Back in the early days of the pandemic, SUNY Downstate President Dr. Wayne Riley found himself leading a major health system responsible for the care of some of the most vulnerable communities in New York City through unprecedented times. As the hospitals filled up with COVID patients his teams had to simultaneously support their staff and plan their response for patients. Dr. Riley discusses some of the immediate steps they had to take in response, from dealing with a lack of PPE to mitigating an immediate oxygen shortage. Many hospitals have found themselves stretched to breaking point both financially and in terms of staffing, and many hospitals have closed. Dr. O’Connor and Dr. Riley discuss the vital role that safety net hospitals play in care of patients in both urban and rural environments, and the margin pressures and funding shortfalls that are causing a crisis in the care of underserved populations.