Erik Mikaitis, MD (Host): Hello and welcome to another episode of Pulse Check, our internal Cook County Health podcast, where we dive deep into the issues shaping healthcare for our patients, our communities, and our system. Today, we're taking a close look at a major piece of legislation, the One Big Beautiful Bill Act, and exploring how it's expected to impact Cook County Health and the people we serve.

The bill is estimated to cut nearly $1 trillion in federal healthcare over the next 10 years while increasing the federal deficit by $3.3 trillion by instituting tax breaks for the nation's highest earners. Nearly 12 million people are expected to lose health insurance over the next 10 years due to changes included in the bill, according to analysis by the Congressional Budget office. This legislation has significant ramifications for health and social service programs that millions of Illinoisans depend on and that our health system relies on to fund our work. Whether you work in clinical care, operations, administration, or community health, I'm sure you have questions about what this means for your work, our patients, our members, and our communities.

I am joined today by two of our systems' legislative experts, Kathy Chan, Cook County Health Policy Director, and Gillian Feldmeth, Senior Manager of Policy and Innovation with County Care. They've both been deeply involved in analyzing the implications of this act and how it will impact us. So, let's jump in, and break down what this bill means, how we're responding, and what you need to know moving forward. Kathy, let's start with the basics. Can you give us a quick overview of what the One Big Beautiful Bill Act includes?

Kathy Chan: Yeah. So, thanks so much for inviting me to this podcast today, despite the less than happy topic we'll be discussing. So, the One Big Beautiful Bill Act, or OBBBA as it's been commonly referred to as, represents the largest cuts in history to Medicaid, SNAP, and the social safety net; cuts to the healthcare programs, as you mentioned earlier, total $1 trillion over the next 10 years. And the OBBBA is really going to make it harder for working families to fulfill basic needs, including healthcare and food.

I'll start first with talking about OBBBA's impact on Medicaid, but I also want to provide some basics about Medicaid first. So, as many of you know, medicaid is a jointly administered and funded federal state partnership program that provides public health insurance to 79 million people nationwide, including 3.4 million here in Illinois. That's about one in every four Illinois residents. Medicaid covers low income and working households, including children, parents, pregnant people, persons with disabilities, older adults who meet income eligibility standards.

And when we passed the Affordable Care Act, the Affordable Care Act actually prompted states like Illinois to expand Medicaid to low income adults who do not have children living in their household. As a result of this Medicaid expansion, over 770,000 adults in Illinois have gained access to Medicaid. Prior to 2014, most of these adults had little to no access to affordable comprehensive health insurance. Close to 50% of these 770,000 adults live in Cook County.

So, Medicaid cuts in the OBBBA fall into a couple of major categories that I'll focus on. First, work requirements, eligibility and cost sharing, and limiting of federal funding to states. First, when it comes to work requirements or as I like to call them, paperwork requirements, these really start in late 2026, early 2027, and this will require certain Medicaid enrollees to prove that they're working or engaged in eligible activities for at least 80 hours a month in order to get or keep their Medicaid benefits. This provision is going to apply to Medicaid expansion adults, so those 770,000 people in Illinois that I mentioned earlier, as well as parents and caregivers who have children 14 or older in their household.

The first thing for everybody to understand is that most Medicaid enrollees who can work, do work. There's little no evidence that work requirements increase employment. But what studies have shown is that work requirements actually lead to Medicaid enrollees losing coverage, not because they're not working or not because they're not eligible, but because of a failure to complete the paperwork requirement.

There's an example in Arkansas. In 2018, the state of Arkansas piloted Medicaid work requirements. And in just the first four months, 97% of the 18,000 enrollees who lost coverage were actually found to be compliant or had exemptions on record, but were disenrolled from Medicaid due to that bureaucratic red tape. And in case you're wondering, there was actually no increase to employment or hours worked among this population, and it was also really expensive to implement. Arkansas spent close to 26 million to implement the work roles. In Illinois, there's estimates that range between 270,000 to half a million Medicaid customers losing coverage as a result of work requirements. And Illinois Medicaid also estimates that they're going to need to add around 250 additional staff and invest in new technology to administer work requirements. I think we would all agree that that money would be better spent on providing direct healthcare. We know that without health coverage, individuals are going to be sicker, more likely to miss work or not hold a job, and really trapping them in the cycle of poor health and poverty.

The second area of Medicaid cuts is related to eligibility and cost sharing. So, the OBBBA imposes new requirements for ACA expansion adults to renew their coverage more frequently, so every six months instead of every 12 months. And we know from the Great Unwind when the redetermination process began again after being paused during the COVID-19 public health emergency, that a lot of people lost coverage during the redo process. But we're, again, still eligible. But because they weren't able to fulfill that paperwork requirement, we're kicked off of the program. And doubling the frequency is going to only increase the number of people who are going to experience lapses in coverage.

OBBBA also imposes new cost sharing requirements for individuals in Medicaid, up to $35 for certain services that they may need to receive with some exceptions. But we know that that out-of-pocket cost, despite how nominal that may seem, could be a real deterrent to people seeking care that they need. There are also additional restrictions that prevent documented immigrants, including refugees, asylum seekers, victims of trafficking from accessing Medicaid. And I want to note here that undocumented individuals have never been eligible for full Medicaid benefits that have been funded with federal dollars. States like Illinois have used state-only dollars to fund Medicaid and Medicaid like programs that pay for services for undocumented individuals, but those are fully funded with state dollars.

And the last thing I'll say here is that OBBBA is going to have significant impacts on state Medicaid budgets. And this is through the limiting of how states can draw down federal Medicaid dollars through provider taxes and state-directed payments, which are mechanisms that all states use except for one to draw down and maximize federal Medicaid spending in their states. States really don't have the ability to make up for the loss of these federal funds. And so, many will have to make difficult decisions about how to constrict their Medicaid budgets, either through cutting eligibility, eliminating covered services, or reducing provider reimbursements. And Illinois estimates that $52 billion in Medicaid funds will be lost over the next 10 years as a result of this change. I think that's enough for me, enough kind of depressing news for me. So, I will stop there and turn it back to you, Dr. Mikaitis.

Host: Well, thank you, Kathy. And like you said, really unprecedented and deeply concerning. Thank you for all that detail. Gillian, can you share from a managed care perspective what parts of the legislation stand out to you the most? And what are the biggest shifts that County Care is preparing for?

Gillian Feldmeth: So, maybe I'll start with just briefly describing what managed care is. Kathy did a great job of sort of Medicaid 101. But for folks who may not be familiar, managed care is a type of health insurance designed to improve health outcomes and control cost of care. In Illinois, like many other states, the Department of Healthcare and Family Services contracts with health plans often called managed care organizations or MCOs-- you'll see that acronym-- to deliver Medicaid benefits to enrollees. So, these plans are responsible for coordinating care, managing costs, maintaining provider networks, and improving health outcomes for their members. And in Illinois and many other states, the vast majority of Medicaid enrollees, especially families, children, and ACA expansion adults receive their care through managed care.

County Care is a public provider-led health plan and the largest Medicaid health plan in Cook County. We have more than 400,000 members and an expansive network of providers. This of course includes the fantastic Cook County health facilities, but other hospitals specialists, primary care providers as well. And we are one of two health plans in Illinois to achieve a four out of five stars from the National Committee for Quality Assurance and among the top 20% of health plans nationally. We're really proud of that. We're over in Harrison Square. So, feel free to visit and stop by. Hopefully, that provides a little bit of context of sort of what we do day to day.

Building on what Kathy shared, I think the top provisions that are going to affect us most align well with what Kathy shared. So, work requirements. While MCOs won't be responsible for confirming compliance or eligibility, we will have an important role in supporting our members with understanding what these requirements are and helping them to stay compliant. We are often the first point of contact for members experiencing coverage loss or confusion about coverage. So, that will be an impact to our members. And in terms of volume, as I mentioned, we have about 400,000 members, give or take. The work requirements, as Kathy described, apply to ACA expansion adults as well as parents of children age 14 plus. So for us, we have about 105,000 ACA expansion adults in our membership, and then an additional amount of parents who would meet that child age cutoff. So, a significant amount of our members would be affected by these work requirements.

The other provision that will certainly affect our day-to-day operations is the more frequent eligibility checks for Medicaid coverage for that ACA expansion adult population. So again, about 105,000 members. Our team already provides hands-on assistance to all Medicaid members, both County Care members, but as well as community members who may have a Medicaid plan with a different health plan. We support members with completing and submitting their Medicaid redetermination paperwork. We do this through multiple mechanisms, outbound call campaigns, text messages. We have a fantastic team that's in person at community events at CCH clinics at FQHCs to support members hands on. And this new requirement will essentially force us to double down on those efforts and be out there more and be in touch with folks to ensure that we can help folks retain their coverage.

The other one that I'll briefly mention that wasn't included in Kathy's overview, and I won't get too into the details, but one of the provisions that is already live enacted upon the signing of the bill is a ban of state Medicaid payments to nonprofit healthcare providers that received a certain amount of federal funds in fiscal year 2023, this is a little bit in the weeds, and offer abortion services including Planned Parenthood. So, this is a concern for Medicaid members nationwide. Importantly, federal law already prohibits the use of federal Medicaid funds for abortion care, except in very limited circumstances. This new restriction impacts reimbursement for all services provided by organizations like Planned Parenthood. Medicaid members seek care at Planned Parenthood for cancer screenings, pap smears, other types of preventive care. So, there's a 365-day ban on Medicaid being able to cover those services, which is ultimately an access and equity issue for our members who seek care from that trusted provider.

So, I think that's the gist of some of the top impacts to us, and how we're thinking about sort of projecting the operational impact to our members and to our staff.

Host: Thank you for all that detail. Again, deeply concerning. I do want to call out though that the team at County Care really was leading the charge when re-enrollment started after the public health emergency that Kathy had mentioned. Of the five MCOs in the county, County Care was leading the pack in terms of retaining and ensuring that the members were able to continue in their coverage. So, congratulations on that. That was truly a great accomplishment. So Kathy, in your opening remarks you mentioned, beyond just the healthcare impact, the bill also focuses on some social service programs that we know could also impact the health of our populations. Can you touch on some of those?

Kathy Chan: Yeah, thanks for this question. So in addition to Medicaid, the OBBBA also cuts SNAP, which some may know better as food stamps. That's the former name of the program. It cuts up by $200 billion. SNAP provides nutrition assistance to 1.8 million people here in our state of Illinois. And every dollar spent on SNAP generates a $1.50 in local economic activity by supporting grocery stores and farmers and other local producers. When it comes to how those SNAP cuts are going to affect people here in Illinois, all 1.8 million residents who currently receive SNAP, including about 650,000 children are going to see the purchasing power of their SNAP benefits decrease over time due to a change in how the federal government is going to start calculating increases to SNAP benefits. So, that will impact everybody who receives SNAP.

Additionally, there are also work requirements that are going to be mandatory for a subset of SNAP recipients. And about 450,000 individuals currently receiving SNAP are going to be at risk of losing their SNAP benefits due to these work requirements exactly for the same reasons that people on Medicaid might lose coverage due to the work requirements imposed in that program as well.

Additionally, there's going to be about 20,000 lawfully present immigrants who will no longer have access to SNAP. These are the same immigrants that are also going to no longer be eligible for Medicaid. So, these are refugees, asylum seekers, survivors of domestic violence and sex trafficking. They are all going to lose access to their food benefits as well.

Right now, presently, SNAP benefits are a hundred percent fully federally funded. So, that means that the dollars that people use to purchase groceries, those are paid for at a hundred percent through federal funds. OBBBA actually shifts the cost from the federal government to states and requires states to pay more for the administrative costs. So, these are the things like the technology programs, the caseworkers that are used to process SNAP applications. Illinois is projected to go from spending $0 on SNAP benefits to about $800 million a year in paying for SNAP benefits if we want to continue the same level of SNAP coverage that we have currently.

And then, last but not least, OBBBA also eliminates SNAP Nutrition Education, which is a program that provides families with education around making healthy food choices, pursuing healthy physical activities, stretching their food purchasing dollars, and just overall, you know, improving how they make choices for healthy foods. This is going to impact about 1800 organizations that currently rely on these funded services. And again, in light of wanting to try to improve health, this is really going against that ability to inform and empower households to make better choices. Food banks and food pantries have already said that they're not equipped to fill this gap as they've already seen increased demand due to increase in grocery costs. And of course, we know the connections to access to healthy foods and the connection that that has to health outcomes. So, we will likely be seeing that downstream for people who are unable to afford groceries or healthy foods in the healthcare space.

The last thing I wanted to note is that there are also changes included in the OBBBA to the health insurance marketplace. And this is a marketplace that was established by the Affordable Care Act that allows for individuals to purchase health insurance and also potentially receive subsidies that bring down the cost of their health insurance. There are changes that are included in the OBBBA that bar, again, legal immigrants from accessing subsidies on the marketplace and instituting other changes that make it harder to enroll or re-enroll into marketplace plans. We expect these things to result in more people either foregoing purchasing insurance or potentially choosing plans that have some out-of-pocket costs, so high deductibles, large copays, that can have detrimental effects as to how people access healthcare.

And finally, something that wasn't included that, unfortunately, we would've liked to see included was the extension of marketplace-enhanced premium tax credits. These were enhanced premium tax credits that allowed for individuals to better afford marketplace plans. These were created during the COVID Pandemic and extended through the end of 2025. They're set to expire at the end of this year. And many experts think that without these enhanced premium tax credits, again, we'll see higher rates of uninsured because people will be unable to afford private health insurance plans on the marketplace. So, you know, unfortunately, more bad news there. And we'll be doing what we can to try to mitigate some of these effects.

Host: That's truly a multipronged attack on some of the most in need in our country. It's really, really a shame. I am a little hopeful though. We have had some early conversations now across multiple sectors, led by our county leadership, bringing the business sector, the philanthropy sector, healthcare education together into conversations to see how we might approach things differently.

I think overall from more of a financial perspective what this is effectively doing beyond just leaving people without coverage and creating a sicker population and all of that for more of the personal and the healthcare level, it's pushing the finances down to state and local governments to have to figure out how to fill this gap. So, I am hopeful that with the start of these conversations, maybe we'll be able to at least fill some of what's happening right now.

Gillian, you spoke a little bit about some of the things you're doing to prepare for 2027, but I was wondering maybe if you could give a little more detail around how you're preparing to support the Medicaid members as we kind of hit some of these enactment dates.

Gillian Feldmeth: Yes, of course. We are busy with preparation and thank you for pointing out the 2027. I do want to call out an additional time. Many of these provisions are not yet in effect. So, each. Particular piece of the legislation that Kathy and I have been referencing has a different implementation timeline. For some of the more impactful things that we've talked about, like work requirements and the more frequent redetermination for the ACA expansion population, both are on a timeline of January 2027.

On that front, we're already preparing to adapt our enrollment and outreach efforts to support members. As I mentioned a little bit, as Dr. Mikaitis, as you mentioned, we have a great track record of supporting members with this type of administrative paperwork and education. So, I think we're well-positioned there. So, we're sort of looking through that and staying in close contact as we get additional implementation details. Even though the bill is quite long, we're still waiting for additional details about how the implementation will actually work and what those specific requirements will be.

On the work requirements front as well, as Kathy mentioned, while the majority of adults with Medicaid already work, we are exploring identifying opportunities to partner with community-based organizations who have expertise in this space, like workforce development agencies and those that offer training opportunities so that if there are folks who need a warm handoff or connection to those services, we have that network ready to go when those requirements are live.

We also are doubling down on our continued quality efforts. So, we want to ensure that we continue to help members to receive timely, high quality care and have a positive experience with County Care. I know these things are scary and they will introduce lots of operational challenges. But in my opinion, one of the best things that we can do now is to continue to support folks with their preventive care, addressing any gaps in their care, ensuring they have connection to trusted providers and investing in services that will improve health outcomes and equity across our membership.

This is sort of more internal-facing leveraging data wherever possible. So, applying our existing data infrastructure to model the operational impact of these policy changes. So, we talked a little bit before about, "Okay, how many members are parents of children age 14 plus. Or their child will turn 14 when the work requirements effect goes into place?" What can we be doing now in terms of outreach and making sure we're reaching the right members at the right time and getting them the right information?" We talked about this a little bit, as Kathy mentioned, you know, Medicaid is a federal state partnership. So, we work closely with the state, with the Department of Healthcare and Family Services to stay aligned on policy changes and operational guidance. We'll continue to collaborate with them. We meet with them regularly, seek clarification when needed so that we can proactively adapt our processes and support a smooth transition not only for our members, but for our provider network as well, who may be confused about how these things will impact them or impact our members.

And then, one other thing that I've been spending a lot of time on recently is internal communication and support. So, our staff from member services, the outreach team or provider relations team, they're often the first point of contact when members have questions about their coverage or when providers in our network have questions. So, we want to make sure that our staff feel informed, prepared, confident that they have the latest information. There's been a lot of information swirling. The bill went through a lot of changes before it was officially passed. There were many different versions. So, we're doing a lot of work to sort of increase internal capacity and confidence in speaking to the legislation in a way that makes sense to members and sort of meets them where they're at.

And the last one I'll mention is participation in national and regional learning collaboratives. So, this is a bill that affects every single state in the United States. We are unique, Cook County Health County care in terms of our setup and our governance. But I think there's a lot to learn and share with other organizations who may look like us or serve members similar to us. So on the County Care side, there's several different organizations that we regularly partner with. One is the Association of Community Affiliated Health Plans. So, those are health plans that kind of look like us, typically a little bit smaller, a little bit more community focused. And we are able to leverage that network to sort of share insights, peer to peer learnings, what are you hearing from your members, those sorts of things. And that helps keep a pulse on how things are being experienced in other areas of the nation and what we might be able to learn and apply or share best practice with those folks.

There's also examples of that on the more regional level. So, we do meet regularly with the other Medicaid health plans in Illinois and are able to collaborate all in service of sort of doing the best we can for our members and for Medicaid individuals in Cook County. Maybe I'll stop there, and pass it back over.

Host: No, that's great. I mean, extremely comprehensive, approach. I really like the approach of ensuring that our team knows and understands. You know, as we've kind of talked at a high level, there was still a lot of uncertainty. But in town halls, really trying to kind of start planting the seed. I also got feedback that as much clarity as could be provided was very much appreciated, because people kind of take different things away and they fill in the gaps and maybe don't quite put it all together.

So in that vein, and this is our last question, so I'll come to you both. Kathy, we'll start with you, but what should our frontline staff know about these changes and how should they be talking about all of this with people who are concerned, whether patients, community members, how should they be approaching this?

Kathy Chan: Yeah, absolutely. This is a great question. As you heard from Gillian, we know that patients are already asking questions and I've already heard from staff as well. So again, just to reiterate, the biggest and most significant cuts to Medicaid don't take effect until late 2026, early 2027. And we are in this kind of wait-and-see process because there is guidance that the federal government is going to be issuing, that states will then need to interpret and then implement. We'll obviously be working very closely with our state Medicaid agency, I think it's fair to say that we are aligned in wanting to make sure that we are doing what we can statewide and locally to mitigate the most harmful effects of OBBBA. So, we are going to want to work collaboratively together, and really build on some of the good work that has already been done that we know works when it comes to the redetermination process. While that was really responding to the once a year redetermination process, I think there's a lot of good foundation to build on, particularly with how frequent those were, the consistent communication, partnerships with community-based organizations, and really getting the message out there about how people can take action and where they can go to get assistance.

For now, I would say staff should certainly encourage patients to continue to schedule appointments, to show up for their visits, make sure that their contact information is current, both with us at the provider side, on the health system, with County Care or with an MCO if they're with a different MCO, and also with Illinois Medicaid. That information is how individuals will be contacted by the department. Once there is information to share about next steps or things that they might need to turn in for verification or how they need to renew, I also want to throw out a plug for patient stories. If you are working with individuals who currently benefit from Medicaid and perhaps are expressing some of those concerns, or think they might fall into a catagery, they're an ACA adult, they are a parent with a child who is 16 and maybe subject to work requirements, our communications team is eager to receive those stories. Those stories can be so powerful in just conveying the real life impact of what these policy changes mean. So please, please, please, if you have patients who have expressed an interest in sharing their story or who have a good story to tell, please connect with our communications team about those opportunities.

And then, last but not least, as the federal landscape is really constantly changing, the OBBBA was one piece, but there is guidance coming out. There are memos being sent out constantly from the federal government. If you have questions, please feel free to contact myself or Letty Close, who's our executive Director of Government Affairs for any questions, concerns, or if you're just getting new information for your network, just to see how, you know, has the health system heard about this, how are we we responding? We want to be a resource as Dr. Mikaitis mentioned, you know, information can be really powerful. But the absence of information, can result in people kind of filling in the gaps with maybe things that aren't a hundred percent accurate. So, we want to try to be source of truth, and a clearing house for some of that information when we can be.

Host: Thank you, Kathy. And I appreciate the plug for stories. I agree, there's such power in that and I think that's a really great way to tell about the impact of what's about to happen. Gillian, I know you covered a lot already on what you've done in internal messaging with staff. Just wanted to see if there's anything else or anything specific that you want to call out that our frontline staff should know.

Gillian Feldmeth: Yeah, I think two quick things. Essentially, echoing what Kathy said, most of the changes in the law have not yet taken effect, we are closely monitoring and available for questions or additional clarifications. And then, when it comes to our patients and our world members, coverage remains active today. We'll make sure they get clear, timely updates as the new roles roll out and the contact information, we really can't emphasize that enough in terms of keeping that accurate and up-to-date so that we can get in touch with them when we need to.

The other thing, and I didn't get his permission to share this before sharing it, but I'm going to do it anyways. Aaron Galeener, the Chief Administrative officer at County Care, shared a quote with staff, which I think really resonated with me, which is that "Storms do not stop those who are anchored in purpose." I think County Care, Cook County Health, we are uniquely positioned to weather this storm, and we will get through it. And I've just been so inspired even over the past couple of weeks since the bill has passed at how collaborative everyone has been. It's more work for everyone. These are tough conversations, but I think who better than us to sort of support our members and patients in weathering the storm.

Host: Yeah, absolutely. Thank you for that. So, thank you. You guys both provided incredible insight to a lot of detail. Really appreciate that. There's no doubt that this federal budget bill is going to have a major impact for our health system, for those we serve, for our communities. As we've shared, two of the biggest provisions in the bill are going to result in big financial losses to our health system and our ability to be reimbursed for the care that we provide.

Estimating that coverage loss due to Medicaid work requirements as we've heard is going to result in an $88 million loss estimating the coverage losses because of the twice annual redeterminations, the re-enrollment that's going to happen is going to be about another $50 million. We are going to start feeling that in 2027 as we discussed. And of course, as the number of uninsured individuals increases, we'll see an increase in our charity care spending. And for reference in 2024, CCH provided $230 million in charity care. We're on track to do the same in 2025. But with these changes happening, we're expecting that it could land somewhere closer to $280 million in charity care.

So, what have we done internally or what are we working on internally? So, there's already an existing budget gap. We started the re-enrollment. We had a state level, the loss of the state's health benefits for immigrant adults program. So already, just for this year, closing $120 million gap. We have asked all our departments to reduce expenditures by 10%. We've demobilized our new arrivals intake center and integrated those services into our existing ACHN structure. And we've frozen about 140 positions for hiring until we kind of better understand and know whether or not we'll have funding to refund those positions. We're continuing on contingency planning for revenue reductions. And right now, we're also in a sprint to shore up opportunities to optimize our operations so that we're as resilient as possible before we really get hit in the next year and a half or so.

It's everything from coding and billing to supply chain optimization, to improving our processes for getting more patients into our ORs and into our clinics. We don't know yet what 2027 will fully look like. But we need to be as prepared as possible, and your help and support is going to be essential to helping make CCH as financially and operationally effective as possible. And to ensure that we're as resilient as we can be to weather these changes, and care for those who rely on us. It's going to take all of us working together and bringing our best every day and moving in the same direction to protect our mission. So, thank you again, Kathy and Gillian, for helping us unpack those changes. And thanks to everyone for watching. We look forward to seeing you on our next episode of Pulse Check.