The Safety Net Moonshot Initiative (SNMI) is a multi-sector effort to structurally redesign Chicago’s health-care safety net. Today, safety net hospitals and providers are under immense fiscal stress, with patient demand far exceeding capacity and resources often misaligned — many facilities spend heavily to keep hospital beds open that go unused, even as other sites are overwhelmed. The initiative proposes consolidating and modernizing the city’s safety net hospitals and clinics into a coordinated network centered on Federally Qualified Health Centers (FQHCs), supported by three new or redeveloped hospitals, a network of ambulatory and specialty care sites, a shared digital backbone, and a reengineered Medicaid payment system. It aims to replace decades of piecemeal bailouts with a sustainable, high-performing model of care.
Chicago’s safety net is collapsing under its own weight. Nine hospitals alone are projected to lose $2.46 billion between 2025–2030, even after state and federal subsidies. Most facilities are over 75 years old, operating under a Medicaid reimbursement structure that pays far below the cost of care. The result is a system that is both economically unsustainable and deeply inequitable, contributing to a 15-year life expectancy gap between affluent and underserved neighborhoods.
Third Horizon, under the leadership of David Smith, is coordinating the initiative in partnership with Schreiber Philanthropy, and an engaged Advisory Group including policy, finance, and health-system experts with deep experience across Medicaid reform, safety-net operations, managed care, and public-private partnership design. Contributors include leaders from Academic Medical Centers, Managed Care Organizations, Community Health Centers, and philanthropy. Collectively, this team has decades of experience designing large-scale health transformation projects across the country.
Unlike previous initiatives focused on single hospitals or grant-funded pilots, the SNMI unites every key sector, including providers, payers, philanthropy, business, and the state under one shared plan. It blends capital formation, governance reform, and payment redesign, treating the safety net as civic infrastructure rather than a series of disconnected institutions.
Philanthropy has long supported community health through grants and pilot projects, but the results rarely endure because the underlying system remains broken. The SNMI represents a rare opportunity to leverage philanthropic resources toward systems engineering with a primary goal of redesigning and capitalizing an entirely new structure that can sustain itself. Funders like Schreiber Philanthropy see this as an inflection point to drive generational change rather than short-term relief.
The SNMI will be implemented through a phased, multi-year strategy led by Chicago Med, a newly created coordinating entity that will oversee capital deployment, operations, and governance across the city’s safety net. Implementation will occur in stages:
Chicago Med will consolidate and modernize the city’s safety net through three new or redeveloped hospitals, a network of 13 multi-service ambulatory centers, and strengthened FQHCs operating as Community Care Hubs. A diverse governing board – representing health systems, community organizations, experts, and consumers – will ensure transparency, equity, and accountability throughout implementation.
Long-term sustainability will be achieved through a diversified funding model and a reengineered Medicaid payment system that rewards outcomes, equity, and efficiency rather than volume. If the State of Illinois implements key reforms – specifically closing the open-access structure and indexing Medicaid payments to at least the Consumer Price Index – the economics of the system become sustainable.
There is sufficient funding within the current structure; inefficiency, not insufficiency, is the primary barrier. This mirrors successful large-scale transformations in states like North Carolina (Medicaid AHEAD Model) and California (CalAIM) – demonstrating that the underlying policy and financing tools already exist.
The SNMI brings these elements together coherently to transform Chicago’s safety net into a durable, high-performing, and equitable system that delivers better care for patients and stability for providers.
The SNMI’s financial sustainability is anchored in a diversified $1.8 billion capital structure combining private, public, and philanthropic investment, supported by dedicated reserves to buffer against economic or political fluctuations. The initiative will be financed through contributions from:
Philanthropy’s role is catalytic and in service of de-risking early design and governance phases to attract larger institutional investment.
Preliminary capital expenditure modeling outlines the following high-level allocations:
These estimates are intentionally conservative and will be refined as project planning advances and cost efficiencies are realized through shared infrastructure and partnership synergies.
Based on an economic review of which stakeholders derive the strongest financial benefit, anticipated capital contributions are expected to come from the following groups:
Academic Medical Centers have the most to lose economically if the safety net fails, and the most to gain if it works more efficiently. Ideally, Academic Medical Centers, Managed Care Organizations, and non-safety net health entities would contribute approximately $1.5 billion in capital, with the State of Illinois, philanthropic funders, and the corporate community bridging the remaining gap.
The SNMI is designed to complement –not duplicate –ongoing and planned investments across Chicago’s safety net. Advocate Health has been an active partner in shaping the initiative, and discussions are underway to determine how its South Side investments can be integrated into the SNMI framework. Similar collaboration opportunities may exist with Northwestern Memorial’s new Bronzeville Ambulatory center.
While St. Anthony has not yet been formally engaged, the SNMI model is intentionally structured with “on ramps” and “off ramps” to allow new partners to participate over time. The initiative views Chicago’s broader ecosystem of hospitals, Federally Qualified Health Centers (FQHCs), and community-base providers as part of an interconnected “utility” for care delivery – one that emphasizes coordination, avoids duplication, and strengthens the overall capacity of the safety net through shared infrastructure and referral pathways.
The SNMI is exploring multiple avenues for mission-aligned capital. Community Development Financial Institutions (CDFIs) and foundations offering mission-related investments could play an important role in bridging capital gaps or providing operational liquidity during the initiative’s early years. Their flexible, community-focused financing aligns well with SNMI’s goals and could complement public and philanthropic funding sources.
At the same time, the initiative’s financing strategy is intentionally designed to remain as simple and self-sustaining as possible. The preferred model prioritizes investments from stakeholders with a long-term economic interest in the stability of Chicago’s safety net – such as health systems and managed care organizations – over loans or instruments that require repayment. However, as engagement with potential funders evolves, mission-related investments, and other impact-oriented capital structures may be revisited as valuable tools to strengthen the initiative’s financial foundation.
Through formal affiliation agreements, shared technology platforms, and coordinated referral management. Chicago Med will serve as the central hub for data, capital, and performance management ensuring unity of effort across the network.
While Chicago’s Federally Qualified Health Center (FQHC) network is strong, many centers face space, infrastructure, or governance limits that make large-scale expansion difficult. The SNMI proposes the development of new multi-service ambulatory care hubs to fill critical service gaps – particularly in urgent care, imaging and diagnostics, birthing, mental health, and specialty services – that extend beyond the traditional scope or capacity of most FQHCs.
This approach is designed to complement, not compete with, existing FQHCs. Expanding certain high-intensity services within FQHCs could create operational strain, administrative burden, and redundancy across organizations. Instead, the initiative envisions FQHCs continuing to deliver high-quality primary care and community-specific services – such as HIV/AIDS support, transgender health, and pediatric care – while new ambulatory facilities handle more complex or resource-intensive needs.
Establishing new sites also serves a broader purpose: it demonstrates visible reinvestment in neighborhoods that have long faced systemic disinvestment. While building 11 new hospitals is neither feasible nor necessary, creating accessible, community-centered ambulatory infrastructure sends a strong signal of commitment to equitable care and long-term stability for Chicago’s safety net.
The SNMI is intentionally structured to align incentives across the safety net and promote shared accountability. Under the proposed model, hospitals gain greater value by participating in a coordinated system that emphasizes care efficiency rather than volume. Federally Qualified Health Centers (FQHCs) “compete” by empaneling patients and serving as centralized Community Care Hubs, ensuring that each patient has an established medical home.
When patients are connected to FQHCs for proactive and preventive care, hospitals face less pressure to deliver uncompensated or avoidable emergency services. This structure shifts incentives toward strong primary care management and coordinated care delivery, ultimately benefiting patients, providers, and the financial stability of the entire safety net.
Chicago Med will be a neutral, non-profit operating entity charged with holding capital, deploying funds, managing shared assets and liabilities, and ensuring system accountability. Its board will include representatives from the community, patient advocates, capital contributors, subject-matter experts, and safety net providers. It will function like a civic utility: transparent, equity-driven, and accountable to public outcomes.
Performance contracts and transparency. Every participating provider will sign agreements with clear benchmarks for quality, access, and cost. Results will be published in an annual public dashboard.
Key outcomes include:
SNMI includes a unified population-health data platform, AI-assisted documentation, and a mobile-first patient portal to connect patients, providers, and payers in real time. This infrastructure enables shared performance tracking and reduces administrative waste.
Each Community Care Hub will have a local advisory council composed of patients, community leaders, and Federally Qualified Health Center (FQHC) representatives. Chicago Med’s board will reserve at least three seats for community and consumer voices to ensure decisions reflect lived experience.
Workforce continuity is a core guiding principle. The plan includes retraining, redeployment, and retention strategies to protect institutional knowledge and ensure that local health workers remain embedded in their communities.
The SNMI does not have the authority or intent to close hospitals. Its goal is to preserve access to care, including incentivizing and streamlining primary and preventative care, while rationalizing infrastructure. Some aging hospitals may be replaced by new facilities; others may be repurposed as ambulatory centers or specialized service hubs. The objective is not fewer points of access, but instead better, modernized access aligned to actual community need and utilization patterns. Existing hospital management teams and boards will have the onus of weighing their hospital’s financial position and fiduciary obligations to determine if participating in this effort is in the best strategic interest of the institution and the interests of the communities they serve.
Participation is completely voluntary, but also economically rational. Institutions that decline may struggle to remain viable under new payment structures mandated by One Big Beautiful Bill Act (OBBBA). SNMI’s design ensures that cooperation is a viable path toward future viability. Organizations seeking to “go it alone” will have SNMI’s full support as a referral and operating partner, should they choose.
By joining the coalition of partners advancing the next phase. The initiative is currently widening its circle to include additional provider, philanthropic, corporate, and civic participants interested in contributing capital, expertise, or advocacy to advance the plan.
The Illinois Department of Healthcare and Family Services (HFS) has expressed openness to systemwide transformation and acknowledges the structural weaknesses outlined in the paper that the SNMI team published in May of 2025. While the state has not yet become a formal sponsor, many SNMI components – such as payment reform, medical home attribution, and the consolidation of directed payments – are consistent with existing state and federal mandates, including the One Big Beautiful Bill Act (OBBBA) and the Centers for Medicare & Medicaid Services’ 2027 integration requirements.
SNMI’s policy priorities include:
Only two elements of the plan would require legislative action: (1) any capital contribution from the State, and (2) a constitutional amendment to advance medical malpractice reform through voter referendum. Neither represents an existential barrier to SNMI’s success, but both are important for long-term stability.
The timing of the One Big Beautiful Bill Act (OBBBA) reinforces the need for comprehensive safety net reform. The law requires that all state-directed Medicaid payments be integrated into actuarially sound capitation rates by July 2027 – effectively ending Illinois’ reliance on fragmented hospital subsidies. SNMI’s design directly supports this transition by consolidating payments, aligning incentives, and replacing piecemeal bailouts with a unified, outcomes-based system.
At the federal level, SNMI aligns with Centers for Medicare & Medicaid Services and the U.S. Department of Health and Human Services priorities around value-based care, interoperability, and health equity. The initiative mirrors the Medicaid AHEAD Model in North Carolina and California’s CalAIM, demonstrating that the policy and financing tools already exist—SNMI simply brings them together coherently.
The SNMI is designed to avoid abrupt hospital closures by creating structured, transparent pathways for distressed institutions to transition into the new system. The approach emphasizes collaboration, workforce redeployment, and modernization rather than shutdowns. Its guiding principle is “transformation, not abandonment.
SNMI’s communication strategy is grounded in truth and transition – emphasizing civic investment and continuity of care. Workforce retraining and community engagement are prioritized to mitigate backlash and build trust. The initiative has maintained ongoing dialogue with the Governor’s Office, which has expressed general support, and is expanding outreach to key legislative stakeholders to build a coalition around reform.
SNMI’s diversified capital structure – blending private, public, philanthropic) investment – and its dedicated reserves provide insulation from political cycles. The model is designed to sustain itself under multiple fiscal scenarios.
The SNMI team is actively assessing the timing and relative impact of policy levers for this project. Priority areas include Medicaid payment reform, network rationalization, and regulatory modernization. A detailed sequencing plan is in development and will be shared as this work progresses.
Chicago Safety Net Moonshot Initiative
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