Cook County, which runs one of the biggest public health systems in the nation, is bracing for a blow to its budget as U.S. House Republicans advanced sweeping cuts to health insurance for millions of low-income people.
But the uncertainty about just how steep the cuts could be could last for months with the wide-ranging proposal now heading to the U.S. Senate. The measure would drastically scale back Medicaid, the public health insurance program for people who are low-income or disabled. The federal government and states typically split the cost.
“We’re clearly going to suffer a financial hit,” said Cook County Board President Toni Preckwinkle. “The only question is what the magnitude of that is.”
At the same time, facing a massive budget hole, Illinois lawmakers are set to end health insurance for more than 30,000 immigrant adults mostly without legal status starting July 1. But Preckwinkle is preparing in case state lawmakers cut even more, erasing coverage for immigrant seniors, too. Combined, Cook County receives about $160 million a year in revenue from these state immigrant health insurance programs.
The cascade of financial losses could be profound to the county’s bottom line and ripple out to the people they serve — largely low-income and immigrant patients at Cook County Health, and more broadly to ordinary residents who rely on county services like the courts or for getting property tax bills on time.
In Illinois, more than 3 million people have Medicaid — around one in four in the state. This program funds everything from seniors in nursing homes and mothers and their newborns, to people with disabilities and those living with HIV. New research suggests that having Medicaid coverage saves lives.
What Preckwinkle said she’s worried about the most is cuts to Medicaid, which makes up around 56% of how much Cook County Health gets paid to treat patients. The county has a mission to treat people no matter if they can pay and already provides by far the most discounted care to patients in the entire state, public health data shows.
County officials expect this amount to climb. Community health centers and other hospitals that serve low-income communities are all bracing for potentially more patients to lose Medicaid coverage. If that happens, leaders at these clinics are mulling whether to lay off workers, scale back hours or close. This would potentially funnel more patients to the county, which might now have a hard time getting paid to treat them.
Dan Fulwiler, CEO of Esperanza Health Centers, which treats mostly Latino patients on the Southwest Side, predicts a potentially dangerous and costly cycle that includes longer wait times to see a doctor. Patients who put off managing their diabetes, for example, then get sicker and become much more expensive to treat in the emergency department.
“All of those things are going to create more pressure on county,” Fulwiler said. “They’re the absolute end of the safety net.”
Planning in the dark
All of this is unfolding as Cook County starts to plan next year’s budget. This year, the spending plan totaled nearly $10 billion, buoyed by $1 billion in pandemic relief dollars soon to run out that funded guaranteed income, anti-violence measures and housing for the homeless.
But it’s hard to plan without knowing just how much they could lose in federal support, Preckwinkle said. She won’t provide details on what might be scaled back, though she said her administration is taking a hard look at what’s absolutely necessary and what they might not be able to sustain.
Still, there are some clues for how much is at stake. For example, the House bill requires that, with some exceptions, Medicaid enrollees work (research shows most already do). The county says work requirements could lead to a $88 million annual loss. That’s based on state estimates and what happened in Arkansas, when around 18,000 people lost coverage either because they didn’t have a job or because of the confusing process to keep their insurance, according to KFF, a non-partisan health policy research organization.
The federal government also would reduce from 90% to 80% how much they share the cost of adults who joined Medicaid when the program expanded under the Affordable Care Act to states like Illinois that fund health care for undocumented adults and children. If this happened, the state has a law that would end the expansion program and estimates at least 700,000 people would lose insurance. The projected impact to Cook County Health: around $200 million a year.
All of these losses could translate into an increase in charity care, or discounted care, for county patients if they can’t afford to pay their medical bills. In 2023, this totaled nearly $140 million at the county’s flagship John H. Stroger Jr. Hospital on the Near West Side alone, almost six times more than the next closest hospital, according to a WBEZ analysis of the most recent Illinois public health data.
The vast county health system also includes Provident Hospital on the South Side and a group of clinics throughout the city and suburbs. Most patients are low-income, Black or Latino.
“It’s hard to know whether people will turn immediately to us,” Preckwinkle said. “Sometimes people when their own system is no longer available to them, they just postpone care until they’re really sick, and then maybe end up in our emergency room, and from there into our system. There’s no way to predict those kind of individual decisions and the magnitude of impact they’ll have on us.”
Dr. Erik Mikaitis, CEO of Cook County Health, predicts that even people with private insurance will be affected by Medicaid cuts. For example, they could find the ER at their local hospital packed with patients who are suddenly uninsured, increasing everyone’s wait time to see a doctor and potentially making medical bills more expensive as hospitals figure out how to recoup lost Medicaid revenue.
Mikaitis said he doesn’t plan to cut services or lay off staff at the health system he runs.
“We’re going to do as much as we can for as long as we can,” Mikaitis said. “We’re committed to our mission to ensuring that everyone has access to care.”
Sean Morrison, the only Republican on the county board, said he’s “cautiously optimistic” potential Medicaid changes won’t cut too deep. He supports the mission of Cook County Health, but said “a lot of this has been political theater” from Democrats, disputing that Republicans would actually cut Medicaid. He points to work requirements instead.
But he acknowledges the county would have to absorb the cost of treating people who lose health insurance, and that could mean other county services could pay the price. He suggests a few solutions, such as having immigrants return to their home countries, raising taxes or cutting back on programs like guaranteed income to fund medical care instead.
“Is the notion of government takes care of everything ever a sustainable model? No, of course not,” Morrison said.
Hope amid uncertainty
Dr. Mark Loafman has worked for about 30 years trying to prevent some of the poorest people from getting so sick they wind up in the emergency department he’s standing outside of.
Lately, he said there’s a lot of anxiety packed into his appointments. His patients at Cook County Health ask how the potential Medicaid cuts might affect them.
“And of course, I don’t have the answer for them,” said Loafman, who leads family and community medicine. “We kind of know that our immigrant population is probably first up (to lose insurance), and that’s coming soon, and then others will follow.”
Over the years, as politicians across the country debate whether to cut Medicaid, he said he’s learned not to panic. Both sides of the political aisle in Washington usually come together to pass a budget that makes sense.
But this time, Loafman said it feels different — unprecedented.
“I think this feels more harsh and more certain that there’s going to be an almost devastating level of cuts coming for some of our patients,” Loafman said. “We’re just going to have to, as we always do, find a way to get through it.”
Still, he’s hopeful.
“I think it’s going to be tough, but that will create the visibility that we need so that the people who aren’t paying attention to this, who don’t see what I see every day, can have a little bit of a change of heart and maybe vote and speak and like something differently on their social media feed and begin to pay attention,” Loafman said. “I think that’s what will get us out of this.”
Kristen Schorsch covers the health of the region for WBEZ.