The current global and US economic and financial crises, in concert with the election of a president and Congress that recognize the urgent need for addressing longstanding deficiencies in the US healthcare sector, have placed reform of the US healthcare system at the forefront of public policy debate and federal legislation. There are an estimated 46 million people in the United States without health insurance coverage, and many millions more are underinsured. The absence of adequate insurance or alternate financing for healthcare services is one of the most fundamental barriers to individuals getting the preventive services and acute/chronic care they need. Failure to address these barriers leads to unnecessary acute and chronic illness, avoidable deaths, absence of wellness, and further strain on personal, local, state, and federal budgets.
The Institute of Medicine has reported that foreign-born residents of the United States are 3 times more likely to be uninsured than native-born residents.1 Among US foreign-born residents, noncitizens are twice as likely to lack insurance as citizens.2 In 2006, an estimated 11 million immigrants in the United States were without insurance, which amounted to 26.6% of the US uninsured population for that year.2 Over the past 10 to 15 years, immigrants have been thought to contribute disproportionately to the growing number of uninsured in the US, with researchers estimating that 33% to 85% of the growth in the ranks of the uninsured is attributable to the US immigrant population.3 The accuracy of the latter percentage estimate is disputed, but the US documented immigrant population is nonetheless a significant factor in the growth of the US uninsured population. In addition to lack of healthcare insurance, immigrants often face additional barriers of low income or poverty, as well as language and cultural barriers.
In this issue of the American Journal of Kidney Diseases, Hurley et al report on a survey of US nephrologists' practices in caring for undocumented ESRD patients.4 This is one of the most complicated problems, for which there is an inadequate database. For those in the United States who develop end-stage renal disease (ESRD), availability of insurance to allow access to renal replacement therapies, including renal transplantation, does exist. Employer-sponsored and individual commercial health insurance products often cover at least some acute and long-term ESRD care, as well as transplantation. For those US residents eligible for Medicare, dialysis and transplantation services are covered, although not without a 3-month eligibility waiting period after initiation of dialysis (unless they are already Medicare beneficiaries). Nonetheless, the cost of basic Medicare premiums, deductibles, copayments, supplemental insurance payments (including prescription drugs), and out-of-pocket expenses can be significant in total. For those US residents eligible for Medicaid, some of these gaps in coverage, due to low income or lack of other assets, are supplemented. Overall, ESRD remains the sole disease-specific healthcare entitlement in the United States, although only for those qualifying for Medicare and/or Medicaid. Arguably, even those covered by Medicare and Medicaid may not receive all the healthcare services normally recommended, because costs that are patient responsibilities (eg, prescription drugs) remain unaffordable for some. Treatment of ESRD is expensive, entitlements or not.
The uninsured immigrant population faces a number of barriers to obtaining insurance coverage and treatment for ESRD. Some may be eligible for Medicare coverage if they or a spouse meets the required work credits under Social Security, Railroad Retirement, or prior US Government service. Others may qualify for Medicaid, depending on state Medicaid eligibility requirements. The last resort for uninsured immigrant populations is to receive uncompensated care from providers who see an ethical and social responsibility towards this population, and who fail to turn away patients in need of life-saving treatments, in this case dialysis treatments. Of all of these options, federal and state policymakers have attempted to use the Medicaid program as a payer of at least some of the dialysis services for uninsured immigrants.
Enacted in 1965, the Medicaid program has been targeted at low-income individuals and families who meet specific federal and state eligibility criteria. Citizenship or legal status has been an underlying criterion for eligibility for the Medicaid program in federal statute since 1986. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 2009 was enacted and significantly increased eligibility restrictions for most federal means-tested public benefits programs, including Medicaid. This was a landmark shift in federal policy, instituting a presumption of ineligibility, with limited exceptions. In addition, some existing immigration laws, as well as the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996, affected legal residents using public benefits in the United States. These complicated statutes, especially IIRIRA, established a general rule that “qualified aliens” were ineligible for Medicaid, unless specific exceptions were made in statute. Fortunately, a number of exceptions were made for Medicaid coverage, including the identification of several categories for which offering of Medicaid was mandatory for all states. In addition, states were allowed the option of offering assistance to “qualified aliens” not falling under any of the mandatory categories. “Qualified aliens” arriving in the United States after August 22, 1996 were not so fortunate. They were, and are, banned from Medicaid coverage for 5 years for any covered benefit, except for emergency treatment. “Nonqualified,” nonexempt aliens are barred from the Medicaid program unless they can become “qualified.”5 Further complicating matters is the taxonomy used for these issues, with “qualified,” “documented,” and “legal” not necessarily meaning the same thing, although generally overlapping. At least 23 states have elected to use state funds for expanded coverage for recent legal immigrants, or for undocumented women and children.6
While multiple statutes governed who was, or was not, eligible for Medicare and Medicaid, a conundrum has arisen because of other well-intentioned federal legislation. The Emergency Treatment and Active Labor Act (EMTALA), part of COBRA 1986 (Consolidated Omnibus Budget Reconciliation Act), requires that any patient presenting at any emergency department requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination to determine whether he/she is suffering from an emergency medical condition. If he/she is, the hospital is required to provide treatment until the patient is stabilized or to transfer the patient to another facility in conformance with the statute's directives. The statute applies whether or not the patient has insurance coverage or ability to pay the hospital for the services received. In 2001, the Centers for Medicare and Medicaid Services (CMS) issued a federal ruling that long-term dialysis and chemotherapy were considered chronic, non-emergency treatments, and were not eligible for federal matching to Medicaid. Subsequent legal actions and intense debate have led to variability across states as to whether dialysis services are interpreted to be emergency or chronic care, and to variability in state policies for reimbursement to dialysis providers. The Medicare Modernization Act of 2003 (Section 1011: Federal Reimbursement of Emergency Health Services to Undocumented Aliens) did attempt to rectify inadequate funding for emergency services to undocumented aliens, including emergency dialysis, by providing $250 million per year for fiscal years 2005-2008 for emergency health services provided to undocumented aliens and other specified aliens. Some states, such as Texas, Colorado, New Mexico, and Georgia, have determined that dialysis is not automatically an emergency and will reimburse for dialysis only when the undocumented patient presents with emergency, life-threatening findings. Other states, such as California, New York, Arizona, and North Carolina, have been providing dialysis services to undocumented immigrants.7 Clearly, there is great variation in coverage, payment, and policy for treatment of undocumented immigrants with ESRD.
Hurley et al report widespread provision of ESRD care to undocumented immigrants with ESRD, with 65% of surveyed nephrologists reporting providing such care, and 61% reporting increasing prevalence. Most notably, 91% reported undocumented patients having access to emergency care, but only 51% reported access to maintenance dialysis. Geographic differences in access to maintenance dialysis were reported; states that have high undocumented populations were associated with greater access, whereas the southern states appeared to offer less access. Inadequate compensation appears to be the most significant perceived barrier to maintenance dialysis access. Of the nephrologists surveyed, 35% report that outpatient dialysis facilities provide uncompensated dialysis care to undocumented ESRD patients.4
Although there are many issues that require attention in the current national healthcare reform discussion, the care of undocumented immigrant patients with ESRD merits scrutiny and policy proposals. At best, inadequate dialysis care in this population leads to suboptimal quality of life and health status, impeding a productive role in family and society for these individuals. At worst, inadequate care leads to avoidable complications that further tax our limited healthcare funding sources, as well as potentially causing death in these patients. Building on available surveys and data collection is essential as a first step. Dialysis facilities submit administrative data to CMS via Medicare claims. Because claims for undocumented immigrants cannot be submitted to Medicare, we lack any significant data from the Medicare program. Medicaid, as discussed above, varies by state. Some states have data on treatment of undocumented immigrants, but others do not, particularly if they do not reimburse for dialysis care in this population. Clearly we need more data and information to best define options and reform national and state policies. This includes the need for more evidence-based comparative analysis and cost-effectiveness analysis on the best way to treat this population. While awaiting such data, we should focus more attention on possible solutions, with inclusion of this topic as a priority in increasing access to healthcare services overall in this country.
In addition to affecting patient outcomes, the lack of a coordinated national policy on care of undocumented immigrants with ESRD affects all providers involved with this care, especially dialysis facilities, hospitals, and physicians. Uncompensated care must be paid for by someone, and dialysis providers who have decreasing margins for the care of Medicare and Medicaid patients may be prone to cutting costs and under-utilizing important services in attempts to remain accessible to the larger patient population they serve. At the same time, we have increasingly limited resources available for healthcare services, with the Medicare Hospital Trust Fund projected to be depleted as early as 2016. Achieving efficiencies in healthcare services is essential if we are to continue to offer broad, basic services to all Americans, as well as more complex and expensive specialty services that contribute to better outcomes for patients.
Federal immigration policy adds further complexity to this problem, with longstanding disagreement about which immigration restrictions are appropriate and how any policy is to be enforced. Many Americans feel that the United States should not pay for any services to undocumented immigrants, including life-saving healthcare services. If that is the case, it is argued that stricter enforcement of immigration law would be indicated to prevent the access issue in the first place. However, many other Americans, particularly the healthcare provider and patient advocacy sectors, have strong ethical and moral commitments to advocating for and treating any patient whose life is at stake, regardless of ability to pay. This philosophic logjam needs to be faced and resolved as we try to balance the many conflicting issues of this problem.
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