Multnomah County officials are warning that Oregon’s handling of Medicaid long-term care is helping push some of the county’s most vulnerable residents into homelessness. In a December letter, county commissioners say state policies are blocking staff from enrolling certain people with severe and persistent mental illness in programs that provide in-home personal care and case management, services they argue are critical to keeping people stably housed. Instead, commissioners say many end up cycling through jails, hospitals and the state hospital, a pattern they describe as both discriminatory and financially shortsighted.
County letter calls state policy discriminatory
In the December DocumentCloud letter to Gov. Tina Kotek and state agency leaders, the Multnomah County Board of Commissioners argues that bureaucratic rules are blocking access to Medicaid long-term care programs. County leaders say the state’s enrollment process treats people differently based on the “type or nature of disability,” language the board believes conflicts with federal guidance. Commissioners urged state officials to change the policy or, at minimum, create a joint workgroup to fix the enrollment logjam.
State enrollment rules leave many without needed care
According to the county, staff are able to process Community First Choice applications for seniors and people with physical disabilities. When the primary diagnosis is a severe and persistent mental illness, however, those same applications are routinely returned as ineligible, leaving local caseworkers with no clear route to secure personal-care supports. County officials say those delays often mean people go without help managing medications, bathing and other daily tasks that make independent housing realistic. “It's life-changing,” said Dave Boyer of Disability Rights Oregon about targeted Medicaid case management, as reported by Oregon Capital Chronicle.
Numbers show the strain on supportive housing
The county’s letter states that nearly half of the people using shelters in Portland have a diagnosis of severe and persistent mental illness. It also reports that about 9% of people with that diagnosis who do receive housing through the regional Supportive Housing Services measure later lose it because their needs exceed what SHS funding can cover. Multnomah County’s Supportive Housing Services annual report says the county moved 1,085 people into permanent supportive housing in fiscal 2025, which commissioners call a major success that still falls short of demand. They estimate that roughly 220 people lose housing when their needs outstrip the level of services available.
Contractor delays and a state pledge to act
The board also calls out Comagine Health, the contractor that helps manage eligibility and enrollment, saying response times can stretch for months and leave people waiting for supports that might keep them in housing. Comagine disputes that picture and told Oregon Capital Chronicle it has piloted electronic submissions and typically processes referrals while patients are already getting care. In a joint letter dated Feb. 25, the Oregon Department of Human Services and the Oregon Health Authority acknowledged systemic gaps and pledged to work with the county to clarify roles and speed up enrollments.
What commissioners want next
County leaders say the first step is procedural, not dramatic. They are calling for a shared workgroup, clearer division of responsibilities among the county, state and contractors, and quicker pathways into Medicaid long-term care for people with complex behavioral health needs. Multnomah County has also warned that recent state and federal funding cuts have tightened the safety net and forced hard budget choices that could reduce shelter capacity and rental assistance, according to a county news release. Commissioners argue that lining up homeless services with behavioral health care, and cutting through enrollment red tape, would help more people stay housed and reduce the high price of repeated crisis care over the long term.
