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From NPR News, this is ALL THINGS CONSIDERED. I'm Audie Cornish.

Nine million people are expected to gain health coverage under Medicaid. That's after it expands in more than two dozen states to cover all poor adults, not just those with disabilities or children under 18. The expansion will also include the nation's homeless, many of whom can now access regular health care for the first time.

In Los Angeles, some estimate as many as 54,000 people live on the city's streets and health workers there are trying to spread the word. Reporter Sarah Varney begins this hour on Skid Row.

SARAH VARNEY, BYLINE: If you were led blindfolded from Los Angeles' grand city hall a few blocks east, you would know when you entered Skid Row. There's the pungent smell of urine and burning marijuana smoke and the sound of music and easy laughter, a carnival rising out of misery.

This is the chaos that Chris Mack plunges into most days. Once homeless himself, Chris is an outreach worker for a local community clinic and he walks the streets to find men and women whose troubled lives might be better with routine medical care.

CHRIS MACK: (Unintelligible) right?

MARTHA CASTRO: (Unintelligible)

MACK: What have you been up to? You all right?

CASTRO: Yeah.

MACK: So you do come to my clinic, don't you?

CASTRO: No, I don't.

MACK: You haven't been here?

CASTRO: No. I...

VARNEY: Chris greets a woman perched on an upside-down plastic bucket with a Burberry scarf covering her head. Her eyes are clouded with drink or drugs, her cheeks smeared with ash. Her name is Martha Castro. Martha tells Chris she has slept on the streets for four years and has been to the doctor just once for a lung infection.

MACK: Do you realize that you can have health insurance?

CASTRO: No. I don't want to apply for nothing else right now.

MACK: You don't?

CASTRO: Yeah. I need to see my son. I need to be in touch with my son.

MACK: OK.

CASTRO: Yeah.

MACK: Where's your son?

VARNEY: Martha is adamant that at 64 years old, she's healthy enough. And anyway, she says, she doesn't have any ID or money.

CASTRO: So then how we going to have insurance for (unintelligible) clinic?

VARNEY: I tell her the insurance, Medicaid, is free to her and she doesn't need ID. But that doesn't matter to Martha, who is high or drunk and perhaps touched by mental illness. That's it, she says, signaling that the conversation is over. About 80 percent of homeless people are mentally ill or addicted to drugs or alcohol, say federal health officials. That makes Chris' job of enrolling them in a complicated public health insurance program all the more difficult.

MACK: Sometimes on the streets, you know people are, you know, following their habit, you know, whether it be smoking or drinking or shooting up. That's part of the ugly reality.

VARNEY: And yet, reaching out is vitally important. Those who work with the homeless say while housing is paramount, regular medical care is a critical intervention for getting lives back on track.

MACK: A person who is not feeling very well can't behave or perform very well. So I think health care is primary.

VARNEY: Under Medicaid, homeless adults can have steady doctor's visits to keep prescriptions filled for asthma, diabetes and schizophrenia, and get referrals to private specialists for lingering ailments. But Chris says he can't force anyone, even someone like Martha, who he suspects has chronic asthma, to sign up.

MACK: You see what I did? All I did was left the door open - Martha, if you need help, you can come to us. That's it.

VARNEY: In a city crowded with chauffeured black SUVs and upscale hotels, L.A.'s homeless are a reminder of life's cruel turns. In the lobby at Chris Mack's bustling community clinic on Skid Row, I met George Farag. He's an Egyptian immigrant and former security guard whose own cruel turn came when he fell asleep one night on the job.

GEORGE FARAG: I work in security before. I sleep on the job. Kick me out.

VARNEY: George shows me his shirt embroidered with his old company's logo.

FARAG: After me lost the job, I lost everything. I sleep on the street two years.

VARNEY: You sleep on the streets for two years?

FARAG: Two years.

VARNEY: One of those nights, George says someone ran over him, a hit-and-run that crushed his right leg. He's come to this clinic before for the occasional prescription, but today, he's signing up for Medicaid, known as MediCal in California. Clinic worker Alberto Moreno helps him.

ALBERTO MORENO: This is the final step before your transition into MediCal.

UNIDENTIFIED MAN: Yeah.

MORENO: You're going to get you Healthnet health card, and you'll be assigned here to the clinic.

VARNEY: Alberto hands George a copy of his new forms and George stuffs them into a worn-out plastic bag.

MORENO: And you're all done.

VARNEY: George says through the glass enrollment window, God bless you. From now on, the clinic will coordinate his medical needs and perhaps do something about the makeshift brace on his leg. Dr. Dennis Bleakley has been treating Skid Row patients at the clinic for more than a decade. He says uninsured homeless adults like George had little access to specialists. Fractured bones, bulging hernias, diseased hearts all went untended.

DR. DENNIS BLEAKLEY: Now, at least, you know, you have a reasonable length of time, access to specialists. It's going to, you know, open up a whole new world for us.

VARNEY: Even with new services available to them, the homeless will remain some of the toughest, most confounding patients. Disorder and addiction easily sabotage the best-laid efforts. And those who work with the homeless acknowledge few make it out. That sober reality doesn't stop Chris Mack, the outreach worker, who is back out on the street.

MACK: Do you have medical insurance?

VARNEY: He's like a rescue diver, plunging into a roiling ocean to bring those who've fallen over back to safety. For NPR News, I'm Sarah Varney.

CORNISH: Sara comes to us through a partnership with Kaiser Health News, a nonprofit news service.

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