Across Montana, such units routinely hit capacity and some struggle to find enough workers to staff them.

This article was published on Tuesday, September 14, 2021 in Kaiser Health News.

By Katheryn Houghton  

Gary Popiel had to drive more than 200 miles round trip to visit his adult daughters in separate behavioral health facilities as they received psychiatric and medical treatment.

It was 2000, and the family's only options for inpatient psychiatric beds were in Helena and Missoula — far from their Bozeman, Montana, home and from each other. Fast-forward 21 years, and Montana's fourth-largest city still lacks a hospital behavioral health unit.

"This would be just as traumatic now as it was then. We still would have to leave Bozeman," Popiel said. "Why should families have to witness their loved one being hauled off or take them themselves to another facility — or outside the state — to receive help?"

For years, healthcare workers and people such as Popiel who've had to travel for family members' mental health hospitalizations have been pushing the city's major hospital system, the nonprofit Bozeman Health, to add a behavioral health unit at its Deaconess Hospital. On Sept. 30, the system's board plans to consider whether to add one as part of an expansion of its mental health services.

Hospital leaders have said initial talks have been broad so far, without specifics on the number of potential beds and whether they're designed for adults or kids.

But even if Bozeman Health adds inpatient psychiatric beds, the gaps in emergency mental healthcare could continue. Across Montana, such units routinely hit capacity and some struggle to find enough workers to staff them.

Montana's quandary reflects a national shortage of inpatient psychiatric beds that can leave people with serious mental illnesses far from the services they need when a crisis hits. Ideally, patients would have treatment options to prevent such a crisis. But more than 124 million Americans live in mental health "professional shortage areas," according to federal data, and the country needs at least 6,500 more practitioners to fill the gaps.

The national nonprofit Treatment Advocacy Center, which aims to make care for severe mental illness more accessible, recommends a minimum of 50 inpatient psychiatric beds per 100,000 people. It is still debated, though, who should provide those beds and where they're prioritized on a long list of stretched-thin mental health services.

Given the patient capacity of Montana State Hospital and private hospital behavioral health units, Montana comes close to that recommendation. But those beds are concentrated in pockets of the state, so access isn't uniform.

For example, Bozeman Health sits in a city of 50,000 in a county of 120,000 and also serves two neighboring counties. The city has 10 crisis beds at the Western Montana Mental Health Center's facility there — the only beds for roughly 100 miles in any direction. The crisis center cares for roughly 400 people a year, providing nurses and psychiatrists who can offer safety plans and medication management, but it can't treat children or offer full medical services as a hospital could. The center also faced criticism for closing its two involuntary beds for six months last year because of a worker shortage amid the pandemic.

Bozeman Health's leadership estimated that on average 13 people who live in its primary three-county service area of Gallatin, Park and Madison counties are admitted to behavioral health units elsewhere each month.

Some patients leave handcuffed in the back of a law enforcement vehicle. Last year, the Gallatin County Sheriff's Office transported 101 people experiencing a mental health crisis — 85 of whom were taken to crisis centers hours away or the state hospital. That's up from 2019 when authorities took 36 out of 45 people in crisis outside the county.

"Every other major city in Montana besides us has managed to get inpatient care" at their hospitals, said Dr. Colette Kirchhoff, a physician in Bozeman.

One man went to Bozeman Health to have a cancerous tumor removed in early August, and the next day he had panic attacks that turned into suicidal thoughts. He was driven two hours in the back of an ambulance to the Billings Clinic. His wife, who asked KHN not to publish their names since her husband wasn't in a condition to give his consent, said she wished they'd had a closer option.

"I was there when he got strapped into a gurney and taken away," she said. "I had to book a hotel and get money from the bank and pack clothes."

Bozeman Health leaders have said the hospital hadn't actively considered a behavioral health unit until now because it had prioritized outpatient mental health services. In recent years, it added mental health treatment into primary care, including hiring licensed clinical social workers. It started telepsychiatry to help local providers with patient assessments. It also plans to provide short-term crisis stabilization and medication management.

"The gold standard is let's make the need for high-acuity inpatient care go away completely," said Jason Smith, Bozeman Health's chief advancement officer. "Getting there may be impossible. At the very least, it's going to be difficult."

Elizabeth Sinclair Hancq, director of research for the Treatment Advocacy Center, is skeptical that would be possible. "Efforts to intervene as early as possible are an important step forward, but that doesn't mean that inpatient beds will become obsolete," she said.

Smith said creating inpatient psychiatric services isn't as simple as adding beds. A construction project would be years away. Adding a unit also would mean ensuring discharged patients have access to additional services and recruiting mental health workers to Bozeman amid the national shortage.

"Whether we're going to be able to recruit the behavioral health professionals that are necessary to lead it and provide that care on a day-to-day basis is a major question mark," Smith said.

Dr. Scott Ellner, CEO of the Billings Clinic, said the number of patients who travel to his hospital for care is evidence the state needs more beds. Last year, the hospital treated 161 psychiatric patients from Bozeman Health's service area. Ellner said Billings Clinic loses money on its psych unit, but the service is part of the hospital's job.

"There's so few resources across the state," Ellner said. "We strongly recommend that there be inpatient beds in Gallatin County."

Where the services do exist, they're often stretched.

Benefis Health System in Great Falls has 20 inpatient psychiatric beds. In an email, spokesperson Kaci Husted said those beds hit capacity a few times a week. When that happens, the hospital puts patients in overflow beds until a spot opens.

And in Helena last year, St. Peter's Health turned away 102 patients because its behavioral health unit was out of space or because a patient needed more care than the hospital could manage. Gianluca Piscarelli, the unit's director, said the system's eight adult beds are often full. The hospital also has 14 geriatric psychiatric beds — the only inpatient program in the state designed for seniors who may have dementia and a serious mental illness — but Piscarelli said the unit may deny someone a spot if it already has too many high-needs patients to manage.

Shodair Children's Hospital in Helena has 74 beds for kids in a crisis but, because of a shortage of mental health workers, the facility could admit only 40 patients as of mid-August, said CEO Craig Aasved. In May, a 15-year-old patient died by suicide there, with a state report blaming understaffing as a contributing factor.

The hospital is working on an expansion with a new building design that would make it easier to group patients by diagnosis, but staffing will still be a strain. He said that while more beds are always needed, some kids come from towns where they don't even have access to a therapist.

Having every hospital add psychiatric beds isn't a perfect solution, Aasved said. "The end result is we'll just have a lot of beds and no staff."

NEED HELP?

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting HOME to 741741.

Katheryn Houghton: khoughton@kff.org, @K_Hought

For Americans looking for swift answers, the cheapest over-the-counter COVID test is the Abbott Laboratories BinaxNOW two-pack for $23.99.

This article was published on Monday, September 13, 2021 in Kaiser Health News.

By Hannah Norman  

Rapid at-home COVID tests are flying off store shelves across the nation and are largely sold out online as the delta variant complicates a return to school, work and travel routines.

But at $10 or $15 a test, the price is still far too high for regular use by anyone but the wealthy. A family with two school-age children might need to spend $500 or more a month to try to keep their family — and others — safe.

For Americans looking for swift answers, the cheapest over-the-counter COVID test is the Abbott Laboratories BinaxNOW two-pack for $23.99. Close behind are Quidel's QuickVue tests, at $15 a pop. Yet supplies are dwindling. After a surge in demand, CVS is limiting the number of tests people can buy, and Amazon and Walgreen's website were sold out as of Friday afternoon.

President Joe Biden said Thursday he would invoke the Defense Production Act to make 280 million rapid COVID tests available. The administration struck a deal with Walmart, Amazon and Kroger for them to sell tests for "up to 35 percent less" than current retail prices for three months. For those on Medicaid, the at-home tests will be fully covered, Biden said.

An increased supply should help to lower prices. As schools open and much of the country languishes without pandemic-related restrictions, epidemiologists say widespread rapid-test screening — along with vaccination and mask-wearing — is critical to controlling the delta variant's spread. Yet shortages, little competition and sticky high prices mean routine rapid testing remains out of reach for most Americans, even if prices drop 35%.

Consumers elsewhere have much cheaper — or free — options. In Germany, grocery stores are selling rapid COVID tests for under $1 per test. In India, they're about $3.50. The United Kingdom provides 14 tests per person free of charge. Canada is doling out free rapid tests to businesses.

Michael Mina, assistant professor of epidemiology at Harvard University, lauded Biden's announcement on Twitter while saying he "had some reservations" about its scale and noted that 280 million tests represent "less than one test per person over the course of a year."

Rep. Kim Schrier (D-Wash.) for months has advocated for rapid testing at a lower cost. "In an ideal world, a test would either be free or cost less than a dollar so that people could take one a few times a week to every day," she said in the days before Biden's announcement.

Biden's initiative "is a great start" for broader rapid testing, Schrier said Friday. "But there is a lot more to be done, and that must be done quickly, to use this really important tool to combat this virus."

A nationwide survey released in February by the Harvard T.H. Chan School of Public Health and Hart Research found that 79% of adults would regularly test themselves at home if rapid tests cost a dollar. But only a third would do so if the cost was $25.

Billions in taxpayer dollars have been invested in these products. Abbott Laboratories, for instance, cashed in on hundreds of millions in federal contracts and gave its shareholders fat payouts last year, increasing its quarterly dividend by 25%. Even so, according to a New York Times investigation, as demand for rapid tests cratered in early summer, Abbott destroyed its supplies and laid off workers who had been making them.

More than a year ago, Abbott said the company would sell its BinaxNOW in bulk for $5 a test to healthcare providers, but that option is not available over the counter to the public. Even with the anticipated price decrease, a two-pack will be more than $15. Abbott did not comment further.

Schrier said in spring that test prices were high because "big companies are buying up all the supplies." Also, "their profit is far higher making 1,000 $30 tests than 30,000 $1 tests" — in other words, they can make the same amount of money for many fewer tests.

In March, the Biden administration allocated $10 billion as part of the American Rescue Plan Act to perform COVID testing in schools, leaving the rollout largely to states. This followed $760 million spent by the Trump administration to buy 150 million of Abbott's rapid-response antigen tests, many of which went to schools. The rollout has been mixed, with states like Missouri mired in logistical challenges.

In late August, Schrier wrote a letter asking four federal agencies to update their distribution plans. She also urged the government to increase spending on rapid testing, saying "time is of the essence" as children returned to school.

Antigen tests can give real-time information to people exposed to COVID, said Dr. Dara Kass, an associate professor of emergency medicine at Columbia University Medical Center. Waiting for lab results from polymerase chain reaction (PCR) tests can take days, and many states — particularly in the hard-hit South — are seeing appointments fill up days in advance. At-home collection kits for PCR tests can cost over $100.

Rapid tests take under 15 minutes to detect COVID by pinpointing proteins, called antigens. The tests are similar to a pregnancy test, with one or two lines displayed, depending on the result.

The Centers for Disease Control and Prevention recommends that fully vaccinated people exposed to COVID wear a mask indoors for two weeks and get tested three to five days after exposure. The unvaccinated should quarantine for 14 days. But that leaves gray area for those vaccinated people hoping to attend classes or go about their lives, Kass said.

"Rapid tests give information," she added, "that allows somebody to engage in society safely." People can follow up with a PCR test, which is more sensitive, for confirmation of a diagnosis.

In Massachusetts, for example, a "Test and Stay" strategy for students exposed to COVID allows them to remain in school: Students take BinaxNOW tests five days in a row following close contact with an infected person.

More than 30 antigen tests have been developed in the U.S. — though just six companies have FDA authorization for over-the-counter use. No rapid COVID tests have full FDA approval. Two rapid molecular options, made by Lucira Health and Cue Health, also have emergency use authorization (EUA).

"Unfortunately, many submissions are incomplete or contain insufficient information for FDA to determine that they meet the statutory criteria," FDA spokesperson James McKinney said.

The agency has taken a stricter stance than its European counterparts. In June, the FDA warned Americans to stop using Innova Medical Group's rapid antigen test, stating that the agency had "significant concerns that the performance of the test has not been adequately established." Yet in the U.K., which has contracts worth billions with the California company, the regulatory agency OK'd the product.

In Germany, regulators have given special authorization to dozens of antigen tests.

"As long as these tests are regulated as medical devices, the FDA has to regulate them not as critical public health tools, but as medical tools, with all of the onerous clinical trials that slow everything down 100-fold," Mina said on Twitter.

With only a handful of rapid tests on the market, it is harder for companies that have not yet received FDA authorization to catch up and, in turn, drive the prices down, said Michael Greeley, co-founder and general partner at Flare Capital Partners, a venture capital firm focused on healthcare technology. "If we're talking about people testing their kids every day going to school," he added, "for many families, the current costs are a real burden."

Broad adoption of rapid testing seems premature, he said, even with a mass purchase of tests by the U.S. government: "We can't even get people to floss, so the idea that people are now going to start rapid testing as their standard operating procedure is a flawed assumption."

Regardless, companies can't keep up with demand.

Ellume said it saw a 900% spike in the use of its tests over the past month. Its at-home rapid test costs up to $38.99. On Walmart's website, it was listed for $26.10 Friday but was out of stock.

The Australian manufacturer received $232 million from the U.S. Defense Department in February to scale up production, after the FDA authorized its at-home use late last year. But the federal Healthcare Enhancement Act, which furnished the funding, does not impose pricing restrictions. Ellume said it will begin production at a Frederick, Maryland, plant this fall. For now, it is shipping tests from Australia.

This summer, Lucira Health stopped selling its about $50 molecular rapid test online to focus on larger clients, including San Francisco's Chase Center, home to the Golden State Warriors, and the Olympics, Dan George, Lucira's chief financial officer, said during a recent earnings call.

The company is still losing money as it ramps up production but hopes to return to selling directly on its website and Amazon later this year.

Hannah Norman: hannahn@kff.org, @hnorms

Doctors often describe ECMO as a way to let the lungs "rest" — especially useful when even ventilation isn't fully oxygenating a patient's blood.

This article was published on Friday, September 10, 2021 in Kaiser Health News.

By Blake Farmer, Nashville Public Radio   

Hospital discharge day for Phoua Yang was more like a pep rally.

On her way rolling out of TriStar Centennial Medical Center in Nashville, Tennessee, she teared up as streamers and confetti rained down on her. Nurses chanted her name as they wheeled her out of the hospital for the first time since she arrived in February with COVID-19, barely able to breathe.

The 38-year-old mother is living proof of the power of ECMO — a method of oxygenating a patient's blood outside the body, then pumping it back in. Her story helps explain why a shortage of trained staff members who can run the machines that perform this extracorporeal membrane oxygenation has become such a pinch point as COVID hospitalizations surge.

"One hundred forty-six days is a long time," Yang said of the time she spent on the ECMO machine. "It's been like a forever journey with me."

For nearly five months, Yang had blood pumping out a hole in her neck and running through the rolling ECMO cart by her bed.

ECMO is the highest level of life support — beyond a ventilator, which pumps oxygen via a tube through the windpipe, down into the lungs. The ECMO process, in contrast, basically functions as a heart and lungs outside the body.

The process, more often used before the pandemic for organ transplant candidates, is not a treatment. But it buys time for the lungs of COVID patients to heal. Often they've been on a ventilator for a while. Even when it's working well, a ventilator can have its own side effects after prolonged use — including nerve damage or damage to the lung itself through excessive air pressure.

Doctors often describe ECMO as a way to let the lungs "rest" — especially useful when even ventilation isn't fully oxygenating a patient's blood.

Many more people could benefit from ECMO than are receiving it, which has made for a messy triaging of treatment that could escalate in the coming weeks as the delta variant surges across the South and in rural communities with low vaccination rates.

The ECMO logjam primarily stems from just how many people it takes to care for each patient. A one-on-one nurse is required, 24 hours a day. The staff shortages that many hospitals in hot zones are facing compound the problem.

Yang said she sometimes had four or five clinical staff members helping her when she needed to take a daily walk through the hospital halls to keep her muscles working. ECMO is unusual as life support, because patients can be conscious and mobile, unlike patients on ventilators who often are sedated. This presents its own challenges, however. For Yang, one person's job was just to make sure no hoses kinked as she moved, since the machine was literally keeping her alive.

Of all the patients treated in an intensive care unit, those on ECMO require the most attention, said nurse Kristin Nguyen, who works in the ICU at Vanderbilt University Medical Center.

"It's very labor-intensive," she said one morning, after a one-on-one shift with an ECMO patient who had already been in the ICU three weeks.

The Extracorporeal Life Support Organization said the average ECMO patient with COVID spends two weeks on the machine, though many physicians say their patients average a month or more.

"These patients take so long to recover, and they're eating up our hospital beds because they come in and they stay," Nguyen said. "And that's where we're getting in such a bind."

Barriers to using ECMO are not merely that there aren't enough machines to go around or the high cost — estimated at $5,000 a day or significantly more, depending on the hospital.

"There are plenty of ECMO machines — it's people who know how to run it," said Dr. Robert Bartlett, a retired surgeon at the University of Michigan who helped pioneer the technology.

Every children's hospital has ECMO, where it's regularly used on newborns who are having trouble with their lungs. But Bartlett said that, before the pandemic, there was no point in training teams elsewhere to use ECMO when they might use the technology only a few times a year.

It's a fairly high-risk intervention with little room for error. And it requires a round-the-clock team.

"We really don't think it should be that every little hospital has ECMO," Bartlett said.

Bartlett said his research team is working to make it so ECMO can be offered outside an ICU — and possibly even send patients home with a wearable device. But that's years away.

Only the largest medical centers offer ECMO currently, and that has meant most hospitals in the South have been left waiting to transfer patients to a major medical center during the recent pandemic surge. But there's no formal way to make those transfers happen. And the larger hospitals have their own COVID patients eligible for ECMO who would be willing to try it.

"We have to make tough choices. That's really what it comes down to — how sick are you, and what's the availability?" said Dr. Harshit Rao, chief clinical officer overseeing ICU doctors with physician services firm Envision. He works with ICUs in Dallas and Houston.

There is no formal process for prioritizing patients, though a national nonprofit has started a registry. And there's limited data on which factors make some COVID patients more likely to benefit from ECMO than others.

ECMO has been used in the United States throughout the pandemic. But there wasn't as much of a shortage early on when the people dying of COVID tended to be older. ECMO is rarely used for anyone elderly or with health conditions that would keep them from seeing much benefit.

Even before the pandemic, there was intense debate about whether ECMO was just an expensive "bridge to nowhere" for most patients. Currently, the survival rate for COVID patients on ECMO is roughly 50% — a figure that has been dropping as more families of sicker patients have been pushing for life support.

But the calculation is different for the younger people who make up this summer's wave of largely unvaccinated COVID patients in ICUs. So there's more demand for ECMO.

"I think it's 100% directed at the fact that they're younger patients," said Dr. Mani Daneshmand, who leads the transplant and ECMO programs at Emory University Hospital.

Even as big as Emory is, the Atlanta hospital is turning down multiple requests a day to transfer COVID patients who need ECMO, Daneshmand said. And calls are coming in from all over the Southeast.

"When you have a 30-year-old or 40-year-old or someone who has just become a parent, you're going to call. We've gotten calls for 18-year-olds," he said. "There are a lot of people who are very young who are needing a lot of support, and a lot of them are dying."

Even for younger people, who tend to have better chances on ECMO, many are debilitated afterward.

Laura Lyons was a comedian with a day job in New York City before the pandemic. Though just 31 when she came down with COVID, she nearly died. ECMO, she said, saved her life. But she may never be the same.

"I was running around New York City a year and a half ago, and now I'm in a wheelchair," she said. "My doctors have told me I'll be on oxygen forever, and I'm just choosing not to accept that. I just don't see my life attached to a cord."

Lyons now lives at her parents' house in central Massachusetts and spends most days doing physical therapy. Her struggle to regain her strength continues, but she's alive.

Since it's kind of the wild West to even get someone an ECMO bed, some families have made their desperation public, as their loved one waits on a ventilator.

As soon as Toby Plumlee's wife was put on a ventilator in August, he started pressing her doctors about ECMO. She was in a northern Georgia community hospital, and the family searched for help at bigger hospitals — looking 500 miles in every direction.

"But the more you research, the more you read, the more you talk to the hospital, the more you start to see what a shortage it really is," he said. "You get to the point, the only thing you can do is pray for your loved one — that they're going to survive."

Plumlee said his wife made it to sixth in line at a hospital 200 miles away — TriStar Centennial Medical Center, where Phoua Yang was finishing her 146-day ECMO marathon.

Yang left with a miracle. Plumlee and their children were left in mourning. His wife died before ever getting ECMO — a few days after turning 40.

This story was produced as part of NPR's partnership with Kaiser Health News and Nashville Public Radio.

Blake Farmer, Nashville Public Radio: bfarmer@wpln.org, @flakebarmer

As of Aug. 26, the Chronicle of Higher Education had tallied 805 campuses that require at least some employees or students to be vaccinated. 

This article was published on Thursday, September 9, 2021 in Kaiser Health News.

By Michelle Andrews

As students head to college this fall, hundreds of schools are requiring employees and students to be vaccinated against COVID, wear masks on campus or both.

But at some schools, partisan politics have bolstered efforts to stymie public health protections.

Events at the University of South Carolina, in a deeply conservative state, demonstrate the limits of political pressure in some cases, even though "South Carolina is a red state and its voters generally eschew mandates," said Jeffrey Stensland, a spokesperson for the school.

As the fall semester approached, Richard Creswick, an astrophysics professor at the University of South Carolina, was looking forward to returning to the classroom and teaching in person. He felt it would be fairly safe. His graduate-level classes generally had fewer than a dozen students enrolled, and the school had announced it would require everyone on campus to wear masks indoors unless they were in their dorm rooms, offices or dining facilities. For Creswick, 69, that was important because he did not want his working on campus to add to the COVID risk for his wife, Vickie Eslinger, 73, who has been undergoing treatment for breast cancer.

But state Attorney General Alan Wilson weighed in early in August, sending a letter to the school's interim president, Harris Pastides, that a budget provision passed by the state legislature prohibited the university from imposing a mask mandate. Pastides, who previously served as dean of the university's school of public health, rescinded the mask mandate, although he encouraged people to still use them.

"We were very upset," Creswick said.

After the university revoked its mask mandate, within days Wilson sent out a campaign fundraising letter touting his intervention in public health measures and stating, "The fight over vaccines and masks has never been about science or health. It's about expanding the government's control over our daily lives."

Creswick and Eslinger, who felt strongly that the mask mandate was indeed about health, filed a lawsuit, arguing that the legislative provision cited by the attorney general did not prohibit a universal mask mandate. The state Supreme Court took up the case on an expedited basis and on Aug. 20 ruled 6-0 in their favor.

The school immediately reinstated its mask mandate and other colleges in the state followed suit.

After the court ruling, Creswick said he heard from professors at several other South Carolina colleges. "They're calling me a hero," he said, sounding bemused.

The attorney general's office didn't respond to a request for comment.

The Centers for Disease Control and Prevention recommends that everyone at colleges and universities wear masks indoors, even if they are fully vaccinated, in locales with substantial or high transmission of the coronavirus. Most of the country meets that standard at this point. The CDC also recommends that colleges offer and promote COVID vaccines.

To be sure, many colleges and universities already require students to mask up or be vaccinated.

As of Aug. 26, the Chronicle of Higher Education had tallied 805 campuses that require at least some employees or students to be vaccinated. Most schools grant exemptions from the vaccine mandate, often for religious or medical reasons. And hundreds of colleges are requiring students and staff members to wear masks on campus this fall, according to a running tally by University Business.

Still, 12 conservative-leaning states prohibit vaccine mandates at higher education institutions, according to an analysis by the National Academy for State Health Policy. The rules vary, and some apply only to public institutions. The group is in the process of analyzing mask mandate bans that apply to colleges and universities.

At Indiana University, a group of students challenged the school's vaccine mandate on the grounds it violated their constitutional right to "bodily integrity, autonomy and medical choice." The U.S. Court of Appeals for the 7th Circuit refused to block the school's policy. The court reasoned the universities can decide what they need to do to keep students safe in communal settings. The students then appealed to U.S. Supreme Court Justice Amy Coney Barrett, who refused without explanation to block the mandate.

Red states with Republican leadership are hardly the only ones where colleges and universities are facing restrictions on their ability to put public health protections in place. But for teachers, whose professions are rooted in encouraging the pursuit of learning and knowledge, prohibitions that fly in the face of science and jeopardize public health can be tough to swallow.

At the University of Georgia in Athens in August, a professor who made masks mandatory in his classroom because of his advanced age and health conditions promptly resigned when a student refused to don a mask. Georgia's university system does not mandate masks or vaccines.

In May, Iowa Gov. Kim Reynolds, a Republican, signed a law prohibiting mask mandates at K-12 schools, and within city and county governments. A few days later, the Iowa Board of Regents, which oversees the University of Northern Iowa, the University of Iowa and Iowa State University, lifted emergency rules that had been in place the previous year requiring indoor masking and physical distancing at the colleges.

The University of Northern Iowa held classes in person throughout the past school year, without major problems, using those mask and distancing requirements, Hawbaker said. But with the rise of the delta variant and the increase in COVID cases in the community, now is not the time to remove safety restrictions, the union asserts.

So far, more than 200 people have signed an August letter sent by the union to the Board of Regents requesting mask and vaccine mandates on campus, and classroom changes to allow physical distancing, Hawbaker said.

"Both the Board and our universities recommend and encourage individuals to wear a mask or other face covering while on campus, and anyone who wishes to wear a mask may do so," Josh Lehman, a spokesperson for the board, wrote in an email. The board also supports students and staffers getting COVID vaccines, which are available on campus.

At Clemson University in Clemson, South Carolina, associate professor Kimberly Paul planned a protest with other faculty members in August to push for a mask mandate. After the state Supreme Court ruled in favor of Creswick, Clemson announced a mask mandate until Oct. 8. That stretch covers the period of greatest COVID risk, according to the school's modeling.

Paul and her colleagues want a mask mandate for the entire semester, after which the need can be reevaluated, she said.

"I'm a biologist, and this hits close to home," she said.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110