CountyCare, which receives a monthly lump sum from the state for every covered member, brought in revenue of more than $650 million in 2014. Cook County Health was able to decrease its uncompensated care from more than $500 million to about $340 million, Shannon said. His system ended the year with a $14.1 million surplus, counting tax revenue, a first for the system. That makes it an outlier among safety net hospitals, which often lose money.
So far, CountyCare has enrolled more than 183,000 members, making it one of the largest Medicaid plans in the Chicago area, where 15 plans compete. Last year, about 68% of Cook County Health's patients had health insurance, up from 46% in 2013, before Illinois' Medicaid expansion under the Affordable Care Act. Most of Cook County Health's insured patients are on Medicaid, which pays relatively low rates. But that's better than no payment at all.
As more Americans gain Medicaid coverage, investing in a health plan is a potential lifeline for urban safety net systems. Having a health plan helps them better coordinate care. But safety net systems like Cook County still have to figure out how to compete effectively with other, often better-resourced insurers, and how to retain their newly insured patients, who for the first time, have other care options. On top of that, Cook County and other systems still have to overcome funding shortfalls, tough political budget battles, and socio-economic and racial inequities.
“Safety net providers that own health plans may be the best positioned to shift their focus to population health,” said
Dr. Katherine Neuhausen, an assistant professor at Virginia Commonwealth University. However, she said, those systems must have large financial reserves, and “recruit enough members to support investments in innovative case management and care-coordination programs and health information technology.”
Cook County Health, known simply as County to most Chicagoans, has been a fixture in the city since before the Civil War. Stroger Hospital was built 13 years ago, after a long political fight to replace the old Cook County Hospital, a giant, ornate Beaux Arts building that opened in 1914, and now stands vacant behind the new hospital.
County has long meant life or death for hundreds of thousands of lower-income Chicagoans, and it has had to survive on a shoestring budget. Now the system is a victim of Illinois' months long budget standoff between Republican Gov. Bruce Rauner and Democratic legislative leaders. In July, a federal judge ordered the Rauner administration to keep paying Medicaid providers in Cook County despite the impasse.
Given these challenging conditions through the years, County “was the most wonderful and most difficult place to work,” said Dr. Peter Orris, a former County occupational-medicine physician who's now at the University of Illinois at Chicago. It has required idealistic providers to think of new ways to reach out and help their patients.
The system's doctor-patient bonds have always been strong. Dr. Gordon Schiff, a County physician who led clinical-quality initiatives and now oversees patient-safety research at Brigham and Women's Hospital in Boston, remembers tussling with a health insurer for two hours to pay for a patient's prescription. He ultimately gave the patient $30 to fill the order—a move that got him reprimanded for “unprofessional” behavior but brought him national support.
Dr. David Ansell, an internal medicine physician who worked at County for 17 years and is now at nearby Rush University Medical Center, recalls seeing an older black female patient whose blood pressure was sky high. Ansell asked her if she was feeling stressed. Tears welled up in her eyes before she told him her two grandchildren were recently shot and killed on her front porch. It was a brutal reminder that social and environmental conditions have a direct impact on individuals' health.
“Witnessing this degree of suffering is not that easy to do,” said Ansell, who wrote a book about his experiences at County.
Economic disparities and racial discrimination came to the fore at Cook County Health during the wave of patient dumping that occurred in the 1980s. Many of Chicago's private hospitals redirected their uninsured patients to County. As many as 700 patients a month were sent to County because “they failed their wallet biopsy,” Schiff said.
That discrimination hit hard in Chicago's black community, whose members have viewed County as the safest and most reliable place for healthcare. “If you were a black patient in Chicago, you came to County even if you had the resources to go elsewhere,” Orris said.
Last year, Shannon was named CEO of Cook County Health and has been part of the system for a large chunk of his career. He worked as a general internist at the old hospital and later was a clinical educator. “I originally landed with the very green notion that, in my specialty, I was going to fix the world's problems,” he said. But after witnessing “the sea of humanity” County treated on a daily basis, he realized he couldn't do it alone.
After a stint at Parkland Memorial Hospital in Dallas, Shannon returned to County in 2012. His predecessor as CEO, Dr. Ram Raju, helped secure the federal Medicaid waiver that created CountyCare. With Illinois expanding Medicaid under the ACA to adults with incomes up to 138% of the federal poverty level, County saw an opportunity to become a provider of choice rather than the provider of last resort, as well as the chance to reduce its burden of uncompensated care.