After Failed Execution, Health Workers Say State’s Rules Flout Medical Ethics

This story describes a lethal injection procedure used in state executions.

In May, a group of healthcare workers spent about an hour trying to establish complete IV access so they could inject Tony Carruthers, an inmate at the Riverbend Maximum Security Institution in Nashville, Tennessee, with a lethal dose of sedative.

Maria DeLiberato, an attorney for Carruthers, was in the room. She said the workers stuck his arms and feet with needles, to no avail. A doctor then tried to insert a central line through his collarbone and shoulder. That didn’t work, either.

Carruthers groaned in pain and blood oozed from puncture wounds, DeLiberato said in a news briefing.

After more than an hour, Gov. Bill Lee called the warden, ordering him to halt the execution attempt. He later granted Carruthers a one-year reprieve.

Now, as another death row inmate’s execution approaches, doctors and nurses in the state say they want medical professionals removed from the execution process. They’ve also joined defense attorneys and nine Republican state lawmakers in demanding a moratorium on the death penalty and an overhaul of the state’s execution methods.

The doctors’ arguments echoed those the American Medical Association has made before the U.S. Supreme Court and in its code of ethics.

Tennessee is among 27 states where the death penalty is legal, according to the Death Penalty Information Center, a nonprofit that offers data and analysis on issues surrounding capital punishment.

Governors in four of those states have halted all executions, citing moral concerns and logistical ones, such as being unable to obtain lethal injection drugs amid pharmaceutical companies’ refusal to sell them for use in executions. Lethal injection is still the primary execution method nationwide, but some states may use gas, a firing squad, or electrocution.

Since the beginning of 2020, 170 people have been executed in 17 states, with most occurring in Florida, Texas, and Oklahoma. In that time, six states have had botched lethal injections, according to the Death Penalty Information Center, which defines those as executions that include a departure from the protocol because of unanticipated problems and that cause more pain for the prisoner than anticipated, whether they ultimately end with a death or not. Several of the stories read like Carruthers’ — protracted but ultimately failed attempts to establish IV access.

Tennessee Health Workers’ Concerns

The IV team gave up on trying to place a typical line into Carruthers after several failed attempts, according to DeLiberato’s account. Following protocol, physician Mark Fowler, a contractor for the state’s prison system, then tried to place a central line in a deeper vein. That’s a quasi-surgical procedure in which a plastic tube is inserted in the chest, groin, or neck. Fowler used a series of syringes, trying to insert the tube under Carruthers’ collarbone and then through his shoulder.

In an October 2025 deposition, Fowler said he hadn’t done such a procedure in the 12 years since he had stopped working in an emergency room, and didn’t know that placing a central line could be among his execution duties.

Fowler told NPR by phone on Sept. 24 that “the doctor does not participate in the execution. The only thing the doctor does is declare the person dead.” He did not have further comment.

Two months after the halted lethal injection, more than 40 doctors and nurses sent a letter to Lee, calling on the Republican governor to pause executions and redesign the protocol to omit health workers from the process.

The letter said that Tennessee’s rules requiring the participation of pharmacists, physicians, and other healthcare workers in executions are at odds with medical ethics, as well as guidelines explicitly laid out by groups such as the American Medical Association. The AMA code says doctors are to preserve life when there is hope of doing so and bars participation in executions.

“This means that the health care professionals who agree to take part in Tennessee’s executions are those willing to set aside their professional ethics,” the letter to Lee reads. “The problems that we have seen, such as in Mr. Carruthers’s case, are the predictable result of working with such unscrupulous actors.”

John Greer, a retired Nashville hematologist, said in a news conference about the letter that he wasn’t surprised the central line placement went awry.

“Placing a central line is not just sticking a needle in a person’s arm,” he said.

Greer said the doctor has to tap a large vessel above the heart. He said that it’s a risky procedure in which an error could cause a collapsed lung or heavy bleeding — and that only those with specific training and routine practice should attempt.

“And I cannot imagine that there would be someone who’s doing these routinely who would be involved in this procedure,” Greer said.

Some Republican state senators also called for a hold on executions and an overhaul of the process, saying that “incompetent administration” of capital punishment gives its critics more ammunition.

This summer, Lee said he didn’t want a pause.

“The Department of Correction did exactly what they should,” he said. “It should not affect executions in the future.”

“It’s one of the most difficult things that we do in this state,” Lee said later. “But I am committed to making sure that it is done in the way that it should be.”

The state’s lethal injection protocol orders the prison to keep a curtain over the media witnesses’ viewing window until the IVs are established, so none of them could offer a visual account of the failed execution attempt.

A lawsuit challenging that policy has been filed has been filed by the Reporters Committee for Freedom of the Press and news outlets including NPR member station WPLN. The lawsuit argues the lack of transparency during the IV placement process obscures problems like the ones that happened in Carruthers’ case.

There’s a broad understanding in the U.S. that the medical establishment doesn’t participate in executions, said Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado’s medical school.

“We came out of World War II with a whole bioethics and medical ethics enterprise that is really strongly opposed to medicine serving as an arm of the state and using specialized medical skills to hurt people or kill people,” Wynia said.

A history of medical abuses by government doctors — such as forced sterilizations and unethical studies of untreated syphilis in the U.S., and murder and torture in Nazi Germany — forged that consensus, he said.

Wynia mentioned other nations where medical professionals still participate in executions.

“But they are, you know, Iran and Saudi Arabia and Russia, sort of authoritarian states, where medicine is an arm of the government,” Wynia said. “Medical involvement in executions ends up happening because medicine is unable to say, ‘No, we don’t do that.’”

Upcoming Execution

On Sept. 30, Tennessee is scheduled to execute Christa Pike, who was 18 years old when she and her boyfriend killed Colleen Slemmer.

Pike’s attorneys this year raised several concerns that the state’s lethal injection protocol would violate her rights. Among them is their contention that because she suffers from a platelet disorder, it’s likely she will need a central line placed. They also argued that she was at risk of needless suffering, alleging Carruthers’ execution showed that Fowler — who has confirmed publicly that he will oversee Pike’s execution — is incompetent at placing central lines.

In June, they put all of those concerns in a request to the Tennessee Supreme Court, asking for a special investigator to collect evidence and hold hearings to determine whether they warranted an order to delay her execution and design a method for only her.

The court did appoint a special investigator, Senior Judge Mark Ward. He held a series of hearings in Knoxville last month. Ward said he didn’t believe Pike’s rights would be violated by the process and submitted his report to the court.

On Sept. 23, the Tennessee Supreme Court denied Pike’s stay, agreeing with Ward, saying none of the concerns amounted to a constitutional violation. On Sept. 28, Lee announced he would not grant her clemency.

This article is from a partnership that includes WPLN, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Food Safety Finds a Place Among ‘Kitchen-Table’ Political Issues

The run-up to the midterm elections is turning into a food fight — literally.

The summer was marred by a massive foodborne outbreak that sickened scores of people and the recall of tens of thousands of pounds of imported meat, turning the safety of the U.S. food supply into a topic of national conversation and a political cause.

Late-night talk show hosts joked about symptoms that included explosive diarrhea. As a precaution, chain restaurants such as Chipotle and Taco Bell yanked lettuce, jalapeños, and other suspected products from menus. Some food safety scientists blamed the outbreaks on federal cuts to public health.

These dynamics collectively have raised questions about whether it’s safe to order a salad or burger.

Democrats have come out on the offensive, saying voters worried about the safety of the U.S. food supply should oust Republicans in the midterm elections. The Trump administration has countered by accusing Democrats of scaremongering over food safety to score political points.

The political fracas reflects the toll that large-scale outbreaks have had on the public psyche. Midterm voters have long cared about pocketbook issues such as grocery prices, but the spate of recalls has them worried about whether the food they’re buying is safe to eat — and political leaders are paying attention.

The outbreak linked to cyclospora in lettuce led to almost 20,000 laboratory-confirmed cases of illness from May through August, compared with 1,180 cases during the same span in 2025, according to the Centers for Disease Control and Prevention. That makes it the largest recorded outbreak of the parasite.

“One of the reasons food safety is in the news this year, and people have been rightfully concerned, is the combination of high-profile restaurant names and the absolute colossal number of illnesses,” said Teresa Murray, consumer watchdog director with the U.S. Public Interest Research Group, or PIRG, an advocacy group, referring to a recent cyclosporiasis outbreak. “It’s thousands of people. It makes it more real.”

Data shows there have been about 200 food recalls so far in 2026, which is about on par with the number at this time last year, according to PIRG data.

Following the Numbers

A majority of registered voters have little or no confidence in government oversight of food safety, with Democrats far more likely than Republicans to doubt the protections in place, according to a July survey by Quinnipiac University. Ninety-four percent of U.S. adults indicated they were concerned about the frequency of food recalls in a poll by GS1 US, a data standards organization.

The share of consumers who strongly agree that the U.S. food system produces food that’s safe to eat declined to about 30% in August, from 40% in November, based on survey data released in September by the University of Illinois and Purdue University.

Democrats have jumped at the chance to repeat criticisms of President Donald Trump’s budget cuts and priorities.

The Democratic National Committee recently posted a list of recalled food items on social media while calling Health and Human Services Secretary Robert F. Kennedy Jr. a “complete disaster” who must resign.

“Trump is dismantling our government — and it’s harming people,” Sen. Elizabeth Warren (D-Mass.) posted Sept. 2 on the social platform X, adding: “Slashed food safety agencies → cyclospora outbreak.” Just weeks earlier, she had written to Kennedy demanding answers for what she described as the administration’s “failed response” and its connection to political contributions.

Rep. Gabe Amo (D-R.I.) posted Sept. 5 on X: “I’m calling on Trump to stop gutting the FDA & restore its inspectors. We deserve safe food.”

The campaign for Rep. Judy Chu (D-Calif.) posted Sept. 5 on X: “Trump is cutting our food safety funding and workforce, and we have seen far too many food recalls this summer.”

But the number of recalls doesn’t tell the whole story.

While recalls aren’t markedly up this year compared with 2025, they are up over a broader time span. The country saw 320 food recalls by the Food and Drug Administration and the U.S. Department of Agriculture in 2025, up from 296 in 2024, according to PIRG.

The total number of recalls grew 21% from 2021 to 2025, based on an analysis by Trace One, a provider of regulatory guidance software. A rise in Class I recalls, which are the highest priority because the products could cause serious illness or death, drove much of the increase.

But recall numbers can be misleading. For starters, federal agencies do not publicize all recalls, especially if products are no longer on the market. Recall data itself is suspect because a single contaminated food can result in multiple recalls if the item is incorporated into processed food or other products.

A far better measure is the number of people sickened, epidemiologists say. And this summer’s specific multistate outbreak from cyclospora was exceptional, affecting people in 21 states.

When it comes to bacterial contamination of food — which is more common and includes E. coli, listeria, and salmonella — the overall trend points to outbreaks in which fewer people are falling ill. That’s a promising sign, some food safety leaders say, although the CDC says an estimated 48 million people each year in the U.S. experience foodborne illness.

“That’s an indication we’re finding more outbreaks and finding more when they are smaller and limiting the extent to which they can get bigger,” said Craig Hedberg, a public health professor at the University of Minnesota and leader in food safety surveillance.

Still, the perception that the food supply is riskier has been enough to ignite political rancor.

The FDA recently asserted on X that recalls for fiscal year 2026 are among the lowest levels recorded in over a decade, stating, “Don’t believe the fake news.” It included a chart that showed recalls dropping to 1,836 in fiscal 2026 from almost 4,000 in fiscal year 2013.

On the same day, HHS senior adviser Calley Means doubled down on the claim, posting on X that Kennedy is doing so well that Democratic operatives are slamming the FDA for doing its job by conducting food recalls.

“It makes sense that these craven, disingenuous attacks are all these influencers have,” he wrote.

But some food safety experts question the numbers, noting that the agency’s recall totals cover a range of products. The tally also includes drugs and medical devices, based on an analysis of the posted data by Susan Mayne, who was director of the FDA’s Center for Food Safety and Applied Nutrition from 2015 to 2023. Some food safety leaders say it’s misleading to imply that food safety recalls have declined if the data the claim is based on includes recalls not related to food.

“This HHS assertion appears to be based on incorrect data,” Mayne said on LinkedIn, a job-oriented social networking site.

It’s About More Than Recalls

Food safety has occasionally taken center stage in politics. In 1993, for example, an E. coli outbreak traced to Jack in the Box fast-food outlets pressured newly inaugurated President Bill Clinton to make it an agenda item at his first Cabinet meeting. His administration wound up adopting a new approach focused on preventing foodborne illness and credited with drastically reducing E. coli infections.

Concern about food safety has especially taken hold now, public health leaders say, because the administration is portraying itself as a safety crusader while cutting staffing and funding for federal agencies responsible for surveillance and inspection.

“There’s a level of hypocrisy from the administration when they promise to make our food safer and then eviscerate the agencies and programs that detect and prevent outbreaks,” said Sarah Sorscher, regulatory affairs director at the Center for Science in the Public Interest.

The FDA continues to have the staff required for outbreak investigations, and no FDA investigators were affected by staffing changes or reductions in force, HHS spokesperson Grace Davis Jamison said in an email.

The CDC lab supporting foodborne outbreak investigations also was not impacted by reductions in force, she said, and the agency maintains a dedicated team investigating foodborne outbreaks and working closely with state and local health departments.

“The Trump Administration has mounted a robust response to each outbreak, working closely with health departments in all 50 states and leading the public health response by promptly identifying known sources and providing Americans with the information they need to protect themselves,” she said.

The administration’s initiatives risk weakening food safety protections. Trump in late August said he would take action to make it easier for small livestock operations to slaughter and process their own meat, raising concerns among food safety leaders that the change could allow inadequately inspected beef to enter the food system.

Trump also announced the U.S. would import more beef from Argentina and Brazil, despite concerns about inspections and safety. The European Union has implemented a ban on Brazilian beef imports because of noncompliance with food safety and antibiotic use.

The administration withdrew a proposed Biden-era rule that would have stopped the sale of raw turkey and chicken containing high levels of salmonella. And it said it would delay compliance with a rule requiring grocery stores and companies to trace food in their supply chains, allowing for quick removal in cases of contamination. Implementation, originally set for Jan. 20 of this year, would instead occur in July 2028.

The actions came after hearing concerns from stakeholders about the time needed to comply, Davis Jamison said.

Some food safety leaders say the administration should do more to prevent foodborne illnesses, saying that failing to direct more resources into preventing problems makes it harder for Kennedy’s campaign to encourage people to eat more fresh foods.

In fact, almost half of consumers changed their habits regarding which groceries they bought and 40% modified purchases at restaurants in the past month due to foodborne illness concerns, according to the survey by the University of Illinois and Purdue University. Concerns about foodborne illness exposure via fresh vegetables increased in August compared with feedback from the previous two years.

“If you want people to eat real food, fresh fruits and vegetables, they have to be safe,” said Sandra Eskin, chief executive at Stop Foodborne Illness, a nonprofit public health organization. “Instead, we have had farmers plowing under fields because people aren’t buying lettuce.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Abortion Is on the Ballot Again as Post-Roe Policies Continue To Evolve

MAPLEWOOD, Mo. — After Missouri voters added abortion protections to the state constitution in 2024, Kelly McCoomb decided to keep her yard sign supporting the measure in the basement of her suburban St. Louis home.

Abortion access is important to McCoomb. She wants her daughter to grow up in a state where the option is available if needed, and the sign was a keepsake from the day Missourians voted to reverse the state’s near-total ban. McCoomb also couldn’t shake the feeling that she’d need to display the sign in her yard again soon.

“I have little faith in our Missouri government,” McCoomb said, sitting on her front porch.

Sure enough, just two years later, the state’s Republican-dominated legislature is asking Missouri voters to overturn the abortion protections they recently supported. The conflicting measures even have the same title: Amendment 3. But while a “yes” vote in 2024 supported adding protections to the state constitution, a “no” vote in 2026 would keep them. McCoomb covered the “YES” on her yard sign with a “NO” made from black duct tape before placing the sign back in her yard.

Voters will weigh in on abortion in Missouri, and three other states, in the November general election. Missouri is also one of two states voting on it for the second time since 2024. Nevada will vote again, too.

The spate of referenda comes after the U.S. Supreme Court overturned federal abortion protections with its 2022 decision in Dobbs v. Jackson Women’s Health Organization, leaving each state to make its own abortion policy. The result has been a patchwork of state rules with varying degrees of bans or limitations, and even a series of “shield laws” in states where abortion remains legal that aim to protect providers from prosecution in states where it’s not.

“I just think there’s a constitutional crisis that’s coming,” said Kristi Hamrick, vice president of media and policy for the anti-abortion organization Students for Life Action.

“Can you have 50 state standards on whether or not a human being is a human being? Can you have 50 state standards on whether human beings have legal protection?” Hamrick said.

Advocacy Groups Work To Clarify Ballot Measures

That patchwork of abortion protections is the reason Nevadans for Reproductive Freedom introduced the 2024 ballot measure to enshrine the state’s law allowing abortions up to 24 weeks after conception into the state constitution, said Denise Lopez, president of the coalition.

The measure received strong support two years ago, with 64% of voters in favor. Nevada law requires two majority votes to enshrine constitutional amendments, so voters will need to support the expanded protection again in November for it to be enacted.

The Nevada ballot measure wouldn’t change the state’s existing law allowing abortions up to 24 weeks after conception. But the proposal would make it more difficult to overturn abortion access, requiring voter approval of any new ban in two elections.

Lopez said Nevadans for Reproductive Freedom has been campaigning to ensure voters are still mobilized.

“Folks care about it,” she said. “They’re seeing what’s happening at the national level, and they want to make sure that whatever’s happening in our neighboring states, like Idaho and Utah, doesn’t happen here in Nevada.”

Idaho, where a ballot measure establishing abortion rights recently qualified to go before voters in November, has one of the strictest abortion bans in the country. Voters will decide whether state statute should allow abortion through fetal viability, the point when a fetus can survive after birth, which is generally considered to be around 24 weeks.

In Utah, abortion is allowed up to 18 weeks while legal challenges to the state’s ban continue.

In Virginia, where abortion is already allowed through two trimesters of pregnancy, until 28 weeks, voters will decide whether to amend their state constitution to codify those rights.

Missouri is the only state voting this year on removing abortion protections already on the books. The measure would repeal the 2024 amendment that guaranteed abortion access through fetal viability in the state and replace it with a ban on abortions with exceptions for medical emergencies, fetal anomalies, and pregnancies resulting from rape or incest. Abortions for rape and incest would have to occur before 12 weeks of pregnancy.

Missouri was the first state to ban abortion after the Dobbs decision in 2022. At that time, abortions had already mostly ceased in the state after three decades of state regulations targeting the practice, including a 72-hour waiting period, minimum dimensions for procedure rooms and hallways in clinics that provide abortions, and a mandate that the clinicians have admitting privileges at nearby hospitals, among others. Only 150 abortions were performed in Missouri in 2021, down from 5,772 in 2011, state records show.

Even though Missouri voters backed the abortion amendment in 2024, it took nearly two years for medication abortions to resume in the state.

A Second Vote Causes Confusion

Margot Riphagen-Dunn, CEO of St. Louis-based Planned Parenthood Great Rivers, said the whiplash of a second statewide vote on abortion mirrors the confusion that patients have experienced about whether abortion is available in the state.

“Chaos is kind of the point here,” Riphagen-Dunn said, “and it is absolutely a tactic that gets in the way of being able to provide.”

The confusion has presented problems for abortion opponents in the state as well.

“I think it’s unfortunate,” said Reagan Barklage, who is a vice president of Students for Life of America and the treasurer of the Missouri Students for Life Ballot Committee. “People need to be very clear on what they’re voting for.”

Barklage said she has had to correct anti-abortion voters while out canvassing to remind them that they are voting “yes” on Amendment 3 this year even though they voted “no” on Amendment 3 last time.

“It is crazy that it ended up being even the same number. I do not think that was intentional, but we’ve got to deal with what we’ve got,” Barklage said, adding, “I hope the pro-choicers kept their yard signs from last time.”

In Maplewood, Missouri, McCoomb said she was happy that her repurposed sign supporting abortion access had been noticed.

“I hope lots of people see and remember to revote,” McCoomb said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Black Lung Disease Remains a Threat, but Federal Officials Delay Effort To Address It

OAK HILL, W.Va. — Each day at New River Health in Oak Hill, Lisa Emery finds disheartening signs of what she describes as a slow-motion repeat of the Hawks Nest Tunnel disaster.

Emery is director of New River’s Breathing Center and chair of the National Coalition of Black Lung and Respiratory Disease Clinics.

The disaster she’s reminded of started in 1930, when construction began on a 3-mile tunnel through Gauley Mountain in West Virginia. Over the course of 18 months, some 3,000 miners, most of them Black, spent long hours drilling through sandstone, engulfed in a cloud of its toxic byproduct, silica dust. More than 750 men died from that exposure.

The risk still exists, and advocates for workers say the government should do more to rein it in.

In April of last year, the Trump administration paused the enforcement of a rule designed to help protect coal miners from an aggressive form of coal workers’ pneumoconiosis, commonly known as black lung disease, the primary cause of which is exposure to silica dust.

(Other occupations at high risk of exposure to silica dust include construction, countertop fabrication, and oil and gas work. The new rule would reduce the permissible limit of exposure in coal mining to the existing level in other industries.)

This April, the Labor Department’s Mine Safety and Health Administration announced an indefinite delay in enforcement of the rule.

Gary Hairston sits on New River Health’s board. For decades, Hairston, a retired coal miner and president of the national Black Lung Association, has been an advocate for miners struggling with the debilitating effects of black lung, including extreme fatigue, an incessant cough, and a sensation of drowning. He regularly lobbies legislators for improved working conditions and black lung benefits. His entreaties, he said, seem to fall on deaf ears. He rarely gets an audience with the legislators themselves.

“I’d just like them to look me in the face,” Hairston said.

Gary Hairston, president of the Black Lung Association, says his lobbying of legislators for improved working conditions and black lung benefits for coal miners seems to fall on deaf ears. (Taylor Sisk for KFF Health News)

Evidence from just-released research underscores the urgency of his appeals for a safer work environment.

In August, the National Institute for Occupational Safety and Health, an agency within the federal Centers for Disease Control and Prevention, released a report on the results of testing conducted over the past five years on miners in central Appalachia — eastern Kentucky, southwestern Virginia, and West Virginia — with 25 or more years underground. Almost 1 in 3 tested positive for black lung disease, the highest rate in nearly 50 years.

The rate in 2018, the last time the agency reported results, was 1 in 5. The lowest reported rate, in 1999, was less than 1 in 10.

“We knew this would happen,” said Sam Petsonk, a West Virginia attorney who has represented thousands of miners in the region. “It’s surprising to me that they only found one in three.”

Silica Dangers

Exposure to silica has increased as more-accessible coal seams are depleted, requiring mining operations to probe deeper, often through sandstone. The stone breaks into sharp particles that are 100 times smaller than a grain of sand and, according to National Institute for Occupational Safety and Health research, are some 20 times more toxic than coal dust. Trapped in lung tissue, those particles can cause a debilitating, sometimes fatal condition.

Kenny Thompson, a retired West Virginia miner who now lives in Richmond, Kentucky, was employed in the mines for 22 years. He would sometimes cut into four feet of sandstone to reach a coal seam.

“You ate a lot of dust,” Thompson recalled. It induced nausea. It took a toll.

In October 2025, he had his left lung removed. Post-surgery, he was in a coma for three months; he flatlined three times, he said. “They were about to really give up on me.”

He had to relearn to walk and to talk. Trekking to the mailbox still leaves him winded, lightheaded, and blurry-eyed.

The new silica rule would cut the allowable level of silica dust in half, thereby meeting the standard of other industries. Miner advocates laud the fact that it would require operators to deploy engineering controls, such as improved ventilation systems and water sprays.

But the National Mining Association and other industry trade groups argue that reaching and maintaining compliance would also require supplementing those controls with workforce measures, such as requiring personal protection equipment and rotating miners from particularly dusty areas. Many miners, and their advocates, say such measures are impractical — because respirators can impede breathing, can limit vision, and often malfunction, and because smaller mines don’t have enough workers to support rotating schedules.

In April 2025, the 8th U.S. Circuit Court of Appeals granted an emergency stay of the rule to give operators more time to comply.

In May of this year, the Labor Department sent the White House Office of Management and Budget a request to gather information on the proposed rule. And in July, the department’s regulatory agenda included a new notice of proposed rulemaking, indicating its intent to amend the rule.

The department’s Mine Safety and Health Administration “recognizes it has a clear duty under the law to impose stricter silica standards,” said Petsonk, the attorney representing coal miners. “They’re failing to provide that measure of protection to American coal miners, so they’re going through bureaucratic motions to make it seem like they’re doing something, when, in fact, they’re just perpetuating an illegal and lethal status quo.”

The Labor Department declined to comment on ongoing rulemaking or litigation.

“We knew this would happen,” West Virginia attorney Sam Petsonk says of a recently released report showing that the black lung rate for coal miners in central Appalachia is at a nearly 50-year high. (Taylor Sisk for KFF Health News)

‘It’s On the Books’

The rule is, in fact, in effect, said Chris Williamson, head of the Mine Safety and Health Administration in the Biden administration — it’s just not being enforced. He and his team filed a legal brief in the closing days of the administration defending the rule.

“It’s on the books,” Williamson said, adding that the Mine Safety and Health Act prohibits weakening existing protections for miners. “I’m just genuinely curious,” he said. “I want to know how they can address the issues that the industry’s raised without weakening protections for miners.”

Meanwhile, younger miners, with a decade or less in the mines, are being diagnosed with advanced stages of black lung. New River Health’s Emery said the youngest person her clinic had diagnosed with complicated black lung was 30. He’d worked underground for 10 years.

This is no longer just your “papaw’s disease,” she said. “It’s your husband’s disease. It’s your son’s disease.” (More than 90% of coal miners are men.)

With families to support, Emery said, “what do these guys do when they’re disabled in their 30s?”

Lisa Emery is director of the New River Health Breathing Center in West Virginia and chair of the National Coalition of Black Lung and Respiratory Disease Clinics. She says the youngest person her clinic has diagnosed with complicated black lung was 30. (Taylor Sisk for KFF Health News)

She told of a man who sat in her office with his wife, describing his symptoms. As he spoke, he began to cry. His wife was taken aback. “‘I didn’t know it was that bad,’” Emery recalled her saying. “And he said: ‘That’s why I haven’t fixed the deck. I haven’t fixed the deck because I can’t breathe, and I’m just so tired.’”

Thompson can relate. “For 22 years, you’re used to getting up, putting your boots on every day, and going to work,” he said. “I’d been in great health shape and 160 pounds. And here I am now, I don’t work at all and I’m 115 pounds.”

Still, he recognizes what the job afforded.

“You know, it put my girls through college,” he said. “And to me, as a dad, that was the best reward that I can give them, to move forward in life, to be successful at what they chose to be and not work like a dog like I had to.”

President Donald Trump said in an April 2025 executive order: “Our Nation’s beautiful clean coal resources will be critical to meeting the rise in electricity demand due to the resurgence of domestic manufacturing and the construction of artificial intelligence data processing centers.”

Six months later, the Energy Department announced a $625 million investment to “expand and reinvigorate America’s coal industry.”

Should the administration announce a weaker rule, it would be “an unconscionable crime against American coal miners,” Petsonk said. “But I fear that’s going to happen.”

In June, Hairston spoke at a reception for a photo exhibit titled “Entirely Preventable: The Toxic Legacy of Silica Dust From Hawks Nest to Black Lung.”

“It seems like coal miners, we’re just a number,” he said. “Just a number.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Economic Frustration Tests Trump’s Standing With Rural Voters, New KFF-AP Poll Finds

About half of rural American voters believe the economy is worse off now than when President Donald Trump returned to office, according to a new survey that points to economic frustration among a key group that has backed Trump and other Republicans in recent elections.

The poll of more than 2,000 rural registered voters by The Associated Press in partnership with KFF found broadly negative views on the national and local economies, including from many Republicans. The costs of groceries, gas, and healthcare rank as top pain points for the rural voters, who were surveyed over two weeks starting in mid-August. And a larger share than among voters overall say they are worried about being able to afford groceries or gas.

At the same time, about half of rural voters approve of Trump’s job performance, more than among U.S. adults overall in separate AP-NORC polling.

The findings suggest that many rural voters haven’t turned on Trump but that they also largely don’t think he has delivered the economic renaissance he promised on the campaign trail.

Ed Westrick, a registered Republican and veteran, rates Trump’s job performance as “mediocre, middle-of-the-road.” Westrick, who lives in rural Texas, isn’t sure he will cast a midterm ballot, a troubling sign for Republicans in a key state in their fight to keep control of Congress.

Rural Americans skew Republican and historically have been an instrumental group of voters for Trump. The survey reveals that while rural voters seem unlikely to support Democrats on a large scale, Trump and the Republican Party could face challenges with them in November.

Deep Unhappiness About the Economy

As the election approaches, only about 4 in 10 rural voters approve of Trump’s performance on the economy. They rate him similarly on his handling of the Iran war, an entanglement that has proved expensive for the U.S. and increased oil and gas prices. And rural voters rank pocketbook concerns and fraud in government programs higher among the things they want to hear about from politicians than other perennial issues, such as gun policy and abortion.

Westrick, 59, is a technical trainer in the electronics industry and has seen an increase in business in part because he works with defense contractors, but he said he’s concerned about the cost of living.

“I hear the politicians talk about making groceries more affordable and making healthcare more affordable but yet none of them are addressing the issues,” Westrick said.

Westrick adjusts a roof on a small building at his home in rural Texas. (LM Otero/AP)

In the poll, about three-quarters of rural voters rated the cost of living in their communities as “only fair” or “poor” — up from about half in a KFF-Washington Post survey in 2017. Rural Americans, who have consistently lower wages than those who live in suburban and metro areas, have been hurting economically for decades, according to Tim Slack, a professor of sociology at Louisiana State University and co-author of the book Rural and Small-Town America.

“Many folks are connecting the cost-of-living crisis to many of the Trump administration’s policy choices: the war in Iran, tariffs, trade wars,” Slack said. “None of those things are going to bring down prices at the pump or the local Walmart.”

“Trump promised to lower prices on Day 1, and instead the cost of living’s continued to climb. And that’s especially painful in rural America,” Slack said, adding that he expects many working-class Republicans to skip voting in November.

Rural Republicans do have a brighter economic perspective than rural Democrats or independents, particularly about the U.S. as a whole, according to the survey. About 6 in 10 rural Republican voters say Trump has improved the national economy, compared with only about 2 in 10 independents and fewer than 1 in 10 Democrats.

But only 45% of rural Republican voters say Trump has made their local economies better off. About 1 in 4 said there are fewer good-paying jobs where they live than five years ago.

In Michigan, 37-year-old independent voter Brittainy Sosebee said she isn’t sure if she will vote in the state’s midterm election, which includes a tight Senate race seen as crucial to the Democratic Party’s push to win back a majority. Sosebee voted for Trump in 2016 and Democratic candidate Joe Biden in 2020; she didn’t vote in 2024.

Sosebee, who lives in St. Johns, a small town just north of Lansing, said she used to have extra money to take a vacation or buy a new pair of jeans without worrying. Now, she scrutinizes every expense, cringing at the rising cost of fresh produce when she shops for her three children.

“We hunt, so we have a lot of venison and things like that, so we don’t have to buy meat from the grocery store, but it’s still crippling,” she said.

Healthcare Policies Go Unnoticed

The KFF-AP poll found that rural voters overall don’t perceive much positive impact from the Trump administration’s healthcare policies even as they have been a top priority for Republican leaders, who have promoted efforts to lower drug costs and touted a $50 billion rural health program.

Only 17% of the voters said the Trump administration’s healthcare policies have had a “positive impact” on their healthcare costs, while 41% said they’ve had “no impact” and another 41% said they’ve had a “negative impact.”

Sitting on her front porch in Woolwich, Maine, 71-year-old Democrat Kathleen Hanning sipped a chai tea latte in the sun and recalled how she stopped voting for Republican Sen. Susan Collins in 2020.

Collins and Trump are “intertwined,” Hanning said. “She is not independently voting on what’s best for Maine.”

Hanning, a retired federal worker, said she hadn’t paid much attention to the health policies in Trump’s signature tax-break-and-spending-cut bill passed last year. The law reduces federal Medicaid spending by roughly $900 billion over a decade but also includes the billions of dollars for the Rural Health Transformation Program, which it created.

A year after the law’s passage, more than 8 in 10 rural voters said they’d heard either “a little” or “nothing at all” about the health fund. About 60% said they had heard nothing, according to the survey.

Rather than transforming, Hanning said, “hospitals up here in Maine are consolidating.” She travels an hour to see a specialist and noted that mothers will now have to drive farther for care because the hospital in nearby Damariscotta announced it would soon close its labor and delivery center.

Nine in 10 rural voters said it was “extremely” or “very” important for candidates to talk about healthcare costs, with more than half saying it’s “extremely important.” Mirroring the general population, rural voters ranked healthcare costs and gas prices as top economic worries.

Rural Republican Voters Still Trust GOP More

When asked which political party they trusted to do a better job handling issues such as the cost of healthcare or the cost of living, rural voters tended to side with their own party. The finding signals that Democratic candidates are more likely to benefit from rural Republicans’ staying home this November than from their voting across party lines in large numbers.

Republicans are more ambivalent about their party’s ability to handle key healthcare issues, compared with Democrats. About 8 in 10 Democratic voters say they trust the Democrats to address healthcare costs, while closer to 6 in 10 Republican voters say the same of the Republicans.

In Manassas, Georgia, a tiny town about an hour’s drive inland from Savannah, Republican voter Wanda Rogers feels the Trump administration is doing the best it can to clean up what she sees as an economic mess that Democrats left behind when they lost power.

“I kind of think people think like I do, that he knows what needs to be done,” she said. “It’s just taking them a while to get it there.”

Still, the 66-year-old said, “gas prices, they’re eating me alive right now.” She said she has stopped traveling to the beach because it has become too expensive.

Pamela Shaw, an independent voter who lives in a rural area near Asheville, North Carolina, said she sees the impact of rising costs in her community.

“When hamburger is over $7 a pound and steak is $15 or more a pound, a lot of people are not able to buy some of the things that they are used to buying,” the 59-year-old said in an interview.

Trump’s Rural Standing Has Slipped

Trump remains relatively popular among rural voters in the KFF-AP poll, with 48% approval — substantially higher than in a July AP-NORC poll of U.S. adults overall, in which only a third approved of his performance. But he’s also down slightly, from 56% approval, among rural voters, based on a similar question asked in the earlier KFF-Washington Post survey.

This year’s competitive elections feature key Senate races in states including Ohio, Michigan, and Maine, all of which have large rural populations. In close races, Democrats may have a chance to “show up and give a message that rural people might find appealing,” said Nicholas Jacobs, a political scientist at Colby College and co-author of the book The Rural Voter.

“But it’s nothing more and it’s nothing less than that — an opportunity,” Jacobs said. “And time and time again, Democrats have shown a certain proclivity for not seizing that opportunity.”

Many rural voters don’t think the major parties or the president respect people like them. About half, 48%, of rural voters say the GOP respects people like them “a lot” or “some,” while 45% of rural voters say this about Trump and 37% say this about the Democratic Party.

On a recent Thursday, registered Republican Nate Lawrence answered his phone after paying $57 to fill up his Chevy Equinox in New Concord, Ohio, a village of fewer than 3,000 people about an hour’s drive east of Columbus.

Lawrence, a middle school English teacher, said the candidates should be talking about spending power: “I need to be able to go to the store and feed my family on what I make as a teacher,” Lawrence said. “I should be able to pay for a house on a teacher’s salary.”

Lawrence has voted for Trump in the past but didn’t in 2024. For Ohio’s Senate race, Lawrence said he is torn and not sure whether to pick Democrat Sherrod Brown or Republican Jon Husted.

Still, even if the politicians say they will lower prices, Lawrence said, he won’t believe them.

“Trump said that, and it didn’t happen,” he said.

About the Poll

The KFF-AP Rural Voters Survey was conducted online and by telephone Aug. 12-24, 2026, among 2,241 registered voters living in rural areas, defined as census tracts that fall within codes 5-10 of the U.S. Department of Agriculture’s 2020 Rural-Urban Commuting Area (RUCA) codes. Voters were reached through a combination of the probability-based SSRS Opinion Panel and a registration-based sample from the L2 voter file. Overall results have a margin of sampling error of plus or minus 3 percentage points, including design effects due to weighting. Error margins are larger for subgroups. In collaboration with the AP, KFF researchers worked to design the survey sample and questionnaire and analyze and report findings.

This report is from a collaboration between KFF Health News and The Associated Press.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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As Health Insurance Costs Soar, Healthcare Workers Also Feel the Pinch

BOISE, Idaho — Joshua and Ashley Durham run a family medicine practice, and for the first time in their lives, they have no health insurance.

When the Durhams began their practice at the end of 2023 — he as a primary care physician and she as a pharmacist who handles the billing — the couple bought coverage for themselves and their two kids on the Affordable Care Act marketplace. But they said their monthly premiums for a similar health plan for this year rose several hundred dollars to nearly $1,600.

They decided to pay out-of-pocket for their medical expenses instead, leaning on $50,000 they had set aside in a health savings account over several years.

“It’s nerve-racking,” said Joshua Durham, 47. “It just takes, you know, one little accident, and then you got a big fat bill.”

The healthcare industry traditionally has more of its workforce on medical insurance than many other fields. Nationwide, 7% of all healthcare workers were uninsured in 2024, compared with 11% of all adults under 65, according to a KFF analysis of the most recent American Community Survey data. And doctors were especially unlikely to forgo health insurance, with just 2% uninsured.

But even healthcare workers are feeling the pinch as health insurance costs rise each year, with employers expecting that costs will jump an additional 8.2% for 2027.

The Republican-led Congress also opted last year not to renew Affordable Care Act marketplace credits enacted during the covid pandemic. While subsidies remain in place for people with low incomes, the pandemic-era credits helped reduce many consumers’ premium payments, especially those working in small businesses such as independent medical practices. Nearly half of marketplace enrollees worked for small businesses or were self-employed in 2024; some of the most common occupations included chiropractic care and dentistry.

Jack Dillon, executive director of the Association for Independent Medicine, which represents 4,000 physician-led practices, said premium increases have become untenable for small businesses, whether employers seek coverage through the marketplace or directly from insurers.

“The cost has become so astronomical,” Dillon said. “You’re looking at it and saying, ‘What’s the value?’”

As health insurance continues to become less affordable, Dillon said, more healthcare employers may seek alternatives to their standard coverage, such as providing higher hourly wages or providing only minimal plans.

The number of people without insurance in the U.S. is expected to increase by roughly 15 million over 10 years because of the expiration of the expanded ACA subsidies and $1.1 trillion in estimated cuts resulting from President Donald Trump’s signature One Big Beautiful Bill Act, according to the Congressional Budget Office.

Healthier people are the most likely to opt out of insurance. That leaves insurance covering a smaller pool of people who tend to be sicker and need more expensive care. So insurers raise prices to cover the remaining enrollees, which fuels even higher premium costs.

‘Healthcare Is a Business’

Samantha LeGault, a nurse practitioner at a health clinic in Boise, said her employer-offered plan’s premium payment rose from $700 to $1,500 a month this year to insure herself, her husband, and four of their kids. LeGault has Crohn’s disease and two of their daughters also have medical conditions, so she said her family has no choice but to continue to pay for that health coverage.

But she decided to skip dental insurance to save money, and she prioritizes dental visits for her children over herself.

She had already struggled to set aside retirement savings and had switched her children from a private school they liked to public school to cut down on costs. Then the new health insurance costs tightened her budget even more. She estimated that about one-fifth of her income now goes toward her monthly premium payments.

“I know how the clinics work, that I am an expensive patient,” LeGault said. “At the end of the day, healthcare is a business in the United States.”

Samantha LeGault, a nurse practitioner for a health clinic in Boise, says her medical insurance premium costs rose from $700 to $1,500 a month this year to cover her, her husband, and four of their kids. She has Crohn’s disease, and two of her daughters also have medical conditions. She continues to pay for health coverage but opted to skip dental insurance to reduce their monthly expenses. (Hayat Norimine/KFF Health News)

The Durhams have three other employees in their practice. Two of them receive health insurance through their spouses, Ashley Durham said. The Durhams said they pay $420 monthly toward their physician assistant’s premiums.

As a primary care physician, Joshua Durham said he doesn’t need regular doctor visits, because he can diagnose and treat himself — and, if needed, the rest of his family, though he acknowledged that’s frowned upon. The American Medical Association’s code of ethics generally discourages doctors from treating themselves or relatives but makes exceptions for emergency situations or short-term, minor problems. Ashley Durham said she’s filled prescriptions for her family.

Arthur Caplan, a bioethicist and professor emeritus at New York University’s Grossman School of Medicine, said that as more people are “turning toward relatives because they can’t access or easily see a regular doctor,” it may make sense to revisit that aspect of the code of ethics.

Out-of-Pocket Expenses

Healthcare workers with less advanced medical certifications than the Durhams often don’t have the option of treating themselves or family members — or don’t have savings to fall back on for healthcare expenses. And many healthcare professionals, such as Jill Kordick, a 64-year-old retired healthcare executive in Norwalk, Iowa, aren’t willing to go without the safety net of insurance.

In her work, Kordick saw hospitalizations become financially devastating for patients, so she said she would never opt out of health insurance — even for just the 16 months before she’d become eligible for Medicare at age 65.

Last year, she qualified for the enhanced Affordable Care Act tax credits, allowing her to pay $75 a month for health coverage. Her premiums rose to $800 a month this year when those subsidies expired.

Because she has a $10,000 deductible, she put off going to the doctor for weeks when she had a sinus infection this year, until it ultimately evolved into an ear infection. She said she regularly rethinks, and sometimes returns, nonessential groceries in her shopping cart. And she keeps her house’s thermostat at 80 degrees in the summer to cut down on air conditioning costs.

Kordick said healthcare is a universal struggle in this country, regardless of how familiar patients are with the industry. “It’s disheartening that it’s as broken and fragmented as it is,” she said.

The Durhams have seen the impact of unaffordable healthcare on their patients. They said they try to lend some leeway to patients when they can — a luxury they have, operating their own practice. In one case, Ashley Durham said, she wrote off $1,160 in bills for a single father whose son didn’t have health insurance rather than send their bills to a collection agency.

“It’s hard, because as a human I want to help them out,” she said. “At the same time, we need revenue for our office.”

Joshua Durham is more nervous about going uninsured than his wife. As a child, he witnessed his parents struggling to pay medical bills for their family of nine in south-central Idaho. Durham recalled that his dad, who was a carpenter, helped build a surgeon’s house to pay for an operation.

Today, Durham also sometimes exchanges work for care. He said he gets free eye exams from an uninsured optometrist and offers him free primary care.

He worries about a worst-case scenario: a car crash, a sports injury, a serious diagnosis.

“Do I have pancreatic cancer today?” Durham said wryly.

So far, the couple has paid around $9,000 total for expenses out of their health savings account this year, including physical therapy to help with the thoracic outlet syndrome that affects Durham’s neck and shoulder, mental health appointments, and contact lenses. The expenses were higher than the Durhams anticipated. But it was still less than what their monthly premiums would have cost them.

Their decision has paid off, Joshua Durham said. At least for now.

The Durhams used the Affordable Care Act marketplace for health insurance for their family of four last year. This year, they chose to pay out-of-pocket for care instead when the cost of their premium payments jumped. (Hayat Norimine/KFF Health News)

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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It’s Hard To Predict Who Will Be Suicidal. It’s Easier To Ensure People Can’t Shoot Themselves.

Paul Nestadt is about as steeped in suicide prevention as a person can be.

He treats suicidal patients as a psychiatrist, has co-authored scores of research papers on how and why people kill themselves, and teaches graduate courses on the subject.

But he’ll be the first to admit: “I can’t tell you which of my patients is likely to die by suicide in the next six months.”

Almost nobody can.

Research shows predictions of who will be suicidal are only slightly better than a coin toss. And they haven’t improved over 50 years.

But that doesn’t make Nestadt hopeless. Instead, it pushes him to pursue interventions that don’t require pinpointing people at risk.

Chief among them: making it harder for people to carry out the act of killing themselves.

“Instead of asking every doctor to figure out which patient will die by suicide and locking that patient up, it might be that we need to make sure there aren’t loaded guns available,” Nestadt said.

In an ongoing series, KFF Health News is examining approaches to suicide prevention that expand beyond providing people at risk with medication and therapy. Although those are lifesaving measures, many clinicians, researchers, and people who have lost loved ones to suicide agree that more is needed. The challenge is that when it comes to firearms, broad policy approaches quickly become constitutionally complicated and politically polarizing.

Research shows that limiting access to lethal means is one of the most promising approaches to save lives. It can involve erecting barriers on buildings and bridges to prevent people from jumping, as well as decreasing the number of pills someone can buy or be prescribed at once.

And reducing access to guns.

“That’s the one that will save the most lives,” said Nestadt, medical director at the Johns Hopkins Center for Suicide Prevention.

It may also be the most difficult to achieve.

More than 28,000 people killed themselves with a gun last year, representing more than half of all suicide deaths in the U.S., according to preliminary federal data. Even as overall suicide rates have dipped recently, gun suicides have hit record highs for five years in a row.

Most Gun Deaths in the U.S. Are Suicides

From 2021 to 2025, suicide deaths by gun hit record highs each year, even as homicides by gun decreased.

Source: <a href="https://wonder.cdc.gov/&quot; target="_blank" style="color:#0071ce">CDC WONDER</a> <br> Note: 2025 data is provisional. The following ICD-10 codes identify firearm death types: X93-95 (homicide), X72-X74 (suicide), W32-34, Y22-24, and Y35.0 (other, which includes accident, legal intervention, and undetermined). <br> Credit: Aneri Pattani/KFF Health News

Many of the deaths are among middle-aged white men and veterans, two groups that have had high suicide rates for years. But more recently, gun suicides have risen among women and among some Black and Latino men. Researchers say a surge in first-time gun buyers during the covid pandemic underscores the need for prevention efforts that can be applied widely.

Some people assume it’s futile to restrict access to bridges, pills, or guns. The thinking goes: Those who want to kill themselves will simply find another way.

But research refutes that. Creating barriers for one method doesn’t typically push people to another.

Suicide risk can surge quickly, with people spending less than an hour or even five minutes between deciding to die and acting on it. Anything that delays such action — for example, having to unlock a safe to access a gun — gives them time to reconsider or for someone to intervene.

A Sharp Rise in Gun Suicides Among Black Women

White women had the highest rates of gun suicides by women in 2015 and 2024, but among women of other races and ethnicities, the increase was faster and steeper over that time.

Source: <a href="https://publichealth.jhu.edu/sites/default/files/2026-07/2024-CGVS-gun-violence-in-the-united-states.pdf?nvep=&hmac=&emci=8288e977-1e8c-f111-b337-000d3a1558ce&emdi=ea000000-0000-0000-0000-000000000001&ceid=&quot; style="color:#0071ce">The Firearm Mortality Epidemic: Examining the U.S. Data From 2024, Johns Hopkins Center for Gun Violence Solutions</a> <br> Note: Rates represent gun suicide deaths per 100,000 people. <br> Credit: Aneri Pattani/KFF Health News

However, in the U.S., discussion around guns — even in the context of a traditionally bipartisan topic such as suicide prevention — is a political lightning rod. Mentions of background checks, waiting periods, or red flag laws often send people running to their respective corners. Gun owners and the firearm industry say many of the policies suicide prevention advocates seek threaten their Second Amendment rights, and many policymakers see the topic as a nonstarter.

President Donald Trump has been a strong ally of gun owners. His administration has rolled back dozens of firearms regulations and rescinded a previous surgeon general’s warning that called gun violence a public health crisis. It has also revoked grants focused on addressing community gun violence and cut federal staff working on the issue.

The White House did not respond to specific questions about how these actions may affect the nation’s high rate of gun suicides or what it’s doing to prevent such deaths. But spokesperson Lauren Bis said in a statement that “President Trump is committed to Making America Healthy Again and that includes mental health.” She pointed to the administration’s support for developing psychedelic treatments for mental illness and an announcement of $52.5 million in grants for veteran suicide prevention.

The Limits of Red Flag Laws

One gun policy that has gained some traction, despite pushback, is the extreme risk protection order, more commonly known as a red flag law.

Adopted in some form in 22 states and the District of Columbia, these laws allow judges to temporarily remove a person’s guns when evidence suggests they pose a danger to themself or others.

Although such laws are often passed in the wake of mass shootings, research suggests they’re more effective at preventing suicide.

Still, they require identifying someone at risk.

Someone like Dorothy Paugh’s dad.

In 1965, when Paugh was a young girl, her dad lost his job. He was distressed, not knowing how he’d support his wife and five children, Paugh said. He reviewed his life insurance policy, told his wife where he kept important documents, and bought a handgun.

“If my mom had been able to get an extreme risk protection order or if Dad’s best friend had asked to hold his gun for a while, maybe my dad would not have shot himself. He might have lived,” Paugh said.

Decades later, Paugh advocated for a red flag law in Maryland and sat in the legislative gallery when the measure was passed.

She believes the law is saving lives.

Studies across other states show that for every 10 to 20 guns removed under red flag laws, one suicide is averted, saving a life.

But Paugh also recognizes the law’s limitations.

“It wouldn’t have saved my son,” she said.

Dorothy Paugh’s father died by suicide in 1965. She lost her 25-year-old son, Peter, shown in the photo, to suicide in 2012. Both men shot themselves. Paugh has since become an advocate for gun policies that have been shown to reduce suicide deaths, such as red flag laws and mandatory waiting periods before completing a gun purchase. (C. Allen Paugh)

Her 25-year-old son, Peter, fatally shot himself in 2012. He’d recently bought a house with his girlfriend and hosted a birthday celebration for his brother. He’d purchased a gift ahead of Mother’s Day — five novels by Charles Dickens, Paugh’s favorite author — that Paugh received after his death.

Unlike in her father’s case, Paugh said, no one saw warning signs for Peter. “I did not know that my son was suicidal. I didn’t have a clue,” she said. Even if a red flag law existed then, she wouldn’t have thought to use it.

The people most vulnerable to firearm suicide usually aren’t identified as such by family members or clinicians, said Michael Anestis, a clinical psychologist and the executive director of the New Jersey Gun Violence Research Center.

Studies have shown that among people who die by suicide, those who used guns were less likely to have sought mental health care in the past. And most veterans and service members who die by gun suicide never tell anyone about their suicidal thoughts in the months leading to their death.

That’s why red flag laws are just a first step in suicide prevention, Anestis said. They target specific individuals at high risk — the aspect that makes such laws more politically palatable — but they do not apply to the many other people who are quietly suicidal.

Paugh’s son, Peter, fatally shot himself in 2012. Paugh says she didn’t see warning signs that he was suicidal. Peter is pictured here hiking the Appalachian Trail in 2009. (Dorothy Paugh)

Lessons From Road Safety

Nestadt, the Johns Hopkins psychiatrist, said the nation needs to approach suicide prevention the way it approaches car accidents.

“You’re not trying to figure out who’s at risk of an accident” by testing people’s reaction time or cataloging who gets into fender benders, Nestadt said.

Instead, governments implemented speed limits, passed seat belt laws, and required auto manufacturers to install air bags and shatter-resistant windshields. The crash death rate declined significantly.

Applying a similar strategy to suicide might involve requiring permits and background checks to buy a gun, as well as instituting waiting periods before completing the purchase.

One study found that enacting a permit-to-purchase law in Connecticut was associated with a roughly 15% decrease in gun suicide rates, while repealing such a law in Missouri was linked to a 16% increase in firearm suicide rates.

Most Suicides in America Involve a Gun

Suicide deaths by gun have been increasing for several years, even as suicides by suffocation — the second most common method — have been decreasing.

Source: <a href="https://wonder.cdc.gov/mcd-icd10-provisional.html&quot; target="_blank" style="color:#0071ce">CDC WONDER</a> <br> Note: 2025 data is provisional. "All other methods combined" includes cut/pierce, drowning, fall, fire/flame, other land transport, other, and unspecified. <br> Credit: Aneri Pattani/KFF Health News

About three dozen states have enacted laws requiring owners to lock up their guns in homes where children live, a practice shown to reduce youth suicides. That’s an issue of particular importance, with gun suicide rates increasing 245% among Black youths and 98% among Latino youths since 2014.

Anestis said laws requiring permits and safe storage can also reduce homicides and other gun injuries.

Those types of violence not only hurt people directly but also increase their risk of suicide. Research suggests people who are exposed to gun violence in their community experience trauma and become habituated to the idea of injury or death. That “double whammy” makes them more likely to kill themselves, Anestis said.

Responsibility, Rights, and Saving Lives

Gun owners and firearm trade associations generally oppose universal measures, such as requiring permits and waiting periods. They prefer education campaigns that teach people how to recognize warning signs, talk about mental health, and safely store guns — initiatives that place responsibility on individuals.

The National Shooting Sports Foundation, which represents the firearms industry, has partnered with the American Foundation for Suicide Prevention to create flyers and brochures to be posted in gun shops.

“Our purpose is to provide educational materials to the firearm-owning community on how to help prevent suicide and save lives,” Bill Brassard, the NSSF’s senior director of suicide prevention initiatives, said in a statement.

The National Rifle Association said policies focused on guns miss deeper concerns that make someone suicidal, such as mental illness.

“Suicide is a serious issue that deserves serious solutions focused on the underlying causes, not on political efforts to restrict the rights of law-abiding Americans,” NRA spokesperson Justin Davis said in a statement. “A truly dangerous individual needs to be incapacitated, not just deprived of one particular means of harm.”

Some initiatives have managed to bring together unlikely bedfellows — gun store owners, public health experts, and even libraries — to provide free locks to secure firearms at home, identify locations that will temporarily store someone’s guns while they’re in crisis, and educate people on how to avoid selling guns to someone who is suicidal.

Those efforts give Paugh hope and fuel her passion to continue advocating for better mental health care, open conversations about suicide, and policies that decrease access to guns.

“It’s not a cure-all,” Paugh said of those policies. But “it does save lives.”

Having lost a parent and a child, she knows how valuable that can be.

“If you’re that one person or that person’s family, it’s all the difference in the world,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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