For small hospitals, including Critical Access Hospitals (CAHs), being part of a system can provide many advantages including access to supplies at a lower cost, more financial flexibility, and higher average salaries for staff. With new and exacerbated challenges for CAHs during the COVID-19 pandemic, these resources have become even more important. At the same time, independent CAHs have some unique advantages as well. In this brief, the Flex Monitoring Team describes findings from a survey of CAH CEOs about their response to COVID-19, with a specific focus on advantages and disadvantages of system ownership or independence as described by survey participants.