The hundreds of thousands of Oregonians who signed up for Medicaid under the Affordable Care Act last year, are younger and healthier than expected -- according to a new study out of the state.

The age and health of new Oregon Health Plan enrollees is important, because on average a population is more expensive to care for if it's older and sicker.

But Lori Coyner with the Oregon Health Authority says the 380,000 Oregonians who were added to Medicaid last year, tended to be young and healthy.

"The biggest jump has been in the age 19 to 35 and then 35 to people in their 50s," said Coyner. "They do not have, it appears, a lot of what's called 'pent-up demand,' meaning that they are very sick and they haven't seen a doctor."

Other parts of the report show Oregon's Coordinated Care Organizations continue to see a decrease in ER visits and fewer hospital re-admissions. That has helped the bottom line, keeping the average cost of care below what it was 2011.

This January, the Oregon Health Plan starts covering the cost of reassignment surgery for transgender people.  It also helps cover the cost of hormone therapy and puberty suppression.

Some politicians question the use of tax payer money, but people in the transgender community call it ground breaking.

When Alexis Paige was born 26 years ago, as far as doctors and family were concerned, she was a boy. But by 11, she began to grow breasts and wanted to be a girl, making school very difficult.

"It kind of culminated in an instance in which I was actually pressed against a wall by someone who groped my breast to see if they were real and wanted to check if I was actually a male or female," she said.

By 16 her hips began to spread. She says she always felt different -- as if she wasn't in the right body -- and it drove her to try suicide.

"I was riding my bicycle when I noticed a car coming, just in that moment, I decided I'd purposely ride out in front of it and I was hoping that it would kill me," she said.

By last year, Paige went through therapy and saw a doctor who prescribed estrogen.

"Suddenly for the first time I had energy, I wasn't feeling sad all the time," she said.  "I actually stopped getting sick. I stopped feeling sore. This was who I was supposed to be."

At that time, Paige had a job and insurance to cover medical expenses. But then she lost that job and was terrified she'd have to end the therapy.

She says knowing that the Oregon Health Plan will now cover her hormones if she losses her job again, is invaluable.

"I know there will be some people who will question that and question whether that's right or it's wrong," she said.

"There's people who argue back and forth about whether it's innate to be trans or it's psychological. And the thing is, so what? I mean, you don't look at someone with cancer and go, 'Oh your cancer wasn't caused by a genetic reason, it was environmental, so we're not going to treat you.'"

Oregon joins California, Massachusetts, Washington D.C. and Vermont as jurisdictions where Medicaid covers medical treatments for gender dysphoria.

By looking at medical billing data, the state estimates at least 175 people will use the new coverage this year.

But there are those who question its validity and expense.

"To a large degree I think the jury is still out on these procedures and whether or not they're legitimate," said Roseburg Republican, state Senator Jeff Kruse. 

He's on the Legislature's Senate Committee on Health Care and Human Services. He says the gender reassignment medical procedures are "elective" and "dubious at best."

Oregon's Health Evidence Review Commission decided to look into coverage for gender dysphoria last year -- after a psychiatrist pointed out that the state had lumped it with conditions like pedophilia.

"People with gender dysphoria that did not receive treatment had a much higher rate of hospitalizations or ER visits or doctor visits for depression and anxiety," said commission director, Dr. Ariel Smits.

"And they had a pretty significantly high suicide attempt rate -- some studies found about 30 percent.  But folks when they received the treatment that they felt was adequate for their gender dysphoria, had an almost normal rate of depression and anxiety compared to the general population."

Their suicide rate also dropped significantly.

But what about the cost?

"It may cost somewhere in the $100,000 to $200,000 range although these numbers are very vague," said Smits. 

"There's also the possibility that it'll be less, or even cost savings, because hopefully these folks will no longer be going to the ER or being hospitalized for their severe depression or suicide attempts."

While the coverage begins this month, Basic Rights Oregon says it may take the state a while to line up services.

The Ebola outbreak has exposed gaps in the nation’s ability to deal with severe infectious diseases, according to a new report from the Robert Wood Johnson Foundation.

Rich Hamburg of Trust for America's Health says Oregon only managed to meet five of the study's 10 key indicators: "Over the last decade we saw dramatic improvements in state and local capacities to respond to outbreaks and emergencies," he said.

"But," he continued, "this year Ebola has been what you'd call a wake-up call - a reminder that an infectious disease threat anywhere is a threat everywhere. It raised attention to serious gaps in our ability to manage disease outbreaks."

Oregon met the study's health funding indicator, but failed for a low vaccination rate, substandard food safety checks, and inadequate health security preparedness.

Half of all states met five or fewer of the key indicators.

Maryland, Massachusetts, Tennessee, Vermont and Virginia tied for the top score – with eight indicators.

Arkansas met two.

Nearly 15 years ago, Oregon had the highest rate of hunger in the nation. Today, the percentage of people facing hunger is nearly as high as it was in 2000. In OPB’s series Hunger In Oregon, Oregonians shared their experience getting food on the table. Here are excerpts from those stories.

 I went from $650 in benefits to just over $200. My income increased slightly as I am no longer a full-time student. I have to be extremely mindful now. We are eating less meat (this is good), more beans. I find we are eating less produce. I bought a bread maker and am no longer purchasing store bought bread.

— Tori Geter, Corvallis

 I'm poor, and they do give you a little status when shopping in a nice store like Fred Meyer — you can still "feel" like a middle-class person, even if you're very far from being middle class!

— Peter White, Chiloquin

My husband passed in January and then in July I was laid off. I almost went into foreclosure and if it wasn't for SNAP I probably would have starved. I didn't get much but it kept me in peanut butter and bread long enough to pull myself out of poverty.

— Darlene Wheeler, Coos Bay

I am a food stamps eligibility worker. The most distress comes from higher education students who have to meet extra eligibility rules in order to (qualify for) SNAP. They are the hidden population that is not being discussed in regular coverage on hunger. Our students go hungry every summer.

— Vesna Stone, Corvallis

We shop at Winco in Longview. Sometimes we are forced to buy things at local, more expensive stores. We started going to food banks to make it through the month. We have seen no "recovery". It is not right to cut [food stamps] and to let the 1 percent go without paying taxes.

— Eldon Rollins, Coquille

[I shop at] Fred Meyer Hawthorne once a week. It's not convenient. I don't have a car, so I need a ride to get there. [Benefits are] gone by the end of the second week in the month. I use my monthly income from SSI after I run out.

— Victoria Deeks, West Linn

My family has a lot of food allergies, so it's very important that we obtain the right ingredients for making meals. We eat less and now scrounge or ask people for money to try to have enough food for the month. Sometimes we just go without.

— Michael Davis, Portland

The SNAP program supplements my disability income. I already eat a very spartan diet -- as healthy as I can, but as cheaply as possible. My "big" splurge on meat comes in the form of cheap hot dogs, otherwise, my protein is supplied by eggs, dairy and beans.

— George Dennison, Lake Oswego

Our little market is very convenient for our local people. I’m here almost every day. Tonight I’m cooking fry burgers. I’m not working right now because of health reasons. It would be nice to get more [SNAP benefits]. But beggars can’t be choosers, you know?

— Jasmine Caldera, Warm Springs

I have a number of friends and colleagues with college age kids who are signing up for food stamps because they qualify as low income, yet are already surviving on student loans alone to get through school. Food stamps should keep you from starving - you are not starving when you receive plenty of student loan money to live on.

— Nicole Pucci, Oregon City

I received [SNAP benefits} the 9th of every month. I buy rice, beans, oil and oil first. In the middle of the month I’ll buy vegetables or fruit. In the last week of the month we go back and buy more. Sometimes when we don’t have any more food stamps we go to the food bank. Last week we went to the store and we spent $200! It would be really hard to feed our family without it.

— Gabriela Diaz, Madras

Living on minimum wage is in no way sufficient to meet the needs of families. Even single people without children can find it impossible. It's hard to determine which things are the most difficult to afford, because it's such a question of priority and necessity. What's more is that those things can change in a moment. Without food stamps and other assistance it can be a real hardship.

— Kristina Brewington, Albany

[SNAP is] a lifeline for people in this area. Nothing else matters if you can’t feed your family. It just seems like that’s such a tenuous existence. It’s a line of defense every week, every month. I do wish you could use it for things like personal hygiene products that are just as critical.

— Deb Goosev, Gilchrist

I spent my entire childhood on food stamps (grew up with a single, disabled mother in Rockwood, OR). Obviously, I owe a great debt to the SNAP program, but at the same time I feel there are some flaws in the system. My personal milk-crate is that, like any type of assistance, anywhere, provision is at best a (very) short solution without education. Things like SNAP, and food boxes, etc., are certainly important, but they are not nearly as effective without education on how to best use them: planning, shopping, and preparing healthy foods that don’t come in a box or bag.

— Perry Perkins