Erik Mikaitis, MD (Host): Hello and welcome to the latest episode of Pulse Check, the podcast where we share news and highlights with the Cook County Health team.

In May, we recognize both Nurses Week and Hospital Week, two weeks that celebrate a large proportion of our team. I continue to be astounded by all of our staff and the incredible work you do day in and day out for our health system and for those whom we have the privilege of serving. You're a vital part of Cook County and you provide essential care and services to our residents.

It's also a privilege to be joined here today by Cook County Board President, Tony Preckwinkle. She will share with us her perspective on the role Cook County Health plays as a public health system, a Medicaid plan, and a public health authority, and how your work makes an impact for the residents of Cook County. Welcome, Madam President.

Toni Preckwinkle: Thank you very much, Dr. Mikaitis. I'm very grateful to be with you today. I'm very proud of the work that our health system does and, of course, grateful for your leadership. We have provided care to the people of Cook County for 180 years. It's something all of us should be proud of, regardless of your age or gender or race or ethnicity, or sexual orientation or immigration status. So, we are proud of the fact that we serve whoever comes to our door, and we will continue to try to do that.

I am particularly grateful for the work of healthcare providers because my daughter is a nurse, and talks to me often about the challenges that nurses face. And I'm grateful to our healthcare staff for the good care that they provide to our patients each and every day. I know what hard work it is.

Host: Absolutely. And I echo your thanks, and I want everyone on our team to know just how grateful we are for their expertise and the passion that each and every one of you bring to your roles. And thank you, Madam President, for your support. We could not have achieved everything that we have in the recent years without your leadership and your advocacy.

Cook County Health is one of the largest public health systems in the country and many local governments, as you know, Madam President, kind of ran away from healthcare. They closed or they sold their hospital operations in past decades. In fact, the number of government-sponsored hospitals decreased by nearly 25% between 1975 and 1995. Cook County bucked the trend. They ran towards the challenge, and they supported the growth of the health system, the establishment of an independent board, the creation of County Care, and the addition of several new facilities and services. So, let me ask you, Madam President, what has been your guiding philosophy when it comes to the health system and its role as part of the county?

Toni Preckwinkle: Well, I believe that healthcare is a human right. I wish that was a universal opinion in this country. Unfortunately, it's not. But notwithstanding that fact, we have worked hard, as I said, for 180 years to provide care to whoever comes to our door. And that means, as I said, regardless of race or income or immigration status or whether you're insured, we are there to provide care for you. And I'm grateful to all the people who do that work.

A strong foundation for any society, any community is healthcare. And we have some real challenges in Cook County around healthcare access and the quality of care that's delivered to our people. We usually talk about the fact that you could live on the north side of Chicago, near North Streeterville and have a 90-year-life expectancy. You live in Englewood and you have a 60-year-life expectancy. So, you can be five miles apart and have dramatic differences in outcomes in your life. And one of the things that challenges us is trying to address those inequities, those disparities. And I'm grateful for the people who do that good work, not just in our physical and behavioral health units, but also in our public health departments as well.

Host: Yeah, absolutely. And I'm part of that, has been working through how we grow, right? The growth of the health plan, our new facilities like at Brownsville, that we just opened last month, and then strategic expansion of services. All of those help further the mission, as you stated, Madam President, where we are able to start to try to address some of those discrepancies.

Similarly, the more revenue that we bring into the health system, the better we're able to address those gaps for people who can't pay. The county has also increased its allocation to the health fund in recent years to help deliver on that mission too. This year, Cook County provided CCH $158 million in taxpayer funding to support key departments that don't have the opportunity for reimbursement, specifically provision of care at Cook County Jail; the JTDC, the Juvenile Temporary Detention Center; as well as operations at the Cook County Department of Public Health. These dollars also help support the provision of charity care. As I said earlier, we've seen a notable decrease in charity care with the advent of Affordable Care Act and also during the pandemic when we saw volumes dip. And more people were able to retain their health coverage thanks to the suspension of Medicaid redetermination.

Now, unfortunately, with the end of the public health, emergency charity care costs have started to climb again. And we're seeing that demand as well where patients without health insurance are now coming back to our health system. So, I think there's a broader policy discussion here. So, maybe if you could, share with us your perspective on some of the emerging details that we're seeing coming out of Washington D.C. and how they might impact the county and our health system.

Toni Preckwinkle: So, I'm a history teacher and I should have started at the beginning. I talked about 180 years of delivering care. But in the last couple decades, there have been some significant events that have impacted our health system. One of which of course is the Affordable Care Act. And I just want to thank Dr. Raju, who was our CEO early in my tenure in this job. He insisted that we become part of the Affordable Care Act by offering our own Medicaid-managed care program, that's County Care. And that, up until this moment, has been a real godsend to the system and to the people that we serve. Because many people who previously were uninsured, now are insured. And as our patients, we get reimbursement from the federal government for their care.

The challenge of course at the moment is that the Trump administration and Washington Republican Congress are pursuing a rob the poor to help the rich strategy in terms of their federal actions. And so, they're cutting programs that serve the most vulnerable in our society and giving tax cuts to the rich. And one of the ways in which they're doing that, of course, is proposing cuts in Medicaid. And this is a nightmare for us. First of all, it deprives us of revenue. And secondly, it means that our charity care numbers will go up. So, we lose revenues and are asked to provide more care without compensation.

So, as I said, I'm a history teacher. I know that in this country we've endured difficult moments before and survived. But this is clearly a pivotal moment in terms of what kind of country are we? We're a country that's going to give tax breaks to billionaires while we deprive working families, single adults, of medical care. It's appalling to me. But however much I'm appalled, it's a challenge that both Dr. Mikaitis and I have to deal with, and we will be as resourceful as we possibly can in meeting that challenge.

Host: Absolutely. Yeah. And, you know, beyond the revenue piece as we've discussed many a time, that the patients behind it when they don't have insurance will tend to not engage in preventative care. We end up then seeing them with more advanced disease, more chronic disease burden, the long-term sequela of untreated and unprevented issues. So, instead of managing diabetes or treating high blood pressure, we're now seeing strokes and heart attacks, which is just incredibly unfortunate. And it cuts against what we just talked about around life expectancy and those discrepancies. So, to your point that some of the folks who can afford at least are the ones who are at risk here. And just on Medicaid, as you know, it accounts for more than half of our health system service revenue. We've gotten over $820 million a year in Medicaid reimbursement. And we've already seen federal grants being cut for public health initiatives. We've seen research grants being cut, and the federal government is the largest funder for public health where federal grants comprise one-third of our department of public health budget. So, it's, as you said, an extremely concerning time. And we're expecting to see more cuts to key health and social service programs, including the Medicaid program.

So, I don't know if you can maybe talk a little bit more about the D.C. level, what we're looking at, and some of the potential other challenges, for example, health benefits for immigrant adults and some of the other concerns that might be looming.

Toni Preckwinkle: Sure. I mean, I think there's some basic information that our listeners should have. There are 1.6 million people in Cook County who are part of Medicaid, our population is 5.2 million. So basically, about a third of our population is dependent on Medicaid in some way or another. Now, that's everybody from young children in our Kid Care program, that's a Medicaid program, or single adults who are part of our Medicaid program, the ACA Act, or seniors who are called dual eligibles, that are eligible both for Medicaid and Medicare. One point six million out of 5.2 million people are dependent on Medicaid for their health insurance. And I think that is a number that people would find surprising who aren't in this arena. One point six million people in Cook County are dependent on Medicaid coverage. And again, the federal government is proposing-- Republicans in Congress and President Trump are proposing dramatic cuts in the Medicaid program. And that's compounded by cuts made here in Illinois. The governor's budget does not include money for what's called Health Benefits for Immigrant Adults, HBIA. And that's undocumented individuals, 42 to 64. His budget does not include any resources for that. That's $111 million hit to our budget every year, this year, and every year thereafter.

The federal government, one of the proposals on the table is to deny federal Medicaid support for any state that provides Medicaid to undocumented people. So, health benefits for immigrant adults and also health benefits for immigrant seniors, HBIS goes away. That's another $50 million, so it's about $160 million hit to our healthcare system if both these programs come to an end. And I frankly anticipate that that's the case.

So at the state level, we're looking at $160 million hit every year. And again, it's not just the revenue we're deprived of, but also the fact that more people will come to us for charity care and come to us in more compromised circumstances as a result of the fact that they've postponed care.

At the federal level, my assumption it's going to be hundreds of millions of dollars in cuts, it remains to be seen. I mean, many red states have significant Medicaid participation in their populations. And it's hard for me to see how republicans from those states can cut this program without electoral consequences.

I had a conversation. I was speaking at an event a couple weeks ago, and we were talking about this difficult moment and one young woman got up and said, "In 2008 during the Great recession--" a depression by any other name. But anyway, a great recession-- said, "This was surely a difficult moment, but it was a time when there was a lot of innovation and opportunity.

I said, "Yeah, that's one way to look at this, except it ignores the pain and misery that inflicted on so many in the moment. And to look at it, to pretend that this is a good thing, because it's an opportunity for innovation is a little skewed to me. So, I think what we're going to see is more people who don't have coverage, more people who postpone care, and as a result of postponement of the care, are more seriously ill or do not survive. And that is tragic in my view. And all of us ought to be doing everything we can to mitigate the harm that's being done at the federal level.

The problem for us is we don't have unlimited resources. We don't print money like the federal government. And we're going to have to make some tough decisions about how we move forward. I'm not looking forward to that, but I think it's inevitable. And I've shared that view with Dr. Mikaitis.

Host: Yeah, we've discussed it quite a bit, unfortunately, in the last few months. And as you know, we have been preparing potential funding cuts could mean for our health system, and how we prioritize those services. As we've both said now, we will likely see patients without coverage showing up with advanced disease, more burdensome to the patients, to their families, to communities. But also more costly care and how we pivot to try to continue to provide that preventative care for people who had previously had coverage and now have lost it.

Now, to date, we haven't experienced drastic impacts, but we are bracing for them. And we're looking at paring back our budget for 2025 by about 10% and are looking for more opportunities to improve revenues and reduce costs as we prepare for '26. Unfortunately, we are expecting to have to make some difficult decisions as you stated.

Madam President, our motto so far through all of this has been we will do as much as we can for as long as we can. Hundreds of thousands of people rely on our health system as their provider of care, their health insurer, and millions more as their local public health service.

Our role is critical to the health and the wellbeing of Cook County. And it's incumbent on us to be the best stewards we can of the resources we do have so that we can care for those we serve. So again, I want to just thank our team for all of your support, all of your hard work through these tough times. Thank you for leaning in even when it gets heavy, and the future feels uncertain. The uncertainty is real. The concern is real, as you've heard. But so is our strength. The soul of our health system is about people. And we see people as human beings regardless of insurance status or immigration status. We offer dignity where the world too often denies it, and we will see each person as worthy of care, worthy of compassion, worthy of hope.

The road ahead may ask a lot more of us, but I know this team and I know there's no team more committed or capable than ours. So, I think we're coming towards the end. Madam President, any final word?

Toni Preckwinkle: Sure. Okay, so I always say that Martin Luther King is an American prophet, and one of the things he said is, "The arc of the moral universe is long, but it bends toward justice." And you know what I always say is the arc doesn't bend of its own volition. At every point in our history, good people have had to step up and try to bend the arc. You know, I remind people, being an African American descent, I remind people that we have survived 250 years of slavery in this country, enslavement, a hundred years of serfdom. And although this is an extraordinarily difficult moment, we've survived worse. And actually, we've survived worse recently, we survived a global pandemic.

And although this is a difficult moment, from my perspective during the pandemic, I felt responsible for the health and wellbeing of 5.2 million people in the middle of a global pandemic. And that was a challenge. This is a challenge too. And we will get through this as we got through the pandemic, working together, being as resilient and hopeful and collaborative as we possibly can. Thank you.

Host: Absolutely. And thank you, Madam President, for joining us for your inspiring words. The health systems achieve momentous growth thanks to your leadership. We're all grateful for your support, especially as we prepare for these oncoming headwinds. And with that, I just want to thank again all the team members who've listened in today and encourage you to stay tuned for our next episode. Thanks, everyone.