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Published in the City Club of Portland Bulletin, Vol. 97, No. 10, January 6, 2015

In 2014, homelessness remains a complex public health challenge in Multnomah County. Individuals and families experiencing homelessness are disproportionately vulnerable to dangers such as communicable diseases and the deleterious effects of the urban environment. They suffer from complications of chronic illnesses and face difficulties with basic health management. For too many individuals, the relentless struggle for safety and stability overshadows health needs – common illnesses are allowed to progress and minor injuries fester until they become emergencies. Challenges in caring for those experiencing homelessness reveal deep fault lines in our current health care system.

Providing quality health care to individuals experiencing homelessness has been a perennial challenge, even in a community with model homeless health service programs. In 2013, more than half of those counted as homeless in Multnomah County reported having one or more disabling health conditions. Many studies have found evidence of premature mortality among homeless persons; the average lifespan of a person experiencing homelessness in the United States is 30 years less than that of a person who is housed. The prevalence of complicated, co-occurring medical, psychiatric, and substance use conditions pose particular challenges to serving significant subsets of the homeless population.

The expansion of Medicaid in 2014, as part of the Affordable Care Act, presents an opportunity to shift much of this narrative. In January 2014, the Affordable Care Act expanded Medicaid eligibility to those with incomes at 138% percent of the federal poverty level, including nearly all homeless adults without dependents and those not currently eligible for Medicare. As a result, more than a quarter of all residents in Multnomah County – including nearly all individuals experiencing homelessness – are now eligible for Oregon Health Plan coverage. Under the charge of Governor John Kitzhaber, Medicaid expansion, managed by sixteen coordinated care organizations (CCOs) statewide, has united previously unaffiliated hospitals, physicians, dental and mental health agencies under one contract. CCOs emphasize preventative and holistic health services for all persons eligible for Medicaid, with the hope of creating a more unified and economical health care delivery model.

Recognizing that Medicaid expansion has the potential to create radical change for individuals experiencing homelessness in Multnomah County, the City Club of Portland charged an all-volunteer research study to answer an important question: How can the maximum health benefit for the homeless population of Multnomah County be achieved from health care reform and expansion of the Oregon Health Plan?

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