TABLE 1. Health System Challenges During COVID-19.

Theme	Challenges	Example
Financial Impact	Care delays and cancellations disrupted revenue streams and severely affected provider finances Providers incurred many pandemic-related costs (and paid premiums) to purchase supplies and restructure clinical workflows	Financial losses for hospitals between March 2020 and June 2020 are estimated to exceed $200 billion The cost of refilling essential medicines increased by 62% during April 2020
Supply Chain	Health systems across the country reported persistent shortages of PPE, essential medicines, and medical devices Outsourced manufacturing and depleted domestic reserves contributed to supply chain vulnerabilities	Hospital demand for dexamethasone increased by 610% while fill rates declined to 54% Over 20% of nursing homes nationwide reported severe PPE shortages well into the summer of 2020
Workforce	Pre-pandemic staffing shortages were an obstacle to the development of surge capacity for COVID-19 COVID-19 has exacerbated the existing challenges of burnout among health professionals	Staff shortages for critical care led to increased demand among health systems for temporary clinicians Surveys of providers indicated elevated levels of stress and symptoms of anxiety, depression, and post-traumatic stress
System and Community-Wide Coordination	Coordination within health systems and with other sectors was complicated by decentralized governance models Outdated technical infrastructure created challenges for data sharing	Health department capacity varied widely across the country, requiring health systems in rural and underserved areas to take on additional responsibilities Funding for the Hospital Preparedness Program was reduced by 46% between 2003 and 2020, limiting the resources available to hospitals to coordinate emergency response