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Cook County Board President Todd Stroger locked eyes on the county hospital's new boss and delivered a lecture.

William Foley, who runs the county's massive public health system, had failed to tell Stroger about a plan to speed up pediatric emergency care at the flagship Stroger Hospital before it was reported on TV.

"I think that we may have to remind you that we exist, Mr. Foley," Stroger said, silencing chattering observers at a recent County Board meeting. "Sometimes I think that you think we're invisible, that we're not part of the whole picture."

Stroger agreed last year to give up direct control of the county hospital, including its 7,000 jobs and nearly $1 billion annual budget, in a political deal to get the final vote he needed to pass a controversial sales tax increase. Since then he and his allies have chafed at the newfound independence of the health board, while his critics have praised the board for taking smart initial steps toward rescuing an ailing system.

The new hospital leaders have been lauded for efforts to eliminate waste, lower costs and improve services. They also pleased reformers by giving up the longs-standing option of filling hundreds of jobs with political appointees.

Stroger and other county politicians have sought to re-exert authority in recent months. Some county commissioners tried unsuccessfully to stop a supply contract that hospital officials said would save up to $20 million a year, and Stroger personally advocated for an HIV/AIDS clinical trial that doctors rejected as too risky.

The skirmishes so far were a precursor to the big battle looming over the first health system budget drawn up entirely by the new regime. Stroger and county commissioners can change the health system budget as part of his administration's spending plan that has to be approved by the end of February.

"My concern is that the budget we have put together will be tinkered with by the people who don't have the same concerns or objectivity," said County Board Commissioner Jerry Butler, D-Chicago, the lone elected official on the 11-member board of directors that oversees day-to-day decisions, crafts long-term plans and proposes the budget.

The proposed budget would cut the system's workforce and lower its reliance on local taxes, the new health officials said. They also plan to restructure how treatment is provided at the system's three hospitals, 16 clinics, HIV/AIDS treatment facility and the medical unit at Cook County Jail.

The latest moves are bringing once reticent critics out of the woodwork.

They say the board needs to be more transparent in its operations and question whether the appointed members can be held accountable. The critics also question the board members' allegiance, noting many work for non-public health care companies including Rush University Medical Center, University of Chicago Medical Center and Mercy Hospital and Medical Center.

Critics also say they are concerned the restructuring is more focused on cost savings than maintaining services for uninsured people, which could influence the upcoming budget debate. Stroger makes no bones about his influence over that process.

"With the money should come some partnership with the (County) Board," Stroger said in an interview. "In the end, as I've told them, the face of the hospitals is the president's, and that's me, and until I leave, that's going to be me. So, if they want their operation to run, they need me to go out there and be in front and make sure that they have money."

Yet the health budget proposed by the new board could weaken Stroger's oft-repeated claim that rolling back the sales-tax increase would force deep cuts in public health services.

An independent analysis by the Civic Federation, a business-backed government budget watchdog group, concluded $46 million of $380 million in revenue from the new tax is going to the public health system.

The proposed budget would significantly boost spending while cutting the system's reliance on county taxes by $73 million -- without service cuts, said Warren Batts, chairman of the independent board. The savings are primarily due to the board securing hundreds of millions of additional federal dollars to treat the indigent, he said. The systems also is billing and collecting more patient fees and plans to finish making net job cuts of about 950 positions during 2010 to save more than $60 million a year.

"We're trying to spend no more than we need to," Batts said. "We're trying to do what's best from a medical point of view."

The Health and Hospitals System board is doing well so far, said Civic Federation President Laurence Msall, adding that "it's too early to pass judgment." Msall noted that authority over the system will automatically return to the County Board in mid-2011, barring action by commissioners or state lawmakers. The sunset provision should be removed, he said.

Few public health systems are still run by elected officials, said Larry Gage, president of the National Association of Public Hospitals and Health Systems.

"You need to make too many decisions too quickly," he said, explaining the trend. "It's as much the bureaucracy as the politics."

The merits of an independent health system are expected to be debated during the upcoming primary, in which Stroger faces multiple challengers for the Democratic nomination.

Thirty years ago, the system was at a similar crossroads with an independent board that had been in place for a decade.

But amid political sniping, control was handed back to the Cook County Board, where it remained until last year.

hdardick@tribune.com