| | Care of the Undocumented Immigrant in the United States With ESRD published online 27 September 2009. The growth of the undocumented immigrant population in the United States has been explosive. The absence of a uniform policy regarding health care for this population has created a unique problem for nephrologists. How should provision of care for undocumented immigrants with end-stage renal disease be delivered and compensated? This problem is exacerbated by the multiple complex laws that govern delivery of and payment for care, as well as that state regulations vary widely and are not easily understood. Furthermore, the ethical and moral commitments of providers to ensure adequate and appropriate care for any patient whose life is at stake, irrespective of his or her immigration status, place nephrologists in a difficult position. This review focuses on the scope of this problem, relevant case law and legislation, current care and payment models, the response of nephrology groups, and ethical dilemmas inherent in caring for this vulnerable population. Recommendations for further study, including convening of a consensus conference, are discussed. The explosive growth of the undocumented immigrant population (those migrating to or residing in the United States without legal permission) in the United States and the absence of uniform public funding for their health care have created a unique challenge for nephrologists across the country. Nephrologists are consulted to provide life-sustaining renal replacement therapies (RRTs) to those with end-stage renal disease (ESRD), but there may be no mechanism available to reimburse these services. This is an unfamiliar challenge for the nephrology community because RRT has been guaranteed for US citizens since passage of the Social Security Amendment of 1972.1 Furthermore, the landscape for provision of ESRD care to undocumented immigrants is difficult to define because coverage for this vulnerable population differs among states and even among hospitals in the same state. Single-center case series, case reports, and news articles suggest multiple unintended consequences of the current funding patchwork for these individuals, including (1) the delivery of substandard care, (2) service delivery costs that exceed those for standard care received by US citizens, (3) missed opportunities to implement life-extending cost-saving care strategies, (4) cost shifting to a limited number of providers, and (5) ethical dilemmas associated with care delivery, such as whether to deliver essential medical care at personal cost. Unfortunately, few population-level data exist describing the needs of this vulnerable population, policies governing their care, demands placed on providers and the health care system that serves them, or the quality of care received, which makes a systematic assessment of current policies challenging. We present a summary of what is known about the undocumented population with ESRD, public policies and case laws defining funding for their care, assessment of current practice strategies, and a brief discussion of the ethical conflicts confronting nephrologists that serve this population. This review is intended to raise awareness of the medical needs of undocumented immigrants with ESRD and stimulate a critical dialogue in the nephrology community about current health care policy. Undocumented Immigrants With ESRD: How Many, How Much?  Estimating the number of undocumented immigrants in the United States with ESRD and the cost of caring for their medical needs is critical to understanding the population's needs and assessing current and future funding strategies. However, these data have not been collected in a systematic manner. Efforts to do so have been limited by difficulties retrospectively identifying this population and legal protections limiting prospective identification.2 These difficulties are illustrated by the May 2004 General Accounting Office's report “Undocumented Aliens,” a survey of 503 hospitals in 10 states (9 states with the highest number of undocumented immigrants plus New Mexico) that attempted to quantify the impact of the undocumented population on hospitals' uncompensated care costs.2 Seventy percent of hospitals responded, but only 39% provided enough information to evaluate the relationship between uncompensated care and the proportion of care provided to undocumented immigrants (using lack of a social security number as a proxy for undocumented status). In addition, <5% of reporting hospitals used a means other than lack of a social security number to identify undocumented immigrants, rendering it impossible to validate lack of social security number as a proxy for legal residence. Despite bringing the federal government's resources to bear, ultimately, only limited conclusions about the scope of this problem could be performed because of insufficient information. Although there are no published estimates of the undocumented population with ESRD, the total number of undocumented immigrants and their demographic profile and distribution across the United States have been derived and may be used to manufacture an estimate of disease burden and distribution.3, 4, 5 Using the residual method (subtracting the estimated legal immigrant number population from the total foreign-born population, data collected by the US Bureau of Labor Statistics and the Census Bureau), Passel et al3, 5 calculate that 11.1 million unauthorized migrants were living in the United States in 2005, up from 8.4 million in 2000, a 32% population growth in 5 years (Fig 1). The majority are Hispanic, with ∼78% born in Mexico or Latin America. Hispanics compared with non-Hispanics are reported to have an ∼33% higher rate of progression from intermediate stages of chronic kidney disease to ESRD6, 7, 8 and an adjusted incident rate approaching 500 cases/1,000,000 population.9 This suggests that there may be 5,500 undocumented immigrants in the United States with ESRD, an estimate that does not consider age, comorbid conditions, or other important characteristics of the population. It should be stressed that this is simply an estimate based on limited data, but serves as a starting point to estimate potential burdens of this problem. No single estimate of the cost of caring for undocumented immigrants with ESRD has been published, and the disparate stream of funding for care of this population makes such an estimate very difficult to gather. The 2004 General Accounting Office report cites Medicaid officials from 10 states (which account for 78% of the undocumented population) as reporting $2 billion in emergency Medicaid expenses (a category of Medicaid spending available to undocumented immigrants with life-threatening emergencies who, except for their immigration status, would otherwise qualify for Medicaid).2 However, this spending is not itemized and only a minority of states fund long-term dialysis therapy for undocumented immigrants with their Medicaid funds. An examination of 2004 emergency Medicaid spending from North Carolina, one of the few states to provide some funding for long-term hemodialysis for undocumented immigrants, shows ∼$4.4 million (of nearly $53 million total emergency Medicaid spending) was categorized as spending for “chronic renal failure.”10 Multiplying the 2005 per-person cost of hemodialysis, $69,758 by the estimate of 5,500 undocumented immigrants residing in the United States with ESRD, would estimate a total cost of $383 million.9 During the past 2 decades, the undocumented immigrant population has decentralized, leading to wider contact with the nephrology community. In 1990, 45% of undocumented immigrants resided in California, but from 2002-2004, more than two-thirds of immigrants lived in 8 states, with California, Texas, and Florida representing the highest density of undocumented immigrants (Fig 2). Estimated 2008 data for undocumented population by state are shown in Fig 3. North Carolina experienced a nearly 700% increase in its undocumented population between 1990 and 2000, the greatest relative growth of any state.12 A recent study of American Society of Nephrology member nephrologists found 65% of responding nephrologists in 44 states reported providing care for illegal undocumented patients with ESRD.13 Furthermore, 61% of responding nephrologists reported an increasing prevalence of this issue, a finding associated with working in a state with high undocumented activity.13 The History of Current Funding Policy: Relevant Legislation and Case Law Access to RRT for undocumented immigrants with ESRD and the quality of care they receive are determined by a complex web of federal laws, state Medicaid policies, and the judicial system's interpretation of these policies. A historic look at relevant legislation and case law offers the framework for understanding the current funding environment. Federal Law At the federal level, there are several pertinent legislative acts (listed in Table 1) going back to Public Law 92-603 passed in October 1972 that guaranteed access to RRT for those with ESRD.1 This ground-breaking legislation, which essentially created national health insurance for those affected by ESRD, made no mention of citizenship as an eligibility requirement for funding. However, in 1986, the Omnibus Reconciliation Act passed Congress, enacting 2 important modifications that affected undocumented immigrants' access to care.14 First, it prohibited federal Medicaid participation payments for care of undocumented immigrants (“aliens not lawfully admitted for permanent residence or not permanently residing in the United States under color of law”),15 except for emergency medical care provided to those who would otherwise be eligible for Medicaid (eg, undocumented immigrants meeting income and state residency eligibility requirements).14 Second, it contained the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates that all hospitals receiving Medicare funds evaluate all patients coming to the emergency department for an emergency medical condition regardless of their immigration status and treat (or stabilize) this emergency condition.14 Under this act, emergent dialysis must be provided to undocumented immigrants with life-threatening complications of kidney failure, but federal Medicaid payments are not provided for maintenance dialysis therapy. The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, also referred to as the Welfare Act) was an important law that affected all immigrants because it extended the prohibition on full-scope Medicaid benefits to many residing in the United States legally.15 In addition, it explicitly denied all state and local public benefits to undocumented immigrants, forcing states wishing to extend public benefit to undocumented immigrants to pass new laws specific to their own state. These restrictions left states to determine independently what public benefits would be offered to undocumented immigrants and restricted federal funds to the treatment of an emergency medical condition. Federal Medicaid dollars for emergency care later were augmented through the Balanced Budget Act of 1997, which provided $25 million annually from 1998 to 2001 to the 12 states with the greatest number of undocumented aliens,17 and by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (section 1011: Federal Reimbursement of Emergency Health Services to Undocumented Aliens), which provided $250 million/y from 2005 to 2008 to hospitals and eligible providers for emergency care delivered to undocumented aliens.18 The Illegal Immigration Reform and Immigrant Responsibility Act (Immigration Act) of 1996 (Public Law 104-208) also had significance relating to provision of health care for illegal immigrants.16 Because they could not provide even the minimal documentation required, this Immigration Act effectively restricted access to health care for illegal immigrants. These restrictions on care, through the requirement of specific documents, also limit the ability of illegal immigrant patients to obtain care through other government-supported systems and public assistance. When combined, the Welfare and Immigration Acts serve as an important roadblock for access to care for undocumented immigrants. State Policy and Laws Emergency medical condition is defined broadly by federal legislation as a “medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— (a) placing the patient's health in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part.”19 This broad definition allows individual states some flexibility to determine what emergency medical conditions will be covered with Medicaid funds. This, in part, explains the wide variation in coverage for outpatient RRT among states. Complicating the study of this topic, there currently is no single source reporting which states fund outpatient RRT for undocumented immigrants. However, our systematic review of states' Medicaid policy manuals and websites suggests it is a minority. To determine specific states' regulations in this regard, it is imperative to consult with the state Medicaid coverage requirements, which are updated regularly (they usually can be found on the specific state Medicaid website). Of particular note, California is a state that currently provides maintenance hemodialysis support for illegal immigrants. Approximately 1,350 of the more than 61,000 patients receiving dialysis support in the state are illegal immigrants.13 The cost of such care approaches $51 million/y.20 New York and North Carolina also provide ongoing dialysis care. Georgia previously had covered dialysis therapy until 2006. The Georgia legislature changed their policy, in part because of concern about the financial effects that long-term dialysis care of illegal immigrants places on the Medicaid system. In Arizona, the state attempted to discontinue payment for hemodialysis therapy in 2002, prompting undocumented immigrant patients to file suit. Ultimately, Arizona continued to provide dialysis care as part of the settlement of this case, showing the role of the courts in determining Medicaid funding for maintenance dialysis therapy.21 Case Law In several states, patients and providers have sought medical coverage by challenging the interpretation of what constitutes an emergency medical condition. One of the first such cases was Greenery Rehabilitation Group versus Hammon.22 In this case, 2 undocumented immigrants and 1 legal resident not yet meeting residency requirement for Medicaid benefits experienced serious brain injury, for which they received care from the Greenery Rehabilitation Group. The Greenery Rehabilitation Group attempted to obtain compensation through emergent Medicaid coverage, arguing that the patients' continued care (including such provisions as enteral nutrition), given the underlying brain injury, constituted continued emergent care. The initial ruling supported the Greenery Rehabilitation Group, but it was determined on subsequent appeal that “emergent conditions are determined as those the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part”22 and therefore did not include what was judged to be long-term care provided by the plaintiffs. This narrow definition of emergent conditions from the court subsequently has been applied to the provision of other care that is routinely recurrent in nature, but in its absence could lead to an emergent state. In Diaz versus Division of Social Services, the North Carolina Supreme Court ruled with regard to coverage for ongoing chemotherapy for acute lymphocytic leukemia that an emergency medical condition exists only as long as the condition manifests itself by acute symptoms at the time of treatment and requires immediate treatment to stabilize the condition.23 Meanwhile, in Szewczyk versus Department of Social Services, the Connecticut Supreme Court ruled differently on a case with similar facts, supporting the plaintiff's condition that treatment should be covered under emergency Medicaid.24 With specific regard to the provision of RRT for patients with ESRD, in Quinceno versus Department of Social Services, the family of a deceased patient in Connecticut filed suit when the Connecticut Department of Social Services declined Medicaid coverage, citing that hemodialysis did not constitute an “emergency medical condition.”25 The court ruled in favor of the Connecticut Department of Social Services, citing the Greenery case and stating there was no basis for distinguishing between this patient's condition and the patients in Greenery. They correlated supportive nursing care and tube feedings with the “continuous and regimented care of dialysis” and believed that despite the potentially fatal consequences of discontinuation of care in either case, it did not constitute emergent care.25 Current Care Models: Strengths and Weaknesses Numerous news articles have documented the trials of treating ESRD in the undocumented immigrant population, including those focused on patient perspectives, the challenges faced by providers, and the role of policy makers.26, 27, 28 However, the peer-reviewed literature contains only 2 systematic examinations of actual practices.29, 30 The result is a picture that suggests critical deficiencies in current models of care, but with too many limitations and too narrow a scope to make generalizable conclusions. In the first study by Coritsidis et al,29 researchers from New York (a state that provides Medicaid funding for maintenance dialysis therapy for undocumented immigrants) characterized a cohort of undocumented immigrants receiving maintenance dialysis at 2 teaching hospitals before 2001 (n = 55) and compared their predialysis care and health care use with a cohort of American citizens (n = 223) with ESRD. With variable statistical significance, undocumented immigrants received less pre-ESRD care (27% vs 61%; P = 0.01), started dialysis therapy with significantly lower glomerular filtration rates (5.53 vs 6.29 mL/min/1.73 m2; P = 0.03), had higher blood pressures (mean arterial pressures, 119.9 vs 108.9 mm Hg; P = 0 .001), had longer length of stays when starting dialysis therapy (10.0 vs 7.7 days; P < 0.06), and had greater costs for this admission ($16,076 vs $11,396; P < 0.003). This study suggests that differences in access to predialysis care between undocumented immigrants and American citizens lead to later presentation in the course of kidney failure and greater costs at the start of dialysis therapy. However, the retrospective design prevents definitive conclusions regarding cause and effect, and no statement can be made about the impact on patient morbidity and mortality. In the second study, investigators from Texas took advantage of a 1997 change in a hospital district's funding policy to examine the costs and outcomes of caring for undocumented immigrants under 2 different RRT provision strategies: standard maintenance dialysis therapy (ie, 3 times weekly) versus ongoing “emergent” dialysis (provided during unscheduled visits to the emergency department).30 Those receiving standard maintenance dialysis therapy (long-term-care group; n = 22) before the 1997 policy were grandfathered and thus allowed to continue to receive routine treatment after 1997. Those presenting after passage of the policy were offered only emergent care (n = 13), typically receiving 2 to 3 dialysis treatments as inpatients after presentation to the emergency department. Most emergent care was provided through temporary venous catheters (removed on discharge) compared with arteriovenous fistulas or grafts most often used for long-term care. The emergent-care group spent more days as inpatients (162 vs 10.1 days; P < 0.0001), had more emergency department visits (26.3 vs 1.4 days; P < 0.0001), received more blood transfusions (24.9 vs 2.2 packed red blood cell units; P < 0.0001), received fewer dialysis treatments annually (98 vs 154; P < 0.0001), had lower measures of dialysis adequacy (Kt/V, 0.9 vs 1.64), and reported greater physical pain and a lower level of physical function. The mean annualized cost of caring for the long-term-care group was $76,906 versus $284,655 for the emergent-care group. It appears from this small sample size that funding standard dialysis therapy was both less expensive and provided higher quality care than funding emergent RRT only. Although limited in scope, these studies appear broadly relevant. In a recent survey of 1,723 American Society of Nephrology member nephrologists, only 50% of respondents (n = 990) reported that undocumented immigrants had access to maintenance dialysis therapy, whereas 25% reported dialyzing these patients only emergently.13 In addition, although these investigations did not prospectively link practice patterns with patient morbidity and mortality, they show an association between immigration status and a funding policy limiting care to emergency states with deficiencies in care. These deficiencies in care are linked to morbidity and mortality. For example, the use of central venous catheters for dialysis, significantly more common in the undocumented immigrant population, is associated with higher rates of infection and death compared with arteriovenous fistulas.31, 32, 33 Similarly, inadequate dialysis dosing (eg, Kt/V < 1.3), more common in undocumented immigrants, is associated with a higher mortality rate.34 Who Pays? Funding for undocumented immigrant RRT varies among states, among providers within a state, and even for individual patients. The General Accounting Office outlines 3 sources of federal dollars available to help cover costs of treating undocumented aliens: Medicaid, which pays for “emergency medical services” only; Medicaid disproportionate share hospital payments, providing supplemental payments to certain hospitals serving a larger number of low-income patients; and the Balanced Budget Act of 1997 (or more recently the Medicare Prescription Drug, Improvement and Modernization Act of 2003), money allocated to providers in states serving large numbers of undocumented immigrants.2 In states with emergency Medicaid funding for maintenance dialysis therapy, it is presumed that state residents (ie, tax payers) are the major payers. Other payers of unspecified amounts include charities, dialysis organizations, and hospital systems. Although survey data suggest that > 40% of undocumented immigrants may have some form of health insurance,35 the extent of this coverage has not been detailed. It is unknown how many have policies that cover dialysis therapy, and for those with such policies, it is uncertain whether payouts ultimately are honored to policy holders residing in the United States illegally. Practitioners with not-for-profit dialysis units or units not associated with national chain dialysis providers may have fewer restrictions on providing uninsured care, although the concentration of uninsured patients on a single provider can be financially devastating.28 As an example, the dialysis unit at Grady Hospital in Atlanta, GA, was a last resort of care for many undocumented immigrants (31% of dialysis patients were undocumented immigrants).35 Clinic staff had to work extra shifts and overtime to take care of the growing patient load, and the dialysis unit was losing $3 million/y. Grady Hospital was faced with the question: Should the hospital close down a dialysis unit that loses $3 million a year or should it continue the program that treats about 80-100 patients a day? Initially, Grady Hospital administrators decided to shut down the unit. However, a few days later, they reversed that decision and kept the clinic open. Several Grady board members believed that closing the clinic would lead to more emergency department visits, longer stays in the intensive care unit, and more deaths.36 In the provider survey referenced, in respondents knowledgeable about reimbursement, the majority reported that it is inadequate and 35% reported that their outpatient dialysis units provide uncompensated dialysis care to undocumented patients with ESRD.13 The Nephrology Community: Renal Physicians Association Statement The Renal Physicians Association recently updated its position statement on the care of undocumented immigrants.37 The principles/beliefs of this statement are listed in Box 1. Box 1 Summary of Renal Physicians Association Position Statement on Uncompensated Renal-Related Care for Noncitizens 1.All health care professionals and health care systems have an ethical obligation to treat the sick. 2.The federal government has the ethical and fiscal responsibility to provide care for patients within the US borders. 3.The financial burden of this care should fall not only on states that have the highest number of uninsured citizens or noncitizens, but also should be a national responsibility. 4.Because of the unique nature of ESRD, all citizens and noncitizens with ESRD should be eligible for emergency federal funding if they do not have insurance or resources to pay for renal-related care. 5.Nephrologists should not be expected to act as agents for the Immigration and Naturalization Service and should not be expected to report undocumented noncitizens because of patient confidentiality and the fiduciary nature of the patient-physician relationship. Abbreviation: ESRD, end-stage renal disease. Source: Renal Physicians Association.37 This position statement is an important launching point to begin in-depth discussions about the provision for ESRD care to undocumented immigrants. Ethical Dilemmas Faced by Providers The absence of adequate funding for emergency RRT and EMTALA's mandate to provide emergency care have created numerous ethical dilemmas for providers. An exhaustive discussion of the ethical and political issues is beyond the scope of this article; however, certain important issues should be highlighted. Certain issues are pertinent to the acute presentation of a patient who may require dialysis services. What does the physician do when called to the emergency department to dialyze an undocumented immigrant with ESRD with hyperkalemia, but without electrocardiographic changes? Is this life threatening and covered by EMTALA? If not, how is this care supported? Should each emergency department have policies that specifically address these issues? In the case of maintenance dialysis therapy, for which most states offer no reimbursement, the dilemmas may seem more subtle. However, there is significant morbidity and mortality that is caused by the lack of appropriate dialysis access, volume and blood pressure management, anemia management, and metabolic bone disease management.38, 39 Recognizing that a substandard dose of dialysis is associated with an increased mortality rate, are nephrologists providing emergent dialysis obligated to provide outpatient dialysis to the same standard of care, understanding if they do not, no one else will? Are vascular surgeons supposed to prepare arteriovenous fistulas for these patients, knowing their services will not be reimbursed? Should tunneled catheters be placed for emergency dialysis, understanding that repeated punctures for temporary catheters create unnecessary pain and may limit future more permanent vascular access options? If the provision of uncompensated care threatens the financial viability of their associated dialysis unit or practice, is it ethical to threaten the ability to provide care to other patients? In some areas, the restrictive nature of compensation essentially compels nephrologists and dialysis providers to deny maintenance care simply to maintain their ability to provide care in general. The services provided by undocumented immigrants in the form of labor (often in high-risk occupations that many have chosen not to pursue) are reaped by many nationally.4, 5 However, because this population concentrates in a limited number of states, the costs are often born by few, because without federal dollars to pay for RRT, state residents are left paying the bill in many cases. Nephrologists in these communities must shoulder the care. In some cases, nephrologists and other care providers may be forced into a situation to recommend that patients move to another state or area just to receive care that would be supported. What is the responsibility of these nephrologists to their patients and the area in which they live or practice? Is it reasonable for areas not providing care or reimbursement to send patients they are unable to care for to other states, placing an undue financial strain on areas with more comprehensive coverage? Should repatriation of undocumented immigrants with ESRD be considered? If so, should this only occur if there is knowledge that dialysis services will be available to the patient? Unfortunately, the answer to these questions requires a national dialogue with thorough assessment of the costs, benefits, and ethical issues. Given the recent discussion of legislation on the federal and state level regarding immigration, there are concerns about the obligation of care providers regarding the reporting of a patient's status. Because some personal documentation is required to receive care, this ensures that in many cases, care providers are aware of the immigration status of their patients. Could having that knowledge create a situation in which nephrologists would be compelled to report their illegal immigrant patients to the legal authorities? Is it ethical to place nephrologists in a situation in which they are de facto immigration officers? The potential effects of this are numerous. Reports already have shown that illegal immigrants often will not seek care if there is concern about deportation.34 Also, for illegal immigrant patients who overcome this concern, the lingering effect on the physician-patient relationship may lead to distrust of the physician. In part, because of these concerns, the Renal Physicians Association position paper is clear in its recommendation that physicians should not be expected to act as agents of the Immigration and Naturalization Service.37 Conclusion The undocumented immigrant population is growing rapidly in the United States, and its decentralization during the past decade predicts that most practitioners in the nephrology community will be faced with the challenges we have described. Recognizing the challenge of undocumented immigrants with ESRD to access care and understanding the current system of funding for their care, including federal and state policies and relevant case law, are important to meeting their needs. However, more will be needed to allow the nephrology community to meet this growing demand. We must focus efforts to better understand the burden of this problem with more robust, anonymous, and confidential reporting systems. We must begin a rational look at the various funding policies that, in some cases, thwart optimal care of this vulnerable population. We must balance discussion with the strong ethical and moral commitments that care providers have in ensuring adequate and appropriate care for any patient whose life is at stake, irrespective of his or her immigration status. In the end, we have to develop a framework that balances our ethical and moral responsibilities with responsible and rational fiscal and legal policies. This discussion should begin immediately, and a consensus conference addressing these issues and involving relevant stakeholders should be convened. Acknowledgements The authors acknowledge Jane Perkins at the National Health Law Program for work on this subject that provided guidance for the authors. Financial Disclosure: None. References 1. 1Social Security Amendments of 1972, Public Law No. 92-603, 86 Stat 1329. 2. 2US Government Accounting Office. Undocumented aliens: questions persist about their impact on hospitals' uncompensated care costs (GAO report no. 04-472, 2004). http://www.gao.gov/new.items/d04472.pdf. 3. 3Pew Research CenterPassel JS. The size and characteristics of the unauthorized migrant population in the U.S. estimates based on the March 2005 Current Population Survey. http://pewhispanic.org/files/reports/61.pdf. 4. 4Passel JS, Capps R, Fix MUrban Institute. Undocumented immigrants: facts and figures. www.urban.org/UploadedPDF/1000587_undoc_immigrants_facts.pdf. 5. 5Pew Research CenterPassel JS. Estimates of the size and characteristics of the undocumented population. http://pewhispanic.org/files/reports/44.pdf. 6. 6Peralta CA, Shlipak MG, Fan D, et al. Risks for end-stage renal disease, cardiovascular events, and death in Hispanic versus non-Hispanic white adults with chronic kidney disease. J Am Soc Nephrol. 2006;17:2892–2899. MEDLINE |
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11. 11Passel JS, Cohn V. A portrait of unauthorized immigrants in the United States (Pew Hispanic Center, a Pew Research Center project, 2009). http://pewhispanic.org/files/reports/107.pdf. 12. 12Census 2000 data for the State of North Carolina. http://www.census.gov/census2000/states/nc.html. 13. 13Hurley L, Berl T, Pratte K, Linas S. Care of undocumented individuals with ESRD: a national survey of US nephrologists. Am J Kidney Dis. 2009;53:940–949. Abstract | Full Text |
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14. 14Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law No: 99-272, 100 Stat 82. 15. 15Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Public Law 104-193, 110 Stat 2105. 16. 16Illegal Immigration Reform and Immigrant Responsibility Act of 1996, Public Law No. 104-208, Div. C, 110 Stat 3009-546. 17. 17Balanced Budget Act of 1997, Public Law No. 105-33, 111 Stat 251. 18. 18Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law No. 108-173, 117 Stat 2066. 19. 19Social Security Act, 42 USC §1903. 20. 20Young J, Flores G, Berman S. Providing life-saving health care to undocumented children: controversies and ethical issues. Pediatrics. 2004;114:1316–1320. 21. 21Scottsdale Healthcare Inc v Arizona Health Care Cost Containment System Administration, 75 P3d 91 (AZ Supreme Ct 2003). 22. 22The Greenery Rehabilitation Group Inc v Hammon, 150 F3d 226 (2nd Cir 1998). 23. 23Diaz v Division of Social Services and Division of Medical Assistance, North Carolina Department of Health and Human Services, 628 SE2d 1 (NC Supreme Ct 2006). 24. 24Szewczyk v Department of Social Services. 881 A2d 259 (CT Supreme Court, 2005). 25. 25Quiceno v Department of Social Services. 728 A2d 553 (CT Super Ct 1999). 26. 26Parks D. Illegal immigrants face life or death dialysis dilemma. Birmingham News; November 2008;http://www.al.com/birminghamnews/stories/index.ssf?/base/news/1226826931175590.xml&coll=2. 27. 27Zarembo A, Gorman A. Citizenship often determines who gets medical care. Los Angeles Times; 2008;http://www.latimes.com/news/local/la-me-dialysis29-2008oct29,0,2166155.story?page=2. 28. 28Chartier K. Undocumented immigration & dialysis (What's the real burden on the healthcare system?). Renal Business Today; January 2008;http://www.renalbusiness.com/articles/undocumented_immigration_and_dialysis.html. 29. 29Coritsidis GN, Khamash H, Ahmed SI, et al. The initiation of dialysis in undocumented aliens: the impact on a public hospital system. Am J Kidney Dis. 2004;43:424–432. Abstract | Full Text |
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30. 30Sheik-Hamad D, Paiuk E, Wright A, et al. Care for immigrants with end-stage renal disease in Houston: a comparison of two practices. Texas Med. 2007;103:53–58. 31. 31Pastan S, Soucie JM, McClellan WM. Vascular access and increased risk of death among hemodialysis patients. Kidney Int. 2002;62:620–626. MEDLINE |
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33. 33Lorenzo V, Martn M, Rufino M, Hernandez D, Torres A, Ayus JC. Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational cohort study. Am J Kidney Dis. 2004;43:999–1007. Abstract | Full Text |
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34. 34Saran R, Canaud BJ, Depner TA, et al. Dose of dialysis: key lessons from major observational studies and clinical trials. Am J Kidney Dis. 2004;44(5 suppl 2):S47–S53. 35. 35Ortega AN, Fang H, Perez VH, et al. Heath care access, use of services, and experiences among undocumented Mexicans and other Latinos. Arch Intern Med. 2007;167:2354–2360.
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36. 36Sams D. Illegal immigrants strain Grady dialysis unit. Atlanta Business Chronicle; October 13, 2006;http://atlanta.bizjournals.com/atlanta/stories/2006/10/16/story14.html. 37. 37Renal Physicians Association. RPA position on uncompensated renal-related care for citizens and non-citizens. www.renalmd.org. 38. 38Hakim RM. Reducing early mortality in hemodialysis patients. Curr Opin Nephrol Hypertens. 2008;17:595–599.
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39. 39Bradbury BD, Fissell RB, Albert JM, et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol. 2007;2:89–99. 1 Division of Nephrology, University of Virginia Health System, Charlottesville, VA 2 Division of Nephrology, University of North Carolina, Chapel Hill, NC  Address correspondence to Mitchell H. Rosner, MD, University of Virginia Health System, Division of Nephrology, Box 800133, Charlottesville, VA 22908
PII: S0272-6386(09)00989-5 doi:10.1053/j.ajkd.2009.06.039 © 2009 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. | |
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