But one Friday at the Vernal Gun & Knife Show, four women stood behind a folding table for the Northeastern Counseling Center with precisely that in mind.

Amid a maze of tables displaying brightly varnished rifle stocks, shotguns and the occasional AR-15 assault-style rifle, they waited, ready to talk with show attendees.

“Lethal access to lethal means makes a difference,” said one of the women, Robin Hatch, a prevention coordinator with Northeastern Counseling for nearly 23 years.

Utah has one of ³Ù³ó±ðÌý of suicide in the U.S. And from 2006 to 2015, in the state were suicides. According to Utah’s health department, suicide rates vary widely by location. For example, the suicide rate in this corner of Utah is 58% higher than the rest of the state.

Suicide by gun is a particular problem: The rate in rural areas is double that in urban areas, according to state officials. A major factor is the easy access to firearms in Utah — and the grim fact that suicide attempts involving guns have a higher mortality rate than by other means.

This was the first time Hatch and her colleagues at Northeastern Counseling did outreach at a gun show. As the auditorium filled with firearm sellers and hunters, the counselors stacked their folding tables with neat piles of free cable locks that thread into a gun to prevent rounds from being loaded, and water-resistant gun socks screen-printed with the National Suicide Prevention Lifeline number.

The idea behind distributing both devices is to slow a person down during a moment of crisis. “Anything that we can do to get people off track a little bit, thinking something different,” Hatch said. “We believe that will help make a difference in our suicide rates.”

Unpredictable Employment Adds Stress

Northeastern Utah is home to oil and gas fields, cattle ranches and the Uintah and Ouray Indian reservation.

Health experts say factors contributing to the area’s high suicide rates include limited access to mental health services in rural communities and the unpredictability of the ranching and oil and gas industries. The boom-bust cycles, along with physical and mental stress, take a toll on workers.

“Injuries and accidents, keeping your job, having a job tomorrow — it’s so up and down,” said Val Middleton, a former oil and gas safety instructor at Uintah Basin Technical College in Vernal. “The guys don’t eat right, typically. No exercise, hard work, long hours, no sleep. That’s what adds up. The divorce rate is high, really high. The family life is low.”

Add high gun ownership and the risks rise.

Dee Cairoli is the pastor at Roosevelt Christian Assembly in a nearby town. He also works part time as an NRA concealed-carry handgun instructor. When hosting classes, Cairoli explains how gun owners can intervene if another gun owner shows signs of a mental health crisis.

“I’ve done it a couple of times as a pastor where I’ve gone to somebody’s house and said, ‘Look, maybe you need to listen to me for a minute. I know what I’m talking about. I promise I’ll keep it in my [gun] safe, but let me have your gun.'”

Cairoli speaks with authority. When he was 15, his father killed himself with a gun.

“It was very tragic, but I never hated the gun. I never blamed the gun. I knew that it was just his desperate moment and that he had just chosen that,” Cairoli said.

He believes that personal tragedy, along with the credibility he brings as a gun user and local pastor, allows people in crisis to trust him.

Not Just A Rural Issue

How to talk about suicide with guns isn’t just an issue in rural Utah. It’s a topic that state Rep. Steve Eliason of Sandy, a large Salt Lake City suburb, also tackles. The Republican has sponsored legislation focused on firearms, suicide prevention and mental health services. It is personal for him, too.

“I’ve lost three extended family members to suicide. All firearm suicides. Young men,” Eliason said.

This year, he worked on bills to fund firearm safety and suicide prevention programs, supply gun locks, create new mental health treatment programs and expand crisis response in rural Utah.

Eliason describes these issues as nonpartisan, but with Utah’s proud gun culture, he’s also careful with his approach. He describes advice he got from a politically liberal friend in public health about how to bring together opposing perspectives about firearms.

“Obviously, there’s kind of two schools of thought on firearms,” he said. “Those two schools of thought, if they were circles, they would overlap into a small oval — that oval is the culture of safety. And she says, ‘I would recommend that you dwell within that oval.’ That’s what I’ve tried to do.”

That perspective led the Utah legislature to appropriate money to fund a study by the Harvard T.H. Chan School of Public Health, in consultation with ³Ù³ó±ðÌý.

°Õ³ó²¹³ÙÌýÌý²õ±è³Ü°ù°ù±ð»åÌý about the problem of firearms and suicide and formed the basis of at least one of Eliason’s 2019 bills, to expand access to gun locks.

Like Eliason’s work at the state policy level, Hatch’s suicide prevention work in her community depends on relationships and trust.

Hatch’s table at the gun show was less busy than others. But the women gave out hundreds of gun locks and gun socks over the course of the day. And attendees said having them there was a fitting way to bring up the subject of suicide and firearms.

“You need to know your community, and you need to address it in a way that your community will accept it,” Hatch said.

If you or someone you know has talked about contemplating suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use ³Ù³ó±ðÌý, both available 24 hours a day, seven days a week.

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Utah residents may have thought they were done fighting about Medicaid expansion last November. But when Utah lawmakers opened a new legislative session in late January, they began pushing through a bill to roll back the scope and impact of an expansion that voters approved in a ballot measure.

That scaled-back version of Medicaid expansion passed the Utah House on Friday by a .

The activists who pushed the ballot measure are not pleased.

“We were very clear about what we wanted,” said Andrew Roberts, a spokesman for , the group that organized the Medicaid expansion referendum, known as Proposition 3. “We are frustrated, and I think Utahns are frustrated.”

That frustration led his group to hire a billboard truck to drive in circles around the Capitol building and through the snowy streets of Salt Lake City and its suburbs. Signs on the sides of the truck flash phrases in LED lights, including “Support democracy. Support Utah’s vote.” A looping video advertisement urges residents to call lawmakers “who don’t respect the will of the people.”

After six years of talking about Medicaid expansion, voters approved the ballot measure on Nov. 6, with 53 percent in favor. If implemented fully, 150,000 Utahns would gain coverage. The skinny expansion — which the state Senate and governor support — will also need federal approval.

Similar legislative efforts to curtail expansion are also happening in Idaho, where voters passed a Medicaid expansion initiative in November. Sixty-one percent of voters . Idaho lawmakers are considering ways to scale that program back.

In politically and fiscally conservative Utah, legislators argue the 0.15 percent non-food sales tax that voters approved won’t be enough to pay for Medicaid expansion. So they’ll pass an expansion, but only a very limited one.

Voters “wanted Medicaid expansion, and that’s what we’re doing,” said Republican state . But, he added, the voters “didn’t fill in the proper blanks. We are filling in those blanks for them. They are not obligated to balance the budget. We are.”

Christensen is leading the rollback effort in Utah. His alternative proposal, , would cap the number of individuals who would qualify for Medicaid, add work requirements and lower the annual income limit. Proposition 3 supporters had wanted the coverage available for people who made up to 138 percent of the federal poverty level, or nearly $17,000 a year. But Christensen’s bill would offer Medicaid coverage only to people who made less than 100 percent of the federal poverty level, or about $12,000 for an individual.

Making those changes would require the state of Utah to get approval for two federal waivers from the federal Centers for Medicare & Medicaid Services. Proposition 3 supporters point out that similar requests from other states have been denied.

“From the perspective of voters, I think voters have a right to be furious right now,” said , executive director of the Utah Health Policy Project, another group that has supported Medicaid expansion.

Slonaker said changing the scope of Proposition 3 would mean fewer people getting health coverage, and the state would receive less money from the federal government. He also fears it could make voters feel disillusioned.

“Why would voters ever want to pursue ballot initiatives and direct democracy if the legislature’s just going to repeal it anyway?” Slonaker asked.

While some Utah lawmakers, such as Christensen, describe being “philosophically opposed” to Medicaid expansion, much of the political debate in Utah is about how much expansion will cost, and whether the new sales tax will pay for it. Supporters point to the fiscal experience of other states.

“You should think of Medicaid expansion as no different than if you said, ‘Oh, hey, somebody’s going to go open up a factory,'” said , an economist at the , in Missoula. “And that factory is going to bring, in the case of Montana, $600 million of outside money into the state that we’re going to pay to workers here.”

Ward recently published on the economic impacts of Medicaid expansion in Montana during the first two years of that program. He said it brought in about $600 million dollars in new funds to the state per year. That money supported about 6,000 jobs, he added, or about $350 million in additional income for residents.

Ward said states like his also can take advantage of savings, because Medicaid expansion makes providing health care to certain groups, like prisoners, more affordable. While states do have to pay 10 percent of the cost of expanded Medicaid (the federal government covers 90 percent — a more generous “match” than traditional Medicaid), the combination of savings and economic growth meant that, in the case of Montana, the program basically pays for itself, Ward said.

“The benefits that people in Utah have is that people like me in other states have done the work trying to figure this out,” he said. “Or at least get some ballpark estimates of it.”

So far, Utah lawmakers remain unconvinced by studies like Ward’s. The bill to restrict Medicaid expansion is moving fast, and could reach the governor’s desk as soon as next week.

This story is part of a partnership that includes ,Ìý and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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Hatch played key roles in shepherding the 1983  to promote drug development for rare diseases, and the 1984 , which helped create a national transplant registry. And in 1995,Ìýwhen many people with AIDS were still feeling marginalized by society and elected leaders, he testified before the Senate about reauthorizing funding for his  to treat uninsured people who have HIV.

“AIDS does not play favorites,” Hatch told other senators. “It affects rich and poor, adults and children, men and women, rural communities and the inner cities. We know much, but the fear remains.”

Hatch, now 84, co-sponsored a number of bills with Democrats over the years,Ìýoften with Sen. Ted Kennedy of Massachusetts. The two men were sometimes called “the odd couple,” for their politically mismatched friendship.

In 1997,Ìýthe two proposed a broad new health safety net for kids — ³Ù³ó±ðÌý.

“This is an area the country has made enormous progress on, and it’s something we should all feel proud of — and Senator Hatch should too,” said , executive director of Georgetown University’s Center for Children and Families.

Before CHIP was enacted, the number of uninsured children in America was around 10 million. Today, it’s under half that.

Hatch’s influence on American health care partly came from the sheer number of bills he sponsored —  — and because he was chairman of several powerful Senate committees.

“History was on his side because the Republicans were in charge,” said , an emeritus professor in public health at the University of Utah and Hatch’s health director in the 1980s.

When Ronald Reagan was elected president in 1981, the Senate became Republican-controlled for the first time in decades. Hatch was appointed chairman of what is now known as the Health, Education, Labor and Pensions Committee. The powerful legislative group has oversight of the Food and Drug Administration, Centers for Disease Control and Prevention and the National Institutes of Health.

“He was virtually catapulted into this chairmanship role,” Sundwall said. “This is astonishing that he had chairmanship of an umbrella committee in his first term in the Senate.”

In 2011, Hatch was appointed to the influential Senate Finance Committee, where he later became chairman. There he helped oversee the national health programs Medicare, Medicaid and CHIP.

Hatch’s growing influence in Congress did not go unnoticed by health care lobbyists. According to the watchdog organization Center for Responsive Politics,Ìýin the past 25 years of political campaign funding,ÌýHatch ranks  for contributions from the pharmaceutical and health sector. (That’s behind Democratic senators who ran for higher office — President Barack Obama and presidential nominee Hillary Clinton).

“Clearly, he was PhRMA’s man on the Hill,” said , referring to the trade group that represents pharmaceutical companies. Green is a professor of the history of medicine at Johns Hopkins University School of Medicine. Though Hatch did work to lower drug prices, Greene said, the senator’s record was mixed on the regulation of drug companies.

For example, an important piece of Hatch’s legislative legacy is the 1984 , drafted with then-,Ìýan influential Democrat from California. While the law promoted the development of cheaper, generic drugs,Ìýit also rewarded brand-name drug companies by extending their patents on valuable medicines.

The law did spur sales of cheaper generics, Greene said. But drugmakers soon learned how to exploit the law’s weaknesses.

“The makers of brand-name drugs began to craft larger and larger webs of multiple patents around their drugs,” aiming to preserve their monopolies after the initial patent expired, Greene said.

Other brand-name drugmakers preserved their monopolies by paying makers of generics not to compete.

“These pay-for-delay deals effectively hinged on a part of the Hatch-Waxman Act,” Greene said.

Hatch also worked closely with the dietary supplement industry. The multibillion-dollar industry specializing in vitamins, minerals, herbs and other “natural” health products, is concentrated in his home state of Utah.

“There was really no place for these natural health products,” said , president of the United Natural Products Alliance and a Hatch staffer in the late 1970s.

As the industry grew, there was a debate over how to regulate it: Should it be more like food or like drugs? In 1994, Hatch sponsored ³Ù³ó±ðÌý, known as DSHEA, which treats supplements more like food.

“It was necessary to have someone who was a champion who would say, ‘All right, if we need to change the law, what does it look like,’ and ‘Let’s go,'” Israelsen said.

Some legislators and consumer advocacy groups wanted vitamins and other supplements to go through a tight approval process, akin to the testing the Food and Drug Administration requires of drugs. But DSHEA reined in the FDA, determining that supplements do not have to meet the same safety and efficacy standards as prescription drugs.

°Õ³ó²¹³ÙÌýlegislative clamp on regulation has led to ongoing questions about whether dietary supplements actually work and  with other medications patients may be taking.

DSHEA was co-sponsored by Democrat Tom Harkin,Ìýthen a senator from Iowa.

While that kind of bipartisanship defined much of Hatch’s career, it has been less evident in recent years. He was strongly opposed to the Affordable Care Act, and in 2018 called supporters of the heath law among ³Ù³ó±ðÌý” he had ever met. (Hatch later characterized the remark as “a poorly worded joke.”)

In his  on the Senate floor in December, Hatch lamented the polarization that has overtaken Congress.

“Gridlock is the new norm,” he said. “Like the humidity here, partisanship permeates everything we do.”

This story is part of a partnership that includes , and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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This story can be republished for free (details).