When Russell and Sharis Lewis want to unwind, they pack up their guns and drive from their home in a suburb north of St. Louis to an indoor range called the SharpShooter on the city’s south side.

Russell dons big protective headphones, carefully lays out his firearms, and selects a Panzer Arms M4 12-gauge semiautomatic shotgun. He takes aim at paper targets, including one labeled “snowflakes,” and squeezes the trigger.

“It’s just something about the power and being able to release that and let it go downrange,” he said. “It relaxes me.”

Sharis, Russell’s wife, practices with her new handgun, a . She bought it because she’s been worried about the increasing crime in her area.

The Lewises are part of a growing cohort of African American gun owners. Nationwide, surveys found that 25% of Black adults in 2021, up from .

Gun buying among African Americans has soared in recent years. At the same time, suicide rates have increased among young Black men. Experts believe the trends may be linked, because having a gun in the home increases suicide risk exponentially, for every person who lives there.

But even gun enthusiasts say that the newest generation of gun owners sometimes lack the training and information they need to keep themselves safe around firearms. Homicides in Missouri reached a , spurring even more people to buy guns. But the number of suicides in the state was , and the suicide rate has been on the rise for a decade.

That’s where Bill Mays works — in the fraught space where gun ownership and suicide intersect.

As a firearms trainer and an advocate of “concealed carry,” Mays has been part of the St. Louis gun community for years. He said he knows how to talk with fellow gun enthusiasts in ways that health experts usually can’t — especially about sensitive subjects like suicide risk, mental health issues, and crisis management for gun owners.

“It’s a matter of, ‘If it walks like a duck, talks like a duck, then what is it?’ I’m a duck!” Mays said. Mays is Black and works for the , a project based at the University of Missouri-St. Louis. The effort aims to persuade gun sellers, gun owners, and their relatives to create systems for temporarily preventing people experiencing a crisis from accessing firearms.

Suicide is usually an impulsive act. One study found that reported that the time between first considering suicide and making an attempt was 10 minutes or fewer. If people in crisis can be kept away from a means of killing themselves for even a short period, their risk of dying can drop dramatically.

“That’s the thing about suicide, is that you can have that feeling, but if someone intervenes, you know, that feeling can easily go away,” Mays said.

A few years ago, Mays said, he was having suicidal thoughts himself. He remembers one episode when a phone call with his daughter pulled him out of the crisis.

Firearms are a focus of suicide prevention efforts because they are more efficiently lethal than other methods.

Missouri’s Safer Homes Collaborative is modeled on the , which sought to soothe any fears about stepping on Second Amendment rights by enlisting gun owners to deliver the message, as part of a strategy called “” — a twist on the concept of “harm reduction” in addiction treatment.

Proponents of means reduction say suicides can be reduced significantly if businesses refuse to sell firearms to people who are in crisis and if family members temporarily keep guns away from people who feel suicidal.

For decades, the suicide rate of older white men has been among the highest in the U.S., in part because of their high rates of gun ownership. Having a gun in the home for everyone who lives there.

However, suicides rates among young Black men almost 50% nationally from 2013 to 2019. And the suicide rate for younger Black children (ages 5-12) and is more than for younger white children.

Although the overall suicide rate for white Americans — including teenagers — remains much higher than the rate among African Americans, , associate director of the Harvard Youth Violence Prevention Center.

Azrael co-authored a new study estimating that from January 2019 to April 2021, . Of the new buyers, about 20% were Black.

Azrael said it’s time to update assumptions about who may be in danger: “Gun ownership is more diverse now, and so when we talk to people about the risks of guns, we want to make sure we’re reaching out across the board, and not just to the people we’ve typically thought of as gun owners in the past.”

Similarly, stereotypes about who is “typically” at risk for suicide are changing. Reba Rice-Portwood said that when she was growing up in St. Louis in the 1970s and ’80s, suicide was seen as a problem that existed outside her African American community.

“When someone would die by suicide and if we heard about it on television or we read about it or something like that, we would always assume that it was a Caucasian,” said Rice-Portwood, 55.

Her thoughts about that changed abruptly and tragically several years ago when she lost Ricky, her son.

Rice-Portwood said Ricky had an “old soul.” He loved Sam Cooke and looked out for older people in his apartment complex. She said her son was also tormented by depression.

One day in 2014, she got a frantic call from her son’s fiancée, who told her that Ricky had shot himself. He was only 22.

“What did I do so bad in this life for God to allow my son to pass?” Rice-Portwood asked.

She strained to understand how her son, who was known to struggle with mental illness, managed to get a gun, a question that remains unanswered. And then, amid her grief and confusion, came some surprising news: Ricky’s fiancée had discovered she was pregnant.

Today, Rice-Portwood is raising her grandson, Jackson, who’s 6 years old. On a Saturday morning at her apartment, he shows off his multiplication skills on a tablet while “Granny” beams.

After working many years inside jails, Rice-Portwood became a mental health counselor. Nowadays, she’s outspoken about the need to address trauma among young African Americans in St. Louis. She grapples with how to stop the spread of gun violence, especially when the proliferation of firearms in her community seems impossible to contain.

Despite what happened to her son, Rice-Portwood keeps a .380 pistol in a safe at home. Like Sharis Lewis, she’s a gun owner for one big reason: fear of crime. “Actually, I went to the grocery store about three weeks ago, you know, and was almost carjacked,” Rice-Portwood said. “That’s the reason why I still have it now.”

St. Louis had the rate among large U.S. cities in 2020, according to FBI data.

Self-defense is the main reason people buy guns, according to , but many Black gun owners say that, for them, self-defense can be a thorny concept.

Sharis Lewis started carrying a firearm because she isn’t comfortable with the idea of calling police for protection. The Lewises live in Florissant, not far from Ferguson, where Black resident Michael Brown was killed by police officer Darren Wilson in 2014.

“Some people, they rely on law enforcement, which, for African Americans, that’s not always the safest course of action either,” Sharis said. “I would rather control the situation.”

For Bill Mays and his friends, discussions about self-defense and guns have taken on increased urgency.

At the next door to the SharpShooter range, Bill Mays met up with the Lewises. After placing lunch orders, they launched into talking about firearms, and recent incidents of violence against African Americans.

Mays said his work in suicide prevention and a renewed interest in religion had changed his relationship with firearms. Mays recently stopped carrying a gun, though he continues to hunt.

“I think a lot about the Bible. And the experience with Jesus — would Jesus walk around with a firearm? Of course not,” Mays said. “But it’s more than that. It’s just a point of — I don’t want to hurt anybody.”

But he wants to keep helping the people who do carry guns, especially the newest gun owners. And he hopes that those conversations, however tough, might help prevent suicide deaths in Missouri.

This story is from a reporting partnership that includes , , and .

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

While growing up in the ’90s in Johnson County, Kansas, in a suburb of Kansas City, I had a friend, Kevin Aaron, who was a dedicated environmentalist.

To strangers, Kevin appeared to be a laid-back punk-rock music fan with a dry and slightly mischievous sense of humor, but those of us who knew him best saw his passion for sustainability blossom during high school.

In his barbecue-obsessed part of the country, he became the rare vegetarian, driven by witnessing large-scale meat production’s damage to the environment. As he grew into a young man, he eagerly researched and then adopted alternative practices — like driving a hybrid car — that he thought might reduce carbon emissions, if only by tiny measures.

In the early 2000s, Kevin was living in the Bay Area and preparing for a career in climate advocacy, enrolled in a master’s program in city and regional planning while studying for a law degree.

During his graduate studies, he became overwhelmed by a sense of hopelessness about the climate. He died by suicide in 2003, at age 27. Kevin had been living with a feeling that his efforts — combined with those of other environmental activists — just wouldn’t be enough to turn the tide on global warming. It added to the depression he was already struggling with, said his mother, Sami Aaron.

Environmental worries can motivate but also overwhelm people. Polling from September 2020 showed that more than half of adults in the U.S. were. And nearly 40% of surveyed Gen Z Americans, born after 1996, said.

The loss of Kevin remains a shock for me, and for others who cared about him — especially his mother, who has become increasingly involved in environmental advocacy.

Aaron often turns to nature for comfort, and she picked a former Superfund site in Olathe, Kansas, that has been converted to a flower-filled sanctuary as the spot for us to talk about her son. She said that the more deeply Kevin became involved in environmental activism, the more his thinking about the future turned pessimistic — his mind and mood overtaken by despairing thoughts, like an invasive species.

“There was one little seed that was planted where he couldn’t then quit thinking about it,” she said.

After Kevin died, Aaron found some solace in yoga and meditation, but continued to see her grief as a private struggle — until a few years ago, when she met some environmentalists in the Flint Hills of Kansas who also struggled with mental health issues.

Aaron wanted to teach them the coping strategies she had learned after her son’s death, so she created a Kansas City-based nonprofit, The organization’s website that Kevin’s death occurred “when eco-anxiety (fear about the ecology of the planet) and solastalgia (grief over loss of beloved places in nature) combined with his own inner demons and he took his own life.” The Resilient Activist offers mental health resources, community-building programs, consulting and other psychological resources for the environmental community.

“We need activists who have the resilience to see us through these difficult times,” Aaron said. “That’s what I wanted to give. It’s like, what would have helped him and others like him.”

In eastern Kansas, the college town of Lawrence is steeped in environmental activism and, on Aug. 31, dozens of protesters gathered before the start of a city meeting, chanting slogans and carrying signs: “Time Is Running Out!” As the evening rush-hour traffic roared past, activists demanded Lawrence leaders follow through on their sustainability pledges.

Many of the protesters were University of Kansas students, like undergraduate Marc Veloz. He moved to Lawrence from Texas, where he became concerned about how flooding was disproportionately affecting communities of color in Dallas. He said taking part in local activism helps get him through what he calls “dark days.”

“There are those days that I just have to lean on the little wins we’ve had to keep me going,” Veloz said. “Because I know that being in that space of despair and anger and sadness, it isn’t sustainable.”

Another student, Kai Hamilton, grew up in the Kansas farming town of Hesston. She recalled that even though her neighbors suffered droughts year after year, the words “climate change” were never said out loud.

“I have vivid memories of being alone in my room in high school and just being so overwhelmed and deeply sad about my lack of control over it and also the lack of action in the world,” Hamilton said.

Another protester, Agustina Carvallo Vazquez, came to KU from Paraguay, where she said she witnessed destructive and exploitative agricultural practices. She planned to study economics and music but started focusing on environmental activism after she grew frustrated by the inaction she found in the United States.

Some amount of anxiety is a natural response to climate change, said , a professor of psychology at the College of Wooster and a board member of the . She said getting involved in activism or environmental groups can help relieve feelings of helplessness, but, paradoxically, advocacy carries the risk added stress — sometimes leading to a diagnosis of mental illness.

Clayton said that anxiety crosses the line to becoming a true concern when it causes activists to turn away or give up on the problem.

“We have to find that common ground, where we can accept that there are some really serious things going on, but it doesn’t lead us to despair,” Clayton said.

For decades, though, many environmentalists resisted prioritizing their own mental health.

In 2018, Greenpeace International signaled a shift when it launched a major study on why so many of its activists were working themselves past their healthy limits. Agustin Maggio, a campaign manager for Greenpeace, explains that many local volunteers and leaders had bought into a kind of “martyr culture.”

“Burning yourself out is almost like a badge of honor,” Maggio said.

Greenpeace and other leading environmental groups, including the , have begun urging volunteers and staff members to take breaks, unplug or even limit the scope of their activism for the sake of mental health.

Ward Lyles, an associate professor of urban planning at the University of Kansas and an environmental activist since the ’90s, said he has changed the way he talks with students about the climate.

“When I first started, I thought it was my job to scare people into action,” Lyles said.

Now, Lyles said, he recognizes that students enter his classes already terrified about what’s happening to the planet — and desperate to do something about it. In class, Lyles welcomes discussions about environmental anxiety and grief, so that emerging activists understand they are not alone in having those feelings.

“In classes where you acknowledge this is hard — this is hard work to do, but we’re here to support each other — then it’s really amazing to watch students come together and talk about finding solutions,” Lyles said.

During the pandemic, Sami Aaron has been leading yoga and meditations to help activists relax and reduce narrow, negative thinking patterns that feed anxiety and depression. Reaching a sustainable future, Aaron explained, will require people to remain optimistic and open to new possibilities.

The goal is “to kind of shift you out of that fight-or-flight mode,” she said. “So that now you’re in a place where you have all different ways of thinking. You have all other options for what can happen and what you can do.”

This story is from a partnership that includes , and KHN.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Throughout the covid-19 vaccination effort, public health officials and politicians have insisted that providing shots equitably across racial and ethnic groups is a top priority.

But it’s been left up to states to decide how to do that and to collect racial and ethnic data on vaccinated individuals so states can track how well they’re doing reaching all groups. The gaps and inconsistencies in the data have made it difficult to understand who’s actually getting shots.

Just as an uneven approach to containing the coronavirus led to a greater toll for Black and Latino communities, the inconsistent data guiding vaccination efforts may be leaving the same groups out on vaccines, said Dr. Kirsten Bibbins-Domingo, an epidemiologist at the University of California-San Francisco.

“At the very least, we need the same uniform standards that every state is using, and every location that administers vaccine is using, so that we can have some comparisons and design better strategies to reach the populations we’re trying to reach,” Bibbins-Domingo said.

Now that federal, state and local governments are easing mask requirements and ending other measures to prevent the spread of the virus, efforts to boost vaccination rates in underserved communities are even more urgent.

At St. James United Methodist Church, a cornerstone for many in the Black community in Kansas City, Missouri, in-person services recently resumed after being online for more than a year. St. James has also been hosting vaccination events designed to reach people in the neighborhood.

“People are really grieving not only the loss of their loved ones, but the loss of a whole year, a loss of being lonely, a loss being at home, not being able to come to church. Not being able to go out into the community,” said Yvette Richards, St. James’ director of community connection.

Missouri’s population is 11% African American, but covid cases among African Americans accounted for 25% of the total cases for the state, according to an  by KFF.

Richards said St. James has lost many congregants to the coronavirus, and the empty pews where they once sat on Sundays serve as stark reminders of all this community has been through during the pandemic.

Missouri’s public covid data appears to show robust data on vaccination rates broken down by race and ethnicity. But several groups are seen lagging far behind on vaccinations, including African Americans, who appear to have a vaccination rate of just 17.6%, nearly half of the 33% rate for the state as a whole.

To Dr. Rex Archer, director of the Kansas City health department, one number is a giveaway that this data isn’t right. It shows a completed vaccination rate of 64% for “multiracial” Missourians. Such an exceptionally high rate for one group beggars belief, according to Archer.

“So, there’s some huge problem with the way the state is collecting race and ethnicity under covid vaccination,” Archer said.

Missouri state officials have acknowledged since February that this data is wrong, but they haven’t managed to fix it or explain exactly what’s causing it. Archer suggested the inflated multiracial rate is probably due to different racial data being reported when individuals receive first and second shots.

Other problems have been detected, including missing racial and ethnic data for many people who have been vaccinated, and the use of multiple categories such as “other” and “unknown.”

The state also noted it used national racial percentages in the state’s vaccination data rather than actual percentages based on the state’s population. For example, earlier in the vaccination effort, the state used national racial data, which shows nearly 6% of the population is Asian, even though Missouri’s population is 2.2% Asian.

Health officials are working to target vaccination campaigns in communities where rates are low, but Archer said the state’s data provides little help.

“I mean, we have to look at it, but it’s got too many variables to be something we can count on,” Archer said.

Though racial and ethnic categories are clearly defined in national U.S. Census data, the same data is not collected uniformly by states.

For example, South Carolina’s vaccination data lumps together Asians, Native Americans and Pacific Islanders in one category. In Utah, residents can pick more than one race. Wyoming doesn’t report racial or ethnic data for vaccinations at all.

Bibbins-Domingo said the missing or inconsistent data doesn’t necessarily mean tracking equity is a lost cause. Vaccination rates for census tracts where racial and ethnic data is known can be used as a proxy to estimate vaccine allocations.

However, Bibbins-Domingo argued that the pandemic has shined a light on racial data problems that have persisted far too long in U.S. public health.

“What my hope is, is that our lessons from covid really cause all of us to think about the infrastructure we need within our state and nationally to make sure we are prepared next time,” Bibbins-Domingo said. “Data is our friend.”

Local leaders and health officials in Missouri are scrambling to boost vaccination rates, especially among vulnerable communities, after Republican Gov. Mike Parson recently announced steps to urge residents back to working in person.

Parson ordered state workers back to the office in May and said he would end additional federal pandemic-related benefits for unemployed workers in June, despite vaccination rates across the state being well below what Missouri health experts had hoped to achieve.

Jackson County, Missouri, which includes most of Kansas City, authorized $5 million in federal CARES funding last month to increase vaccinations in six ZIP codes with large Black populations and low vaccination rates. The project will address problems of both access and hesitancy and focus on reaching out to individuals and neighborhoods.

Although many of the state’s vaccination efforts have involved large mass events, St. James Pastor Jackie McCall said she’s been talking with many in her church and community who need encouragement to have faith in the vaccines.

“So let’s go ahead and let’s trust,” McCall told congregants. “Let’s trust the process. Let’s trust God. Let’s trust the science.”

This story is part of a reporting partnership that includes ,  and KHN.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees, like on a recent stop for carryout food.

“No one in the entire restaurant was wearing a mask,” Muhindura said. “And there’s no social distancing. I had to get out, because I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?'”

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencingÌý infection and death rates.

Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.

Kansas City has a mask mandate, but in many smaller communities nearby, masks aren’t required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.

At the same time, according to an analysis by KHN, aboutÌý3 in 4 counties in Kansas and MissouriÌýdon’t have a single intensive care unit bed, so when people from these places get critically ill, they’re sent to city hospitals.

A recent patient count at St. Luke’s Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.

Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke’s.

“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients,” said Larsen. “We get the sickest of the sick.”

Ìýhead of Kansas City’s health department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.

“We’ve had this huge swing that’s occurred because they’re not wearing masks, and yes, that’s putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed,” Archer said.

´¡Ìý newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while

Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas’ conservative legislature, to implement stringent, statewide mask requirements but without success.

Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of “making the mask a political issue.” He said county leaders should decide whether to close businesses or mandate masks.

“We’re going to encourage them to take some sort of action,” Parson Thursday. “The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door.”

In an email, Dave Dillon, a spokesperson for the , agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.

The reasons for theÌýÌýinvolve far more than the refusal to mandate or wear masks, according to health care experts.

Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.

Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.

Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained , a rural health researcher at Syracuse University.

“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat said.

Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.

Individual cities, such as Kansas City and St. Louis,Ìý³ó²¹±¹±ðÌýmanaged to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states’ hospital systems.

The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.

“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” said , an epidemiologist at Johns Hopkins Bloomberg School of Public Health.

Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region’s hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.

Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system’s chief medical officer, .

But bed space isn’t the only hospital resource that’s running out. Half of the hospitals in the Kansas City area are now reporting “critical” staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.

“The hospitals are not fine, because people taking care of patients are on the brink,” Muhindura said. “We are tired.”

This story is from a reporting partnership that includes , and .

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Voters approved expansion by a margin of 6.5 percentage points.

Missouri joins five other mostly conservative states that have passed Medicaid expansion via ballot initiatives — most recently, Oklahoma, . Most of the remaining 12 states that have not expanded Medicaid are Republican-leaning states in the South.

Nika Cotton, owner of Soulcentricitea, a new tea shop in Kansas City, Missouri, woke to the news on Wednesday morning. Cotton, whose children are 8 and 10, said she will qualify for health care coverage under the expansion.

“It takes a lot of stress off of my shoulders with having to think about how I’m going to take care of myself, how I’m going to be able to go and see a doctor and get the health care I need while I’m starting my business,” Cotton said.

Medicaid expansion, which states have the option of adopting as part of the Affordable Care Act, extends eligibility in the program to individuals and families with incomes up to 138% of the federal poverty level. A family of three, like Cotton’s, could make up to $29,974 to qualify.

The federal government pays for 90% of expansion costs.

As of 2018, 9.3% of Missourians were uninsured. And in 2019, researchers from Washington University in St. Louis estimated that around 230,000 people in Missouri would enroll for Medicaid if it were expanded. The study also showed expansion would save the state an estimated $39 million a year, largely by eliminating the need for other state health spending.

Missouri’s adoption of expansion follows a trend of increasing support in largely Republican states, according to health policy expert of the Commonwealth Fund.

“What we’ve seen in our surveys over the years is when you take the labels off of the policies, when you take the Affordable Care Act label off, when you take Medicaid expansion off, and just start asking people whether or not you think low-income families should have access to Medicaid coverage, the support is overwhelming,” Nuzum said.

Support for expansion came largely from voters in and around Missouri’s urban centers such as Kansas City, St. Louis, Springfield and Columbia. In Kansas City for example, 87.6% of voters backed the measure.

Amendment 2 was rejected overwhelmingly by conservative voters in the mostly rural parts of the state that have the highest uninsured and poverty rates. Voters in McDonald, Morgan and Scotland counties, which have the three highest uninsured rates in the state, rejected the measure by margins of nearly 2-to-1 or greater.

Expansion opponents warned that high enrollment in the program could lead to the state’s 10% share of the costs becoming a significant burden for Missouri, especially when state revenues are down.

“When state revenues fall, it begs the question, how are you going to pay for this?” said Ryan Johnson, in late July. He is a senior adviser for , a conservative policy advocacy organization.

“We’re concerned that they are going to have to raid public education,” he said, “and that’s a disservice to the kiddos who hope to go back to school this fall, the teachers, the administrators and everyone involved in the public education system.”

Responding to declining revenue related to the coronavirus, Missouri’s Republican governor, Mike Parson, recently reduced the 2021 budget by nearly $449 million, with education taking the hardest hit.

Health care experts have said that the economic effects of the pandemic, including high unemployment and lower state revenue, could strain the capacity of state Medicaid programs. However, health care advocates argue that expansion benefits individuals and families struggling as a result of the pandemic, and the influx of federal dollars and the jobs that result from expansion could help the economy.

“If we’re worried about the economy and we’re worried about people working, Medicaid expansion is actually a way to encourage people to work and not have that worry they’re going to lose health insurance for themselves or their families,” said Ryan Barker, vice president of strategic initiatives for Missouri Foundation for Health.

Republican state lawmakers have fiercely resisted Medicaid expansion. The expansion question was placed on the ballot after a petition.

Expansion advocates enlisted the Fairness Project, a Washington, D.C.-based campaigning organization, in developing and executing their campaign strategy. The Fairness Project has been involved in successful Medicaid expansion campaigns in other mostly conservative states, including Maine, Utah, Idaho, Nebraska and Oklahoma.

The “ was supported by a wide range of groups, including the Missouri Chamber of Commerce and Industry, the Missouri Hospital Association, the NAACP, the AFL-CIO and the AARP, among others. And, the coalition forged unlikely alliances, including Planned Parenthood supporters and Catholic Charities of St. Louis, which is operated by the Archdiocese of St. Louis.

YES on 2 campaign material made almost no mention of the Affordable Care Act, which has been unpopular in Missouri, and some of its flyers didn’t use the words “Medicaid expansion.”

Although support for the measure was much lower in conservative rural areas, Fairness Project executive director said Missouri’s expansion success relied on both activating progressive urban voters and engaging rural voters — though conservative resistance remained a significant obstacle to reforming health care policy.

“I think there’s still a lot of work to do to push back against the hundreds of millions of dollars, the public messages coming from as high as the White House, that there’s something wrong with the Affordable Care Act,” Schleifer said.

Opponents to expansion included Gov. Parson and other Republican lawmakers, Missouri Right to Life, Missouri Farm Bureau and Americans for Prosperity.

In the days leading up to the election, the “No on 2 in August” campaign sent a mailer suggesting that expansion would lead to an influx of undocumented immigrants seeking health care, but undocumented immigrants are not eligible for Medicaid and would not be under expansion, either.

The flyer, which featured a man in a medical mask emblazoned with the Mexican flag, read “Amendment 2 Means Illegal Immigrants Flooding Missouri Hospitals … While We Pay for It!”

The “No On 2 in August” campaign did not respond to requests for comment about the flyer.

Between serving customers on a busy morning on Wednesday, shop owner Cotton said her excitement about expansion was only slightly diminished by having to wait almost a year for it to take effect.

“It’s better late than never,” said Cotton. “The fact that it’s coming is better than nothing.”

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

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

The Missouri Hospital Association reports that it no longer has access to the data it uses to guide state coronavirus mitigation efforts, and Kansas officials say their hospital data may be delayed.

The Trump administration this week directed hospitals to change how they report data to the federal government and how that data will be made available.

In an email, Missouri Hospital Association spokesperson called the move “a major disruption.”

“All evidence suggests that Missouri’s numbers are headed in the wrong direction,” Dillon said. “And, for now, we will have very limited situational awareness. That’s all very bad news.”

The absence of the data will make it harder for health and public officials, as well as the general public, to understand how the virus is spreading.

“It’s hugely problematic,” said , a public health researcher at Washington University in St. Louis. “The only way that we know where things are going up and where things are going down and where we need to be putting resources and where we need to be planning is because of those data.”

The White House instructed hospitals to report data to the Department of Health and Human Services through a new system created by a Pennsylvania-based company, TeleTracking, instead of to the Centers for Disease Control and Prevention.

The directive came as a surprise to hospitals, according to Kansas Hospital Association spokesperson .

“From our perspective, these changes are big,” Samuelson said. “We only found out Tuesday, and we had to update the data by Wednesday night — so, less than 48 hours.”

The Missouri Hospital Association currently does not have access to the new HHS system, according to Dillon. He said the new system is also significantly different from the CDC system.

“The new datasets for reporting are not identical and in several cases are ill-defined,” Dillon said. “That has complicated hospitals’ efforts.”

In the wake of the announcement, the Missouri Department of Health and Senior Services posted a notice on its website this week that the daily and weekly updates on hospitals, including the numbers of people hospitalized and the availability of standard hospital beds, ICU beds and ventilators, would be temporarily halted.

“Missouri Hospital Association (MHA) and the State of Missouri will be unable to access critical hospitalization data during the transition. While we are working to collect interim data, situational awareness will be limited,” the .

Dillon said the hospital association hopes to have “within a few days or weeks” hospital and coronavirus data that had been available through the CDC.

“However, in the short term, we’ll be very much in the dark,” Dillon said.

The hospital association will create an alternative reporting system for hospitals, according to Dillon, and plans to continue producing weekly reports, despite the uncertainty about data.

The Missouri Department of Health and Senior Services did not respond to inquiries regarding the data.

Kansas health officials are still able to access hospital and coronavirus data through the CDC and TeleTracking, according to Kansas Department of Health and Environment spokesperson .

However, Kansas Hospital Association spokesperson Samuelson said the Kansas hospital data may be delayed if it is incomplete.

“If we’re not able to get a bulk of our members converted and uploading, I’m not sure we want to show it because then it will look like things have gotten a lot better,” Samuelson said.

The most recent data shows that as of July 12, 875 Missourians were hospitalized with COVID-19, among the highest reported numbers since an early May peak of 984. Kansas’ most recent data shows 1,393 people have been hospitalized with the disease.

The Trump administration said the reporting change was needed due to reporting delays and other problems with the CDC.

But the move has been widely criticized for being disruptive, especially as COVID-19 infection numbers reach new highs and hospitals in some areas of the country are reaching capacity.

“By now, we should have a foolproof, streamlined reporting system for COVID,” Maddox said. “And this change — midstream — is not going to do anything to help our ability to fight the disease.”

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

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Loo is the bar manager for the popular restaurant in Kansas City, Missouri, and he credits increased drinking and looser liquor laws during the pandemic for his brisk business. Alcohol also seemed to help his customers deal with all the uncertainty and fear.

“Drinking definitely was a way of coping with it,” said Loo. “People did drink a lot more when it happened. I, myself, did drink a lot more.”

Many state laws seemed to be waived overnight as stay-at-home orders were put into place, and drinkers embraced trends such as liquor delivery, virtual happy hours and online wine tasting. Curbside cocktails in 12- and 16-ounce bottles particularly helped Waldo Thai make up for its lost revenue from dine-in customers.

Retail alcohol sales jumped by 55% nationally during the third week of March, when many stay-at-home orders were put in place, according to , and online sales skyrocketed.

Many of these trends remained for weeks. Nielsen also notes that the selling of to-go alcohol has helped sustain businesses.

But the consumption of all this alcohol can be problematic for individuals, even those who haven’t had trouble with drinking in the past.

Dr. Sarah Johnson, medical director ofÌý, an addiction treatment program based in Louisville, Kentucky, with locations in the Midwest said that, virtual events aside, the pandemic has nearly put an end to social drinking.

“It’s not as much going out and incorporating alcohol into a dinner or time spent with family or friends,” Johnson said. “Lots of people are sitting home drinking alone now and, historically, that’s been viewed as more of a high-risk drinking behavior.”

There are some objective measures of problematic drinking. The Centers for Disease Control and Prevention defines heavy drinking as 15 or more drinks a week for a man or eight or more for a woman.

But Johnson said that more important clues come from changes in behavior. She explains that, for some people, a bit of extra drinking now and then isn’t a big deal.

“If they are still meeting all of their life obligations, like they are still getting up and making their Zoom meetings on time, and they’re not feeling so bad from drinking that they can’t do things, and taking care of their children and not having life problems, then it’s not a problem,” Johnson said. “It’s when people start to have problems in other areas of their life, then it would be a signal that they are drinking too much and that it’s a problem.”

But there are signs to watch out for, she says. They include:

• Big increases in the amount of alcohol consumed
• Concern expressed by family or friends
• Changes in sleep patterns, either more or less sleep than usual
• Any time that drinking interferes with everyday life

Johnson noted that for many people, living under stay-at-home orders without the demands of a daily commute or lunch break could be problematic.

“Routine and structure are important to overall mental health because they reduce stress and elements of unknown or unexpected events in daily life,” Johnson said. “These can trigger individuals in recovery to revert to unhealthy coping skills, such as drinking.”

Johnson explained that while some people may be predisposed to problematic drinking or alcohol-use disorder, these can also result from someone’s environment.

Johnson said that people who are unable to stop problematic drinking on their own should seek help. The federal Substance Abuse and Mental Health Services Administration runs a 24/7 and website, , offering referrals for addiction treatment.

Peer support is also available online. Many Alcoholics Anonymous groups have started to , as does the . And for people who are looking for more informal peer support, help connect communities of sober people.

Darrell Loo at Waldo Thai said that he has been concerned at times about people’s drinking but that he generally has seen customers back off from the heavy drinking they were doing early in the pandemic.

Loo and others in the Kansas City restaurant business are pushing for the carryout cocktails and other looser laws to stay in place even as restaurants slowly start to reopen.

“This will go on for a while. It’s going to change people’s habit,” Loo said. “People’s spending habit. People’s dining out habit. So there’s definitely a need to keep doing it.”

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

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

The move represents a reversal after NPR station KCUR in Kansas City, Missouri, reported last week that from its data, painting an overly optimistic picture of the outbreak. Kansas had instead looked at “symptom onset” data — a metric that by definition excludes people who test positive for the coronavirus but don’t develop symptoms.

The policy change was enacted Monday, said a spokesperson for the Kansas Department of Health and Environment.

Kansas entered the first phase of the last week, allowing gatherings of 10 or fewer people and letting libraries and child care facilities reopen. Gov. Laura Kelly, a Democrat, said in a news conference last week that leaders would take additional steps cautiously.

“We’ll continue to reevaluate Kansas’ disease spread, testing rates, hospitalizations, personal protection equipment availability and other factors before moving from one phase to the next,” said Kelly. “Science and data will dictate how quickly or how slowly the reopening unfolds.”

Kansas’ efforts to track and mitigate COVID-19 have been hampered by years of low health funding, which advocates say have left the local, county and state health departments unprepared for the pandemic.

The symptom-onset metrics undercounted coronavirus cases in Kansas, according to epidemiologists. Graphics representing that data seemed to show that new cases had been declining over the past several weeks, when they actually had been increasing.

Kansas has been testing large populations in nursing homes, prisons and meatpacking plants — a proactive measure not all states are doing. That effort is finding hundreds of asymptomatic and presymptomatic cases. But the symptom-onset data excludes people who never get symptoms and delays reporting people who test positive and eventually get sick with COVID-19.

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

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When children are diagnosed with attention deficit hyperactivity disorder, stimulant medications like Ritalin or Adderall are usually the first line of treatment.

The American Academy of Pediatrics issued new guidelines Monday upholding that central role of medications accompanied by behavioral therapy in ADHD treatment.

Some experts say, however, they are disappointed the new guidelines don’t recommend behavioral treatment first for more children, as that might lead to better outcomes, recent research suggests.

When 6-year-old Brody Knapp of Kansas City, Mo., was diagnosed with ADHD last year, his father, Brett, was skeptical. He didn’t want his son taking pills.

“You hear of losing your child’s personality, and they become a shell of themselves, and they’re not that sparking little kid that you love,” Brett Knapp said. “I didn’t want to lose that with Brody, ’cause he’s an amazing kid.”

Brody’s mother, Ashley, had other ideas. She’s a school principal with ADHD herself.

“I was all for stimulants at the very, very beginning just because I know what they can do to help a neurological issue such as ADHD,” Ashley Knapp said.

More and more families face the same dilemma. The , and now, 1 in 10 children in the U.S. are diagnosed with it.

The new guidelines from the American Academy of Pediatrics recommend that children with ADHD be screened for mental illness and monitored closely, but the treatment recommendations regarding medication are essentially unchanged from previous guidelines published in 2011.

Anyone over age 5 should start taking medication and get behavioral therapy as soon as they are diagnosed. Children under 5 should start with behavioral treatment before taking any medications.

Still, many experts worry that the role of medication in treatment is too large.

“It’s certainly true that when you watch TV, you’re not going to see a lot of commercials about behavioral treatments, but you very well may see some new ones about medication,” said Dr. Carla Allan, an ADHD specialist at Children’s Mercy in Kansas City and a member of the ADHD Clinical Practice Guidelines Subcommittee. Allan is Brody’s doctor and had a role in drafting the latest guidelines. While she wants to see more ADHD patients receive behavioral treatment, she said, she agrees with the AAP’s decision to hold steady on its recommendations about medication.

Other experts say the guidelines should have done more to prioritize behavioral treatments.

“I think it’s a huge disservice to not just the children that we’re trying to treat but also to the parent who would prefer to have behavioral interventions,” said Erika Coles, a psychology researcher at Florida International University.

A behavioral intervention can range from cognitive therapy to school support. It can be as simple as parents setting up a system of expectations reinforced by rewards or punishments.

These interventions are designed to teach children strategies they can use on a daily basis to help stay focused and to reinforce social skills that may fail to develop when children struggle to concentrate.

After school, Ashley Knapp used behavioral techniques to keep son Brody on track with his chores. This is supposed to help him internalize the discipline and “grit” needed to complete difficult tasks, but it can feel to her like micromanaging, she said.

“I don’t like the idea that I have to tell my kids or anybody what to do,” she said. “I want them to be able to think for themselves and make those safe choices, but at this point, that’s just not possible yet for Brody.”

But the techniques — things like counting to keep him on the task of putting away his toys, and rewards like time playing legos after he finishes a chore — are helping him, she admitted.

While the AAP guidelines advise a combination of meds and behavioral treatment, the research backing this combination is problematic, according to Coles, because the two approaches weren’t evaluated separately.

“If you look at studies that did the combined treatment of both medication and behavioral interventions, you can’t disentangle what leads to the best outcome,” Coles said.

A published in 2016 in the Journal of Clinical Child & Adolescent Psychology explored the sequencing of treatment methods and showed that kids with ADHD between ages 5 and 12 who were given behavioral treatment before starting pills had less behavioral problems than kids who started with pills right away.

A co-authored by Coles took it further. It found that children ages 5-13 with ADHD who received therapy first often needed less medication. And 37% of the children who got therapy first didn’t end up needing to take pills at all.

“Really, what it’s suggesting is that if we use behavioral intervention as the first line of treatment, we can reduce or eliminate the need for medication in children with ADHD,” Coles said.

Fewer meds also means fewer side effects. Some kids have trouble sleeping, lose their appetite or experience personality changes, and there’s not much research on what it means to stay on these drugs for years, especially when one is still growing.

The studies backing therapy first are promising and compelling, but they are small. Coles’ research looked at 127 children, while the 2016 study evaluated 146.

A spokesperson for the American Academy of Pediatrics ADHD Clinical Practice Guidelines Subcommittee said the group reviewed the recent behavioral-first research but didn’t find the evidence strong enough to warrant a change in the guidelines.

However, both the academy and its critics agree that not enough children are getting adequate behavioral treatment.ÌýOnly about 60% of kids with ADHD in the U.S. ever got any behavioral interventions outside of school, while 90% had received medication, according to a 2018 study published in the Journal of Pediatrics.

Numerous advocates point out that there are not enough trained therapists, the interventions can be time-consuming for families, and many families can’t afford it.

Brody’s family started with behavioral treatments alone, but after four months he experienced a violent meltdown, which made the family decide to give Brody some medication too. He now takes Concerta.

Brody’s dad said he’s OK with that and that doing the therapy first gave him insight.

“It’s not necessarily for the child,” Brett Knapp said of the parental training he received. “It really is for the parent to realize what an ADHD kid looks like. And for the perspective, I think it helped out greatly to kind of realize how I need to interact and how I need to talk and how I need to work with my child.”

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

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Lori Pinkley, a 50-year-old from Kansas City, Mo., has struggled with puzzling chronic pain since she was 15.

She has had countless disappointing visits with doctors. Some said they couldn’t help her. Others diagnosed her with everything from Ìý³Ù´ÇÌýÌýto the rareÌý.

Pinkley has taken opioids a few times after surgeries, but they never helped her underlying pain, she said.

“I hate opioids with a passion,” Pinkley said. “An absolute passion.”

Recently she joined a growing group of patients using an outside-the-box remedy: naltrexone. It is typically used to treat addiction to opioids or alcohol,Ìýin pill form or as a monthly shot.

As the medical establishment attempts a huge U-turn after two disastrous decades of pushing long-term opioid use for chronic pain, scientists have been struggling to develop safe, effective alternatives.

When naltrexone is used to treat addiction in pill form, it’s prescribed at 50 milligrams. But chronic pain patients say it helps their pain at doses of less than a tenth of that.

Low-dose naltrexone has lurked for years on the fringes of medicine, and its zealous advocates worry it may be stuck there. Naltrexone, which can be produced generically, is not even manufactured at the low doses that seem best for pain patients.

Instead, patients go to compounding pharmacies or resort to DIY methods — YouTube videos and online support groups show people how to turn 50 mg pills into a low-dose liquid.

Some doctors prescribe it off label even though it’s not FDA-approved for pain.

University of Kansas pain specialistÌý recently started prescribing it to her patients, including Pinkley. Nicol explained that for addiction patients it works by blocking opioid receptors — some of the brain’s most important feel-good regions. So it prevents patients from feeling high and can help patients resist cravings.

At low doses of about 4.5 mg, however, naltrexone seems to work differently.

“What it’s felt to do is not shut down the system, but restore some balance to the opioid system,” Nicol said.

Some of the hype over low-dose naltrexone has included some pretty extreme claims with limited research to back them, like using it to treatÌýÌýand neuropathic pain or even using it as a weight-loss drug.

In the past two years, however, there’s been a significant increase in published on low-dose naltrexone, many strengthening claims of its effectiveness as a treatment for chronic pain, though most of these were small pilot studies.

an associate professor at Dartmouth’s Geisel School of Medicine, authored a Ìýof low-dose naltrexone research.

Vrooman said that, when it comes to treating some patients with complex chronic pain, low-dose naltrexone appears to be more effective and well-tolerated than the big-name opioids that dominated pain management for decades.

“Those patients may report that this is indeed a game changer,” Vrooman said. “It may truly help them with their activities, help them feel better.”

So how does it work? Scientists think that for many chronic pain patients the central nervous system gets overworked and agitated. Pain signals fire in an out-of-control feedback loop that drowns out the body’s natural pain-relieving systems.

They suspect that low doses of naltrexone dampen that inflammation and kick-start the body’s production of pain-killing endorphins — all with relatively minor side effects.

Despite the promise of low-dose naltrexone, its advocates say, few doctors know about it.

The low-dose version is generally not covered by insurance, so patients typically have to pay out-of-pocket to have it specially made at compounding pharmacies.

Advocates worry that the treatment is doomed to be stuck on the periphery of medicine because, as a 50-year-old drug, naltrexone can be made generically.

, a professor of health care management at the Wharton School at the University of Pennsylvania, explains that drug companies don’t have much interest in producing a new drug unless they can be the only maker of it.

“Bringing a new drug to market requires getting FDA approval, and that requires doing clinical trials,” Danzon said. “That’s a significant investment, and companies — unsurprisingly — are not willing to do that unless they can get a patent and be the sole supplier of that drug for at least some period of time.”

And without a drug company’s backing, a treatment like low-dose naltrexone is unlikely to get the promotional push out to doctors and TV advertisements that has made household names of drugs like Humira and Chantix.

“It’s absolutely true that once a product becomes generic, you don’t see promotion happening, because it never pays a generic company to promote something if there are multiple versions of it available, and they can’t be sure that they’ll capture the reward on that promotion,” Danzon said.

The drugmaker has had huge success with its exclusive rights to the extended-release version of naltrexone, called Vivitrol. In a statement for this story, the company said it hasn’t seen enough evidence to support the use of low-dose naltrexone to treat chronic pain and therefore is remaining focused on opioid addiction treatment.

Lori Pinkley said it’s frustrating that there are so many missing pieces in the puzzle of understanding and treating chronic pain, but she, too, has become a believer in naltrexone.

She’s been taking it for about a year now, at first paying $50 a month out-of-pocket to have the prescription filled at a compounding pharmacy. In July, her insurance started covering it.

“I can go from having days that I really don’t want to get out of bed because I hurt so bad,” she said, “to within a half-hour of taking it, I’m up and running, moving around, on the computer, able to do stuff.”

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

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