In addition to board appointment, Preckwinkle proposes that the next CEO would be appointed on the "advice and consent of the County Board" and with collaboration from officials downtown. That future CEO's "salary, termination, term, severance and any contract bonus provisions" would also be subject to review and approval from the board.

The county health board's independence has always been limited; the Cook County Board ultimately approves the health system's budget. Preckwinkle makes all of the health board's appointments, with approval from county commissioners. Her administration negotiates nearly all labor agreements with the hospital's unions and guides purchasing decisions. But board members said the changes would make the board even less independent. In the long run, under a different board president or set of county commissioners, that lack of independence might compromise the system's mission to provide care to all, regardless of ability to pay, board members suggested.

While Preckwinkle "cares about public health and providing care to those who don't have access," a future president might not, Reiter said. The "way we're structured now is what good government looks like."

"I don't see this as a particular sign of bad faith, but I'm very struck by the discrepancy between" County Board concerns with finances and communication and "their approach to solve it," health board member Michael Koetting said, expressing bafflement at some of the proposal's components and adding that cooperation through legislation "never works."

Another health board member, Sidney Thomas, said he had great concerns about moving more human resource operations to the county board. The health system exited federal oversight to eliminate political influence in its hiring practices—known as Shakman decree—in 2018. Thomas said he didn't want to "go back to the way things used to be."

Koetting agreed. "The further HR management gets from the transaction that is the core of the business, the more goofed up it gets."

Hill Hammock, the board's chairman, said the proposed ordinance does nothing to address the elephant in the room: the rising cost of charity care.

"The county is going to, I believe, need to increase its subsidy of us, and it is not realistic to think that by more efficient operation of this system, we are going to become self-sustaining," Hammock said. "I've never had that opinion. We're going to continue and need to have more dependence on the county and more financial dependence on the county. I don't think any of the steps here have anything to say about it, other than we're going to talk more."

Cook County Health & Hospital System has an operating budget of about $2.8 billion and expects to spend roughly $590 million on charity care for fiscal 2020. The health system makes up about half of Cook County's $6.2 billion 2020 budget.