Migrants sent to Chicago since late summer often arrive with very little — little food, few possessions, and for many, little or no access to health care for as long as they can remember despite their perilous journeys.

Dr. Denise Cunill recalled one such family of four who arrived at Cook County Health’s new clinic for asylum seekers in September with used flip-flops on their feet.

As Cunill prepared to give a routine exam and asked the kids to put on gowns, the teenager among them apologized — she hadn’t showered, she told the doctor. But she was grateful for the care. The teen couldn’t recall the last time she had seen a doctor, Cunill recalled, tearing up at the memory.

Taking care of immigrants like this family — a core mission of Cook County Health — “has enveloped my soul,” said Cunill, herself the daughter of an immigrant.

With one detail after another, Cunill lays out how the health system has tended to the rapid flow of migrants to Chicago: immunizations to ready kids new to this country for school, medication for wounds and chronic conditions that have been untreated, and even surgery.

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Cunill, a pediatrician for 25 years, said she’s long taken care of the migrant population, but not at this volume. Providers are seeing about 60 to 90 patients a day, nearing capacity for the county’s clinic.

About nine months into operating the clinic for asylum seekers, Cook County Health is bracing for a financial storm of sorts, as one headwind converges with another. All told, the health system is anticipating at least a $40 million drop in revenue this year.

There’s the cost of running the clinic for migrants and the possibility more health services will be needed as this population continues to swell. The state stopped contributing money to the clinic in February.

Add to that, Cook County Health is bracing for a deluge of low-income patients losing their public Medicaid health insurance and becoming uninsured, yet still needing treatment but with perhaps no way to pay. That’s because after a three-year pause during the pandemic, the state is back to requiring that people prove they qualify for Medicaid.

County leaders say they’re weighing all of these issues, and are awaiting word from the state about once again chipping in. But the situation remains fraught.

Cook County’s long history of providing care to those in need

Cook County Health is one of the biggest public health systems in the nation, with a legacy and a mission to treat patients whether they can pay or not.

It’s a place where immigrants have long sought care, often seeing themselves reflected in the doctors and nurses who treat them. The health system includes two hospitals — flagship John H. Stroger Jr. on the Near West Side and Provident on the South Side — and a network of clinics that ring the city and suburbs.

Cook County Health’s Northwest Side clinic is the main medical provider for the migrants, typically tending to them a day or two after they arrive in the city. So far, the clinic has treated more than 6,500 migrants. Nearly 30% have been children.

Chicago’s government is coordinating who does what and transports migrants to the county’s clinic, while other providers help screen asylum seekers who sleep on floors of police stations and inside shelters.

Some 10,000 migrants have arrived since Texas Gov. Greg Abbott started sending busloads of people to Chicago, saying overwhelmed small border towns needed relief.

And while Cook County quickly carved out space in an existing clinic to provide health care for the new arrivals, there’s the question of who pays for it going forward.

The state stopped covering the cost of typically expensive temporary nurses at the clinic. A spokeswoman for Gov. JB Pritzker did not respond to questions about how much the state contributed and why that funding ended.

The county has so far spent about $20 million on the clinic, which includes staffing, screenings and treatment on-site, as well as for patients who need more specialized care at Stroger Hospital.

Cook County Board President Toni Preckwinkle has personally lobbied state lawmakers in Springfield. Her ask: at least $28 million to cover the rest of the state’s fiscal year through June 30 and next year’s costs.

“We anticipate that there will be an influx of asylum seekers when the emergency health order ends on May 11,” Preckwinkle said during a recent media briefing, referring to the pandemic disaster declaration three years ago when COVID-19 raged across the globe.

In other words, even more asylum seekers could make their way to Chicago and need the county’s medical services.

Meanwhile, Cook County Health doesn’t know how many people may lose Medicaid coverage, but say it could translate to a roughly $40 million loss, some of which the health system hopes to absorb.

This all comes as the health system in the last five years made progress on improving its bottom line. The county had reduced by about 60% — or $345 million — the amount of medical care they provided without getting reimbursed for it, after sounding the alarm bells for years over the rise of what’s called uncompensated care. Much of the steep decline is due to COVID-19: The public was implored to steer clear of hospitals to make room for patients sick with the virus, while more people qualified for and remained on Medicaid.

Cook County Health CEO Israel Rocha Jr. and his team are heading into the 2024 budget season, and taking all this into account.

“We’re not in the position of saying we’re not going to care for people who are at our doors,” Rocha said at a recent media briefing. “We’re going to do what we have to do, but it does come with a consequence and a cost.”

How to pay for it all

Treating a wave of migrants isn’t new for Rocha. He’s run hospitals near the Texas border and in Queens in New York City, which is known as the world’s borough with residents from dozens of countries.

But as Rocha puts together a proposed 2024 budget, in an interview with WBEZ he said he’s looking at what expensive projects or hires could be delayed to compensate for the brewing financial shortfall. For example, there are plans to expand cancer treatment with pricey imaging equipment that may have to be put on hold.

The projected loss in Medicaid funding alone translates to the salaries of some 160 physicians or 400 nurses, an example of how far $40 million goes at Cook County Health, where staffing is already challenged, Rocha said. Not having enough providers could ripple down to patients, he said. The key to helping especially the county’s vulnerable population is getting them in the door.

“All the beautiful marvels of medicine is after that visit,” Rocha said. “So unfortunately, that’s really what I would say is the biggest impact. What is the amount of access that will be cut?”

There are some bright spots. The health system expects to receive nearly $7 million from the state for asylum seekers who are eligible for Illinois health insurance programs, including one for undocumented immigrants.

And while the health system’s own Medicaid health insurance program called CountyCare is expected to lose at least 80,000 members, the health system doesn’t expect the financial impact to be significant.

When asked if he would be going to the county board with a request seeking funding beyond an annual subsidy the health system typically receives, Rocha wouldn’t say. He quipped that he didn’t want to give away his budget plan just yet.

And then there’s still the $28 million ask to state lawmakers, who have blown past their own self-imposed deadline to pass a budget for the next fiscal year, in part because of disagreements about the costs of expanding a state health insurance program for immigrants. Records show many of these patients have sought care at Cook County Health. The Legislature is expected to return to the statehouse for a possible debate on the budget Wednesday.

“I remain an optimist,” Rocha said. “I hope that the story of the work we’re doing and the acknowledgement of the impact that it has for our community … would encourage people to want to support us.”

Finding joy

Back at the clinic, Cunill points out the crackers, Pedialyte, soup and oatmeal they keep on a table next to her desk. It’s for migrant children who are dehydrated.

Many children have arrived underweight and undernourished. Many mothers have not only breastfed their toddlers, but also older children to make sure they had something to eat, Cunill said. So these moms, too, are malnourished and dehydrated.

Most of the kids are otherwise healthy. But the sick are often incredibly ill, with syndromes and diseases that have never been diagnosed: seizure disorders, congenital heart issues, kidney issues.

Cunill mentions the joy she’s seen, too.

“Let’s talk about them being able to actually have other children to play with, and not necessarily [with] other children that they need to climb through trees, climb through a jungle, swim in water that they’ve never swam in before,” she said. “Kids just being kids.”

Her face brightens when she opens the door to a room that has been turned into a “boutique.” Here migrant families can pick through shelves of donated clothes, shoes, school supplies, newborn blankets and more.

Down the hall, the waiting area was packed with people who were waiting for appointments.

Paola Anez, 26, who is pregnant, spent part of the afternoon there with her 5-year-old daughter. Through a translator, she described an eight-month journey from Peru to Chicago, trekking through jungles, being deported and crossing the Rio Grande in desperation before being arrested.

Now she, her daughter and husband are staying at a refugee center after spending two weeks at a Chicago police station, sleeping on the floor.

On this day, they received medical check-ups and vaccinations.

“They did all types of tests,” Anez said through a translator. “They did everything, all types of checks on me.”

County health officials say they’re making contingency plans for whether they will have to find more clinic space for migrants if the city asks.

That could be necessary, Rocha says, if providers consistently treat more than 100 migrants a day. The clinic hasn’t reached those numbers since the first week of January, but with busing continuing from border states, the numbers are starting to climb back up.

Kristen Schorsch covers public health and Cook County for WBEZ.