Caring for Undocumented Immigrants With Kidney Disease

Abstract

The care of dialysis-dependent undocumented immigrants exemplifies a problem at the crux of 2 US national agendas: immigration and health care reform. Undocumented immigrants represent 3% of the US population and 27% of the uninsured, and an estimated 6,500 individuals are dialysis dependent. With no uniform national policy, an estimated 30% to 50% of these individuals receive treatment only in life-threatening situations (emergent dialysis). Since 2005, about 400 undocumented immigrants have received a kidney transplant (>70% living). Although the Affordable Care Act specifically excluded noncitizens, its policies have indirectly allowed more than 200 individuals to purchase insurance from a health insurance exchange and transition from emergent to thrice-weekly hemodialysis. Under the Trump administration, uncertainties with health care plans, threats of deportation, and rescinding of policies such as sanctuary city status are bound to result in unforeseen challenges for this vulnerable population. Global variation in the care accessible to migrants, refugees, undocumented immigrants, and asylum seekers argues for the need for a framework to transform advocacy into public policy to improve the lives of patients with kidney disease worldwide. Access to nonemergent dialysis is humane and cost-effective; it deserves to be espoused and advocated by leading medical organizations.

Strategies for Responding to Undocumented Immigrants With Kidney Disease

“…27 Few immigrants have been able to get coverage for regularly scheduled dialysis under unsubsidized commercial plans, but the sustainability of this option is unknown and still leaves many without coverage. 3 Although emergency dialysis is covered by law, 29 regularly scheduled dialysis is still not the standard of care for most undocumented immigrants in the United States. 30 Research has shown the potential benefits to both patients and the country of regularly scheduled dialysis, so continued advocacy for undocumented patients with ESRD is needed to make sure they get the proper care they deserve.…”

Is Organ Retransplantation Among Undocumented Immigrants in the United States Just?

“…3 In the United States, current policy-the Omnibus Budget Reconciliation Act of 1985 and the Personal Responsibility and Work Opportunity Reconciliation Act (PWORA) of 1996excludes undocumented immigrants from federally financed public benefits including Medicare, Medicaid, the Children's Health Insurance Program, and Affordable Care Act (ACA) insurance subsidies and exchanges. [4][5][6][7][8][9] Enacted in 1986, the Omnibus Budget Reconciliation Act prohibited the use of federal funds for undocumented immigrants except in emergency situations, 8 as dictated by the simultaneous enactment of the Emergency Medical Treatment and Active Labor Act (EMTALA). Under EMTALA, all states must provide federally funded emergency medical treatment, including emergent-only hemodialysis, which would be needed for the care of failed kidney transplants.…”

“…Under EMTALA, all states must provide federally funded emergency medical treatment, including emergent-only hemodialysis, which would be needed for the care of failed kidney transplants. 4,6,10 In addition, 11 states and the District of Columbia currently use state funding sources to provide undocumented immigrants with maintenance dialysis. 11 Notably, kidney transplantation is not considered an emergency treatment for end-stage renal disease (ESRD) and thus, under this legislation, is not eligible to be federally subsidized for undocumented immigrants.…”

“…Thus, under current legislation, only transplant recipients with permanent legal status have opportunities to receive federal funding for long-term maintenance of their transplanted organ in most states. [4][5][6]8 Transplant patients, unlike other surgical patients, have a lifetime of health care costs associated with their transplant. In 2017, the total cost of a kidney transplant and a single year of necessary immunosuppressive medications was estimated to be over $400 000.…”

Transplantation and Undocumented Immigrants: A Tale of Two States

“…Undocumented immigrants comprise 3% of the U.S. population, with the majority residing in California, Florida, Illinois, New Jersey, New York and Texas . They also represent 27% of all people living in this country without the benefit of health insurance . Currently, in all 50 states, undocumented immigrants who have kidney failure must receive dialysis as an emergency treatment in emergency departments .…”