Cook County is predicting a $211.4 million budget shortfall for 2026, a relatively modest gap that officials said was more of an estimate than usual thanks to extraordinary uncertainty coming out of Washington.
County Board President Toni Preckwinkle, who has been able to boast budgets free of taxes, fees or layoffs for the last several years, told reporters at a Tuesday briefing that the 2026 projection is the most “problematic,” and cautioned that “this is our best guess.”
The county is expecting a general fund shortfall of $102.6 million, thanks mostly to higher wages and fringe benefits when its current contracts with union employees expire. Its health fund, meanwhile, is projecting a $108.8 million deficit thanks to a significant drop in patient revenues.
Among the biggest long-term potential threats: how Congress ultimately decides the fate of Medicaid, which has helped prop up the finances of Cook County Health; and various federal grants President Donald Trump targeted with an avalanche of executive orders.
The budget proposal that passed the U.S. House — but not yet the full Senate — cuts Medicaid by at least $625 billion over the next decade. As it stands, most of the biggest impacts would not hit until the county’s 2027 budget, but health leaders say they are planning their response now.
New proposed work requirements and more frequent checks to determine whether people qualify for Medicaid would begin at the very end of 2026, and cost an estimated $88 million in patient fees, according to county estimates. The beginning of a provision meant to curtail the Medicaid program helping immigrant seniors would start in October 2027, according to the county. Ending that Health Benefits for Immigrant Seniors program would mean a $50 million drop in patient fee revenue for the county.
The state is already sunsetting its health care program for immigrant adults, which is expected to cost the county $5.5 million in net patient service revenues through the end of this year.
Cuts to covered health care typically means the CCH, a safety-net hospital, ends up providing tens of millions of dollars of uncompensated care to people without insurance at its emergency rooms and clinics.
CCH plans to enroll patients previously covered by the state’s immigrant adult program in its CareLink program, which covers 100% of primary and specialty care, hospital care and imaging costs for the next year, a spokeswoman said.
Even without federal concerns, the county is expecting other costs to rise, since several union contracts expire in November, opening up bargaining countywide. During the last round of bargaining, the county granted retroactive 3.5% pay increases dating back to 2021 and a 5% raise in 2025. And a pending lawsuit from road builders over the county’s spending of “lockbox” money on public safety offices could affect the bottom line of the general fund.
Last year, the projected shortfall mostly took care of itself by the time fall budget season rolled around. Revenues were higher than expected, closing most of the $218 million projected gap.
The county is expecting some cushion. Its main general fund is projected to end this year with a $145 million surplus, thanks to a dip in payroll costs and better-than-expected sales tax revenues thanks to a closed loophole involving online sales.
Preckwinkle’s finance team policy is not to use that money to plug the next year’s gap, but officials said they might use the money to keep paying for programs and positions at risk of being cut if federal grants end.
As federal pandemic aid dollars dwindle, Preckwinkle’s team has also narrowed its list of programs it might extend after 2026, the county’s deadline for spending its total $1 billion allocation.
It would cost about $100 million a year to keep 19 programs — ranging from lead pipe removal and brownfield remediation to violence prevention and medical debt relief — going. The county has set aside $166 million in a “reserve” fund to help pay for those, meaning officials must either cut down on its offerings or find another $255 million to keep them running.
Preckwinkle will make her budget proposal on Oct. 9, with a final vote scheduled for Nov. 20.
