The Mountain West is facing a hospitalization crisis, and even states that cracked down early are feeling the effects of those that didn't.
In Washington State, the frustration is palpable.
"For our healthcare workers to be having to put themselves at risk, for residents of states who are not following the best science is exceptionally frustrating," said Cassie Sauer, CEO of the Washington State Hospital Association.
Over the past several months, Washington has followed stricter public health protocols than many Mountain West states, including by issuing a statewide mask mandate. Most recently, it's gone into another lockdown in hopes of blunting the current surge.
Meanwhile in Idaho, there are no plans for a lockdown, and while some local ordinances require masks, "we are seeing noncompliance with these local orders," as Gov. Brad Little said during a recent pandemic press conference.
Despite acknowledging this noncompliance, Little has repeatedly turned down requests for a statewide mask mandate, and has said law enforcement officers can't be everywhere. He maintains "that this comes down to personal responsibility."
That approach hasn't been working, though. Idaho ranks among the top states for COVID-19 infection rates, and some hospitals are running out of ICU beds.
Sauer believes Washington State is bearing a lot of that burden. An increasing number of Idaho patients are showing up there, much to the dismay of hospital managers.
"One of the hospital leaders said, 'We do not support extending an invitation to send us more,'" Sauer said.
But an unfunded federal mandate from 1986, called EMTALA, said larger hospitals must take critical patients from anywhere if they have room. If they don't, they face steep fines.
There's more at stake than fines, though.
"We have to work together because we really don't know who's going to be next, and that's really the reality of it," said Mahshid Abir, an emergency doctor at the University of Michigan and a policy researcher for RAND Corporation.
She said resentment and feelings of not wanting to treat people across the border are a manifestation of something else - the stress and mental fatigue of watching people die while citizens and politicians refuse to listen.
"Because at the root of not wanting to take care of people from across the border is mental health issues, is stress, is kind of having it - you've reached your limit," she said.
She said we need to stop the state-by-state bickering that we saw with PPE and ventilators early on in the pandemic, and instead develop a national plan so hospitals aren't pitted against each other for a pool of limited resources.
"What we have to really realize that the pool is narrow, but not everyone is going to need all those resources at any given time, so there's definitely plenty of room for sharing and collaboration," she said.
And Abir said it's critical for governments to use money and recognition to incentivize hospitals, which may be competitors, to work together now to save as many lives as possible.
Ian Hunter has seen the benefits of this cooperation first hand. He's both a doctor and chief of staff at Sheridan Memorial Hospital in Wyoming, which works closely with Billings Clinic in Montana. Sheridan's hospital is smaller and has limited resources, so it typically transfers critical patients out to Billings.
While Billings still takes some Wyoming trauma patients into its already overwhelmed facility, Hunter said that hospital has run out of room for his Wyoming COVID-19 patients.
"Prior to COVID, we would never have taken care of patients that sick in Sheridan, Wyoming. But now you have to. There's no ICU beds anywhere," he said.
Hunter is grateful that the Montana hospital can continue helping them via telehealth, though. That way, someone at Billings Clinic can check patient charts, then visit the patient's room and check their ventilator settings over a HIPAA-compliant video service.
"They will teach me something, they will teach the nurse something, they will teach the respiratory therapist something...and just help us become better at taking care of critical patients," he said.
Hunter expects infections in his county to continue to surge, though. Every day he checks on his backup hospitals in case Billings can't take more patients. As of mid-November, he said things weren't looking great.
"Wyoming Medical Center is full. Can't send anybody there. Rapid City is full. Can't send anybody. Cheyenne intermittently will have beds, but they're becoming full as well. Denver and Salt Lake are very much on a case-by-case basis," he said.
So as the public health officer for the county, Hunter ordered a mask mandate. Wyoming Gov. Mark Gordon hasn't done the same for the entire state, though.
Gordon, like Idaho's governor, continues to rely on personal responsibility and local governments, even as he expressed alarm over the growing healthcare crisis at a recent press conference.
"So when you see Utah close its hospital, that's a problem for Wyoming. When you see Eastern Idaho Regional Medical Center close their hospital, that's a problem. When you see Billings Clinic close their hospital, it's a problem. When South Dakota has to send their hospitals to Wyoming because they're too full, that's a problem. And when we have capacity issues down in Colorado, that's a problem," he said.
Just south of Wyoming, Jennifer Riley is with Memorial Regional Health in Craig, Colorado. She said locally, there's COVID-19 fatigue. Even with a state mask mandate, many in the community aren't listening anymore, and her hospital is facing its own challenges transferring patients out.
"COVID positive cases aren't our only concern, this is hunting season. So we're looking at chest pains and strokes and trauma and things that are typical this time of year," she said.
She said they've been able to transfer patients out when they needed to so far, but their main backup hospitals in and around Colorado are also hitting capacity.
Some in Colorado are even asking for help in Kansas, but Kansas needs help, too. Utah has already declared a state of emergency, and hospitals are struggling, according to Gov. Gary Herbert.
"They cannot give the best care when hospitals are at capacity, and medical professionals are exhausted and spread too thin. And that is what is happening right now," he said, announcing the state emergency declaration.
Moving forward, every state in the Mountain West projects COVID-19 rates will climb and their healthcare systems could be overwhelmed. Some Utah facilities are already rationing care. And that's even before the expected fallout from Thanksgiving.
So, for now, Abir said the entire nation needs to focus on mental health care for hospital workers and making sure everyone works together - even if that means financial incentives from federal and state governments to get there.
"We have the data, we have the evidence, we know how to do this," she said. "We can still do it, and I think whenever we start doing it, it's lives saved."
This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.