CHICAGO — From their offices in a crumbling former nursing school, Aimee Dinschel and Michelle Pihlaja-Olson were preparing to interview 25 applicants for public health jobs. It should have been a moment of optimism for their hospital system, which only recently began to turn a profit after more than a century of bleeding money, and which was expanding its services to the poorest residents of Cook County. Instead, the women were worried.
The health care bill moving through the Senate, and particularly its rollback of Medicaid, would threaten millions of dollars of funding for the county hospital system here. It could end mental health and behavioral services for low-income patients. And it has cast a pall of uncertainty over hospital staff: Dinschel and Pihlaja-Olson could not be sure that the jobs they were hiring for would still exist in a few years.
They weren’t sure their own positions would exist, either.
“What if we don’t have jobs in a year?” said Dinschel, a mother of two who is the main income earner in her family. It’s a question she’s considered several times since the election. “It’s hard to find a job, and this is a good position.”
Dinschel and Pihlaja-Olson, who manage health care for Medicaid enrollees, are among 300 workers and contractors for the Cook County health system whose jobs rely on the Affordable Care Act’s Medicaid expansion. The morning we spoke, Republican senators had unveiled the Better Care Reconciliation Act, which would cut federal funding to cover Medicaid expansion for low-income Americans who qualified for the program for the first time under Obamacare.
The Congressional Budget Office estimates 22 million fewer Americans would have insurance under that plan. But health coverage isn’t the only thing at stake. The Senate bill could slash hundreds of thousands of jobs and stunt growth in an industry that has boosted post-recession job creation.
It’s unclear exactly how many jobs are on the line. But public health experts at George Washington University estimate that 912,000 health care workers in the United States could lose their jobs if Congress rolls back the Medicaid expansion and removes tax credits to help people buy private insurance. (The BCRA phases out Medicaid expansion and caps, but does not eliminate, tax credits).
Illinois is one of 31 states that chose to expand Medicaid coverage with federal dollars from Obamacare. It received $3.2 billion in federal funding to do so in fiscal year 2015. If the Senate bill passes, it could be one of the states with the highest number of job losses, according to the analysis.
The law would also strain public budgets. Fewer people with insurance means more people show up at the emergency room who can’t afford their care. As patients worry about the possibility of losing their insurance in a post-Obamacare world, public hospitals have another worry too: that they’ll return to the bad old days of financial instability, costs that are eventually passed along to taxpayers.
Mary Sajdak, who oversees about 60 care coordinators who work with Medicaid enrollees in Cook County, choked up when she described the calls she gets from patients who are frightened about losing their health care.
“When you see what years and years of untreated chronic disease does to a person, then you give them a chance, and give them a prescription card, it makes their poverty less isolating,” she said, wiping away tears. “To give that to people and then take it away, it makes me profoundly sad.”
Cook County hospitals had climbed out of the red
Cook County’s public hospitals have treated Chicago’s poorest residents for more than 100 years. The vast system includes John Stroger Jr. Hospital in West Chicago, the inspiration for the TV show ER, which has one of the busiest emergency rooms in the country.
For most of the hospital’s history, the majority of the patients it served had no health insurance at all. When they needed to see a doctor, they went to the emergency room. Under federal law, hospitals cannot turn away someone in a medical emergency, even if they don’t have health insurance and cannot pay. Cook County hospitals charge uninsured patients based on their income — anywhere from zero to 50 percent of their total medical bill. Local taxpayers end up subsidizing the rest.
In 2009, right before passage of the Affordable Care Act, about 53 percent of the system’s patients were uninsured, costing county taxpayers more than $500 million. After the ACA expanded Medicaid coverage in 2014, providing health insurance to hundreds of thousands more people, the county hospital system broke even for the first time. About two-thirds of the hospital system’s patients now have health insurance, mostly because of the Medicaid expansion, says Dr. Jay Shannon, CEO of the Cook County Health and Hospitals System.
Shannon said the influx of nearly $200 million in Medicaid revenue has helped the hospital hire extra staff, such as psychologists and behavioral health specialists who work with patients to identify — and change — behaviors that are hurting their health, such as smoking, drug use, or unhealthy eating. That includes dozens of social workers, such as Dinschel and Pihlaja-Olson, who have helped Medicaid enrollees navigate the health care system and use preventive care services.
“The changes have been very, very striking for us,” said Shannon, whose office is not far from the construction site of a nine-story medical facility, which will replace the county’s dilapidated community clinic and administrative offices.
But Shannon may soon have to make some difficult choices. He is closely watching what Republicans in Congress are doing to replace Obamacare, and has serious concerns that both the House and Senate want to eliminate the Medicaid expansion. If that happens, he will have to cut back somewhere.
“I have to keep the lights in the hospital on; I have to keep the surgeon on call,” he said. “I may have to pull back on care coordination and mental health support. We would have to put off overdue investments in capital. These are the kinds of tough decisions we have to make.”
Cook County commissioners are panicking as well. They don’t have the money to subsidize uninsured patients if they are kicked off Medicaid. Larry Suffredin, a county commissioner for 15 years, said rolling back the Medicaid expansion could cost the county up to $400 million a year. Right now, he said, the savings from Medicaid have been funneled into the county courts, jails, and sheriff’s office. Suffredin said the commission will not raise taxes, but doesn’t know how else to keep people on Medicaid if Congress takes away the federal money.
If the time comes, Suffredin hopes the state will step in and help. But the chance of that happening doesn’t look good. The state of Illinois is in the midst of one of the worst financial crises in its history, and is struggling to balance its budget. Suffredin said it’s frustrating to see lawmakers in Washington, DC, be so irresponsible with their politics.
“You can’t just put the genie back in the bottle,” he said. “This is not a simple accounting exercise. Every decision they are making has an impact on people’s health and public safety.”
Jobs on the line
Dinschel and Pihlaja-Olson both chose careers as social workers because they wanted to do something meaningful with their lives. Dinschel, a native of Chicago, was passionate about social justice issues in college and realized that she could make a career working with people whom others often overlooked. She got a master’s degree in social work, got married, had two daughters, and worked for years helping homeless residents find food and housing.
Soon, many of her colleagues began getting jobs in the field of health care coordination — a field that began growing after Illinois expanded Medicaid with money from the Affordable Care Act. In 2016, Dinschel got a job in the industry too. She started working as a care coordinator for high-risk Medicaid patients in Cook County. The job paid better, she said, and had great benefits. And it wasn’t so different from what she did before. Instead of helping homeless people find food and housing, she was helping low-income Americans get medical care and live healthier lives.
“When I am doing something to help others, it’s more than just a job,” said Dinschel, sipping a tangerine LaCroix after several back-to-back meetings with her staff. She now manages a staff of 10 care coordinators.
Pihlaja-Olson has a similar story. She used to work with victims of domestic violence before she was recruited by Cook County around the same time that Dinschel switched jobs. She said it’s important that her three sons learn to have empathy for people, and she hopes she is setting an example for them.
As a care coordinator, Pihlaja-Olson screened Medicaid enrollees for potential chronic diseases, such as diabetes, asthma, or even cancer. Many of them had never had health insurance before, so they needed to unlearn the habit of using the emergency room for medical care.
“We basically had to teach some people how to use health care. How to make an appointment, how to use their insurance cards,” said Pihlaja-Olson, who had just come back from the county jail, where she was starting a pilot program to get inmates drug addiction treatment. She also supervises a staff of 10 social workers, nurses, and community health workers.
After Trump won the election, some employees started asking Pihlaja-Olson if they would lose their jobs. She didn’t know what to say. “I just said, ‘You’re okay for now,’ and tried to calm people’s fears.”
She doesn’t even know what will happen to her job.
“I think I could find another job,” said Pihlaja-Olson, who, like Dinschel, is her family’s main income earner. “But I worry a lot about the staff that I supervise and whether they will have jobs.”
Dinschel, who was seated next to her in a conference room, nodded. It used to worry her a lot more, she said, but now she just feels weary about the news surrounding the Affordable Care Act.
Down the hall, their boss seemed weary too. “The inconsistency we’ve been living with is hard,” said Sajdak, who oversees care management for the health and hospital system. “How do you plan for something like this?”
She said she would do everything possible to prove to hospital executives that health care coordinators are invaluable. After all, she said, they develop plans with each Medicaid enrollee to make sure they get regular care and see their doctors, which ends up saving hospitals more money in the long run. “If we can show that we can reduce hospitalization rates, then we might be able to survive. Hope is not really a plan,” she said at her office next to Stroger Hospital.
In the past few months, Sajdak has had to reassure her employees that she is committed to keeping them on staff. But she acknowledges that even her job isn’t safe.
“I was hoping to finish my career seeing [the Affordable Care Act] bloom and grow,” she said. “I don’t know if I will.”