* 6/18/26 - Crains - Cook County faces $550M budget shortfall, the largest gap under Preckwinkle....
Buzz Sawyer
Cook County is staring down a $550 million budget gap for 2027, the biggest deficit projection in County Board President Toni Preckwinkle’s tenure due in large part to inflation and an anticipated healthcare crisis induced by the federal One Big Beautiful Bill Act.
The county’s preliminary total budget gap is made up of an anticipated $336 million shortfall in its general fund and a $214.7 million shortfall in the county health enterprise fund.
Preckwinkle said at a preliminary press briefing the process for 2027 “is going to be a really tough budget year, but we begin it from a position of strength.”
She pointed to budgets that over the last 15 years have been balanced, strengthened the county’s reserves and improved bond rating.
While preliminary budgeting numbers are released in June most years, county leaders often present a gap that is narrowed by the time county staff finalize a budget to present to the Cook County Board in October. The current budget year’s projected gap in June 2025 was $211 million.
However, economic conditions in 2026 and 2027 will cause uncertainty and increase costs, said Budget Director Kanako Ishida Musselwhite.
Rising inflation due to the Iran war and surging commodity prices, along with overall tariff pressure, are driving up prices and costs, she said. At the same time, Musselwhite said, real gross domestic product, which impacts county revenues, is projected to slow in 2027 after rising in 2026.
The general fund is under significant pressure from restrictions on the use of transportation-related taxes, contributing to a structural budget deficit of $258 million, plus payroll expenses growing by $108.9 million and accelerating pension contribution levels of $36.7 million.
The cost of healthcare also looms large even in the general fund budget, as some of the most significant expense increases the county expects come from higher healthcare benefits cost and employees choosing the more expensive preferred provider health plan option for their care, Musselwhite said.
The gap could have been larger if not for a $130.5 million revenue bump compared to budget expectations, primarily from larger sales tax receipts.
Cook County Health’s shortfall
The county’s health enterprise fund preliminary gap is driven by the threat of thousands of county residents losing Medicaid eligibility beginning in 2027.
The One Big Beautiful Bill Act’s mandated Medicaid work requirements and twice-yearly redetermination will drive an expected drop in CountyCare revenues of $250.6 million.
Net patient service revenues from patient fees for the county Medicaid plan are expected to decline by $164.8 million as Medicaid coverage is reduced and self-pay rises. Fewer Medicaid-covered patients and more uninsured patients inevitably means higher costs for uncompensated care for the county’s main safety-net health system.
Additionally, federally directed payments to the county health plan are projected to decline by $74.8 million due to the OBBBA, the budget briefing said. Payroll expenses and employee health benefits costs are also expected to grow by $66.8 million.
To close the health care budget, Cook County Health will look at decreasing reliance on overtime, increasing overall productivity and finding more money in non-labor contracts through better revenue cycle management, said Scott Spencer, acting Cook County Health CFO.
The system can be more productive by maintaining access to care and creating capacity in the health system where there is demand and making sure patients who see Cook County Health for primary care stay within the county system for specialty care like cardiology, surgery and radiology, CCH spokeswoman Alexandra Normington said.
Cook County’s options
As officials work through the budgeting process over the summer, the county also has about $1.4 billion in reserves to tap into.
However, much of that money is specifically earmarked to fund risks to certain programs, said Deputy CFO Dean Constantinou, and the county does not want to use reserves to make up budget shortfalls, as that just “kicks the can” into another budget year.
After releasing the preliminary budget figures today, the county will spend the next few months looking at cutting expenses and increasing revenues. A town hall budget meeting in the Cook County Boardroom is scheduled for public input on July 9. The executive budget will then be presented to the elected board in the second week in October.
When looking at revenue, Preckwinkle said “belt tightening” comes first and tax increases are the last resort.