Despite the “catastrophic blow” dealt by COVID-19, Cook County Board President Toni Preckwinkle had some good news for Cook County residents whose lives have drastically changed during a pandemic: no new taxes or tax hikes from the county government.

At least for next year.

That’s if commissioners on the Cook County Board like the Democratic president’s pitch. On Thursday, she unveiled her proposed budget for 2021. The ritual comes after months of negotiating with elected and appointed county leaders who run the government’s public jail, courts, health system and more — against the backdrop of COVID-19.

“In the midst of a historic pandemic, this proposed budget will have no tax increase, no cuts to critical services and will be balanced while increasing – increasing – our investments in equity,” Preckwinkle said during a virtual budget address.

“We refused to balance this budget on the backs of the residents and the businesses who need resources the most, especially during a pandemic,” she said.

Still, Preckwinkle’s proposed $6.9 billion budget largely avoids massive cuts in services, and includes only small fee increases, which total fewer than $2 million. The financial plan, like in previous years, continues to focus on making Cook County a more equitable place to live and work by investing in initiatives that Preckwinkle said especially help the most vulnerable residents.

Meanwhile, a financially frightening projection – that the county’s health system would have to provide around $590 million in medical care this year without getting paid for it – turned out not to be as dire.

Preckwinkle’s priorities include investing in small businesses hit hard by the coronavirus, housing for people when they leave the county jail system and partnering with regional public transit agencies to make rides cheaper.

She also wants to address health care disparities that were made worse during the pandemic by expanding access to medical care at Cook County’s public health system, Cook County Health. The system is one of the largest public health systems in the nation. It includes John H. Stroger Jr. Hospital on the Near West Side, Provident Hospital on the South Side, a group of clinics and a Medicaid insurance plan with some 375,000 enrollees who are low-income or disabled.

Stroger provides by far more free care to people who are uninsured or can’t afford to pay their bills than any other hospital in the region. It’s a mission-driven service, but that makes it especially hard for the health system, and therefore the county, to keep up financially.

A budget dependent on health care

The proposed nearly $7 billion budget is about $700 million more than the 2020 financial blueprint. County leaders say that’s largely because the health system’s Medicaid insurance plan, called CountyCare, is expected to grow as more people lose their jobs or take pay cuts during COVID-19.

CountyCare is a significant piece of the budget, accounting for nearly a third of it next year. The health plan is expected to generate about $2.2 billion. It’s projected to insure about 378,000 people in November, then decrease to just over 350,000 members by this time next year.

The health system is working to woo more CountyCare members to see doctors within Cook County Health, said Andrea Gibson, interim chief business officer at the health system. That helps keep money within the health system, but it’s been a long-time struggle. The CountyCare network is vast. Members can choose from dozens of hospitals in the Chicago area, some 20,000 specialists and 4,500 primary care physicians for preventative visits.

Having more insured patients also helps offset how much Cook County spends to treat people who don’t have insurance, or people who have private insurance yet don’t pay their bills. Former Cook County CEO Dr. Jay Shannon estimated in 2019 that these two buckets would cost the county nearly $600 million this year.

But because of the pandemic, the amount is forecasted to be closer to $418 million in 2020, and $487 million next year.

“There’s a lot that happened in 2020 that no one projected,” Gibson said.

Since mid-March, Cook County Health has seen fewer patients overall, including people with or without insurance, Gibson said. When the pandemic picked up, hospitals in Illinois canceled elective surgeries and switched from in-person to video visits with patients. The idea was to make space for a crush of COVID-19 patients.

WBEZ documented how people in Cook County delayed medical care, potentially contributing to the coronavirus death toll. Doctors say patients are starting to come back.

Investing in the county’s public health department and its hospitals and clinics is a key initiative for Preckwinkle. Her 2021 goals include implementing a $40 million grant to track down people who may have come into contact with someone who has COVID-19 to help curb the spread of the virus. This is known as contact tracing.

But some of her other proposals have come under fire from unionized nurses at Cook County Health who are concerned about what they see as less access to patients during a pandemic. Mercy Hospital in Bronzeville, another so-called safety net hospital for low-income people of color, is about three miles north of Provident. After years of losing money and patients, Mercy plans to close next year.

Under Preckwinkle’s budget plan, she intends to close the South Shore Clinic and Woodlawn Clinics and funnel patients who use those facilities to Provident, a move she said was not about cost-cutting but rather about trying to “improve services for the community.”

“Every single patient at those clinics will be able to keep their same doctor, access the same services they receive now – just at a new location many already travel to: Provident Hospital,” she said.

Preckwinkle also wants to staff Provident to reflect how often patients actually use it. It’s now staffed for 17 hospitalized patients a day, but on average typically has around 12. Provident’s emergency department would be downgraded to a stand-by unit, with people who aren’t as sick sent to walk-in clinics on campus.

Additionally, Preckwinkle’s proposed budget would nearly eliminate pediatric care at Stroger Hospital. The county says there are typically only two kids a day. But Stroger will keep open pediatric intensive care units, as well as trauma and burn care for kids. The health system’s budget presentation shows a handful of nearby hospitals with room to treat the youngest patients.

The proposed changes drew criticism from National Nurses United, which represents nurses in the county health-care system.

“Now is the time to care for the suffering people of Cook County,” said Martese Chism, a registered nurse and a longtime case manager at Cook County Health. “Cutting health care services is an immoral and unconscionable position to take during a global pandemic and while so many are unemployed and uninsured. Cutting services during this time amounts to a death sentence for Black and Brown communities.”

A federal rescue

When COVID-19 hit, devastating governments around the nation, Cook County leaders braced for a budget deficit that they projected would swell to an estimated $409 million. Sales tax, for example, is a huge way the county makes money. That’s people dining at restaurants. Buying tickets to concerts. Going to the movies. Those largely ground to a halt as the pandemic took off here in March.

Pandemic-related funding from the federal government was a lifeline to help close that gap, Rizki said. The county also plans to save money by leaving 659 jobs vacant, and the health system is laying off around 130 people, though county leaders say there will likely be fewer layoffs as people resign or retire. Altogether, the county plans to have nearly 22,000 employees next year, nearly 2,200 fewer people than a decade ago.

Here’s another financial lifeline: The county tapped about $76 million of its $400 million in reserves. And the county will for the first time be able to generate money from new taxes from online sales. Along with marijuana and sports betting, these buckets are projected to bring in $1.1 billion over the next five years.

But, long-term, the outlook for Cook County’s finances is bleak. The county projects the deficit to hit about $377 million by 2025, mostly fueled by losses at the health system.

In the immediate, there remain lots of unknowns, like how many businesses will survive this winter. More closures could translate to less sales tax for the county. Or if Illinois Gov. JB Pritzker calls for more restrictions if there’s a surge in coronavirus cases.

“Our hope is that by summer of next year, the recovery goes back into Phase 5,” Rizki said. “Now we can go safely back into stadiums. Concerts and things like that could go back into play … But it could go really badly from there, or it could go better than that” depending on if a COVID-19 vaccine becomes available.

The county is expected to host a series of public hearings in the coming weeks about the proposed budget. Then, County Board commissioners are expected to vote on the proposal in late November. The new budget would begin on Dec. 1.

Preckwinkle concluded her speech with a stark warning: Even though she was able to deliver a relatively pain-free spending blueprint, county government is “not out of the woods yet,” particularly if the pandemic doesn’t ease next year.

“I will not mince words here. This pandemic has dealt Cook County and its residents a catastrophic blow,” she said. “And let me be abundantly clear, while we’re in this spot because of good wise and tough decisions made over the last decade, Cook County cannot – cannot – absorb another financial calamity in 2021.”

Kristen Schorsch covers public health on WBEZ’s government and politics team, and Dave McKinney covers state politics. Follow them @kschorsch and @davemckinney.