire in the Pulse nightclub in Orlando in June 2016, killing 49 people and wounding dozens more.
The health care system treated close to 50 patients from the nightclub shooting and has since covered nearly $12 million in unbilled charges for them -- meaning it wrote off anything not covered by the victims' insurance policies. It also worked closely with uninsured survivors or those who had further medical bills to help them find coverage, hospital leaders said at the time.
"The costs are not limited to just the first hospitalization. They increase with time," Cheatham told CNN. "These high-velocity weapons, the assault rifles ... They cause devastating fractures that may require ongoing surgery."
Taxpayers nationwide are footing many of the bills of not just mass shootings, but all US gun violence. The government report found that in 2016 and 2017, firearm injury patients who had Medicaid or other public coverage made up more than 60% of that $1 billion in initial hospital costs.
In 2019, Stanford researchers estimated that hospital readmissions of patients within six months of a gun injury cost "taxpayers, private insurers and uninsured families an average of $86 million" annually between 2010 and 2015.
"We end up as a society paying a huge amount for these injuries," Sarabeth Spitzer, the study's lead author, said at the time.
In Illinois, young Cooper Roberts' life was forever changed after the Highland Park Fourth of July attack. A gunman killed seven people and injured dozens of others.
Cooper, 8, was shot and received significant injuries including a severed spinal cord, which left him paralyzed from the waist down. Since the shooting, he's undergone numerous surgeries as doctors worked to repair injured organs and stave off infections. After spending weeks in the hospital and later a rehabilitation facility, Cooper returned to a challenging new normal: navigating life with a wheelchair in a home that was in many ways no longer accessible for him, his family said.
Family friends began a GoFundMe campaign after the attack, which has raised more than $2 million. And in October, a local bar held a fundraiser to further help cover the child's "ongoing medical needs and other expenses like home adaptations, medical equipment and assistive devices."
For those who are uninsured, the bills after a mass shooting can be astronomical. But even those with insurance often end up paying hefty bills out of pocket.
Many long-term care costs, like home health care or necessary accommodations, like ramps for disabilities someone may have as a result of a shooting, are often not considered medical costs by health insurance and not covered, said Dania Palanker, an assistant research professor at the Center on Health Insurance Reforms at Georgetown's Health Policy Institute. And some insurance programs could deem some equipment, like a wheelchair, not medically necessary or cap the dollar amount they're willing to contribute, Palanker added.
There are other programs that can help cover some of the costs -- including the GoFundMe pages victims create in the aftermath of mass violence, state compensation programs and funds created by nonprofits or other private entities that work to disburse donations. But they, too, have their limitations, including how much money they're able to transfer to each victim, how many survivors they're able to find and reach, how much paperwork families have to navigate to receive reimbursements and how quickly those checks arrive.
After a shooter killed 23 people in an El Paso Walmart in 2019, Veronica Carbajal, who was then an attorney at Texas RioGrande Legal Aid, told CNN that while there were different types of aid for victims to cover things like housing and medical costs, some programs didn't pay out right away, leaving injured survivors digging into their savings to pay the bills.
"They are dealing with physical pain and mental pain, but the bills are still due," Carbajal told CNN that year.
But it's not just the physical wounds that are costly. Survivors of mass shootings, their families and their communities are often scarred by the violence for the rest of their lives, experiencing a number of physical, mental and other setbacks, including losing their job and income because of a disability.
"Imagine a young person is shot and loses their ability to walk or work and then suddenly someone in that family has to stay home and lose their job to care for their loved one. All those economic consequences then could affect their ability to keep their housing, to put food on the table," said Jeffrey Butts, a research professor at John Jay College of Criminal Justice. "Those costs could stay with them and their families for decades."
"It's really hard to estimate (what) the ripple effects of gun violence can extend beyond," he added. "The safest thing to say is, it's enormous, the economic consequence of every shooting in America."
Survivors of gun violence had more than a 50% increase in psychiatric disorders after their injury and an 85% increase in substance use disorders compared with their peers, while family members also saw an increase in psychiatric disorders, according to a study published in Annals of Internal Medicine in April 2022.
"Most of the population really has no experience where they can relate with what these victims go through," Cheatham, in Orlando, said. "This is a life-changing occurrence that they did not plan on. It affects them, it affects their family members, it affects their ability to work and have a normal livelihood."
"The impact of these mass casualty events, the effects are just far-ranging, and they go on for years, if not the victims' entire lifetime," he added.
Those who witness a mass shooting can struggle for decades with things like post-traumatic stress disorder and depression -- a leading cause of disability globally that has been linked to physical conditions like cardiovascular disease.
"It's really had to quantify what the actual impact of some of the psychological results of being witness to a mass shooting are, because they extend into so many domains, like not being able to work, not being able to attain your highest educational goals, and even having medical conditions that place you in the care of very expensive hospital systems and can reduce your life spans," said Amy Barnhorst, vice chair of community mental health at the University of California, Davis Department of Psychiatry.
Back in Colorado Springs, James Slaugh is at home, trying to use his injured arm as much as possible to restore his full range of motion. He's been thinking about the bills that will soon arrive, but for now is taking life "one day at a time." Charlene will likely be discharged from the hospital next week, brother Mark Slaugh said.
"These incidents ... leave a lot of deeper wounds," Mark Slaugh said. "The damage goes beyond just the people that were attacked, it goes beyond the holes and the wounds, which almost heal a lot faster than people's finances and their psychological, mental and spiritual well-being."