Rapid Response, a biohazard clean-up crew, sweeps up people’s belongings during the forced removal an encampment of unhoused people as Portland police put an arrested unhoused woman in their squad car in the central eastside of Portland, Ore., on Jan. 28, 2026.
Eli Imadali / OPB
Multnomah County commissioners urged state officials late last year to change what they characterized as a discriminatory policy that’s contributing to people with “severe persistent mental illness” falling into homelessness.
In a December letter to Gov. Tina Kotek and the directors of Oregon’s health and social services agencies, all five members of the county’s board of commissioners said bureaucratic barriers were keeping people with serious mental illness from enrolling in Medicaid long-term care programs that could keep them housed.
County officials called it a “moral failure and fiscally wasteful.:
The letter, obtained via a public records request, points to a situation facing a group of vulnerable people caught at the intersection of the Portland area’s worsening homelessness problem and the state’s fractured mental health system.
Instead of long-term care, these individuals are often stuck in a costly cycle of homelessness that involves interactions with police and short-term treatment before returning to the streets, commissioners wrote.
Treatment at the Oregon State Hospital, the county jail and hospitalization are all more costly options than Medicaid long-term care, according to the letter.
“I think it is an issue of a system that is so intensely focused on crisis and does not invest in preventative services, earlier services, or for those individuals who need long-term (care),” said Commissioner Meghan Moyer, who spearheaded the letter and said she is seeking a “marriage between our homeless services system and behavioral health system.”
In a joint statement to the Capital Chronicle, the Oregon Department of Human Services and the Oregon Health Authority indicated that they are working together to “address these systemic gaps and ensure that individuals with complex needs” can access Medicaid’s long-term care services.
The agencies also provided a joint Feb. 25 letter from Liesl Wendt and Sejal Hathi, the leaders of the respective agencies, to the Multnomah County Board of Commissioners acknowledging the barriers while committing to work with the county.
Dave Boyer, managing attorney for advocacy group Disability Rights Oregon, said the Medicaid programs could provide targeted case management to people with serious mental illness.
“It’s life-changing,” he said. “You’re talking about all of those services that folks need to be housed.”
Some needs surpass supportive housing
Nearly half of the people accessing shelters in Portland have a “severe persistent mental illness” diagnosis, according to the commissioners’ letter, obtained through a public records request.
The county has seen some success in moving this population out of homelessness using the Supportive Housing Services, a regional voter-approved measure that provides funding for counties to prevent and reduce homelessness.
During the 2025 fiscal year, the county moved 1,085 formerly homeless people into permanent supportive housing, which includes rental assistance and social services.
Approximately 9% of people with a severe persistent mental illness diagnosis who receive housing through the measure end up losing it “because their needs exceed what SHS funding can provide,” commissioners wrote in the letter. That pencils out to about 220 people.
A small percentage of people who have gone long periods without adequate treatment for severe mental illness need more personal care services that can include help with bathing and medication management, said Moyer, who previously worked as Disability Rights Oregon’s public policy director.
While these individuals are eligible for Medicaid long-term care programs that would fund additional services and case management to keep them housed, the state is preventing their “legitimate enrollment,” commissioners wrote in the letter.
State blocks enrollment in long-term care for some
How the state handles an application for one Medicaid long-term care program depends on who is seeking care, according to the letter.
County staff can process applications for seniors and people with disabilities for Medicaid’s Community First Choice Option, a program that provides in-home services to help them live independently.
But the letter states that if county staff try to process an application for someone with a primary diagnosis of severe persistent mental illness, the state Department of Human Services returns it with a note that the person does not qualify.
“The State of Oregon is discriminating based on ‘type or nature of disability,’ violating federal guidance and the Affordable Care Act Community First Choice Option,” commissioners wrote in the letter.
Neither the state Department of Human Services nor the health authority responded to questions about whether this amounted to discrimination.
The letter from agency heads to the Multnomah County Board of Commissioners outlines efforts underway to expand the availability of caregivers and streamline enrollment.
The agency leaders also suggested forming a workgroup to develop a shared process to enroll people with severe persistent mental illness in Medicaid long-term care programs.
That workgroup, they wrote, would clarify the responsibilities of the county, state, and contractors to “reduce duplication and delays.”
Contractor responds late, county says
Medicaid’s Home and Community-Based Services also provides support for people with mental illness.
However, the commissioners wrote in their letter that Comagine Health, the company the state contracted to oversee enrollment into the program, can take months to respond to applications, “leaving individuals without services that would help them stay housed.”
Comagine, a national consulting company, previously came under scrutiny after a state audit in 2023 found it mismanaged behavioral health care for Oregon Medicaid patients.
In a statement, Comagine disputed the claim that it’s unresponsive. Patients are usually already receiving services when they are referred to the program, and the eligibility process occurs alongside care, according to the statement. Comagine also launched a pilot project to allow providers to submit applications electronically, the company said.
“They are the ones that you think about when you think about serious mental illness,” Boyer said. This includes bipolar disorder, major depression, and schizophrenia, which he said often require a higher level of care.
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