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American Journal of Kidney Diseases

Tragic Options and Compromised Care: Undocumented Immigrants With ESRD

      Related Article, p. 354
      In this issue of the American Journal of Kidney Diseases, Linden et al
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      provide a single-center overview of the characteristics of their undocumented patients with end-stage renal disease (ESRD) and the results of a survey focusing on immigration issues and attitudes toward employment and transplant. The US nephrology community is paralyzed by the challenges of finding the optimal treatment strategy for undocumented immigrants with ESRD. With no national health care coverage for these patients, each state basically has adopted 1 of 2 treatment strategies: providing emergent inpatient dialysis to patients with urgent indications for hemodialysis or providing long-term outpatient dialysis. These disparate treatment strategies developed due to inconsistent interpretations of Medicaid coverage, which have been well described elsewhere.
      • Campbell G.A.
      • Sanoff S.
      • Rosner M.H.
      Care of the undocumented immigrant in the United States with ESRD.
      • Straube B.M.
      Reform of the US health care system: care of undocumented individuals with ESRD.
      It is important to note that none of the dialysis stakeholders, including the large dialysis organizations, have objected to providing dialysis to undocumented immigrants when reimbursement for dialysis services is available.
      According to the Pew Research Center, California has the largest undocumented immigrant population in the United States, with an estimated 2.55 million in 2010, and despite the size (and elusive nature) of the population, long-term outpatient dialysis is covered by the state government.

      Pew Research Center. Unauthorized Immigrant Population: National and State Trends, 2010, 2011. Pew Hispanic Center.

      • Zarembo A.
      • Gorman A.
      Dialysis dilemma: who gets free care?.
      Texas is second, with an undocumented population of 1.65 million. However, in Texas, undocumented immigrants with ESRD have only one option, to present to an emergency department with urgent indications for dialysis, a practice that takes advantage of Medicaid payments for emergency care. The well-publicized situation at Atlanta's Grady Hospital, a safety-net hospital, became a national story when the dialysis unit closed, leaving a group of undocumented immigrants with ESRD with no viable options for continuing long-term outpatient dialysis. Georgia does not cover dialysis for undocumented immigrants except for emergent dialysis, and Grady Hospital had provided uncompensated care for these patients until doing so became financially unsustainable.
      • Sack K.
      For sick illegal immigrants, no relief back home.
      There are inherent conflicts among all the stakeholders currently providing care to these patients. The large dialysis organizations, smaller chains, independent units, and the few remaining dialysis units operated by safety-net hospitals are not willing or able to provide uncompensated care to this population. Medical centers will continue to provide emergent dialysis due to the interpretation of the Emergency Treatment and Active Labor Act, which permits Medicaid payment for undocumented immigrants until patients are stabilized, but does not cover maintenance dialysis. Conversely, nephrology providers must believe that the ethical underpinnings of our profession are being challenged when we are not allowed to provide appropriate treatment to these vulnerable patients.
      • Nzerue C.
      Between a rock and a hard place.
      • Rodriguez R.
      The dilemma of undocumented immigrants with ESRD.
      Although the Accreditation Council for Graduate Medical Education emphasizes professionalism and ethical behavior among our trainees, these principles are being threatened when our nephrology trainees are forced in some states to provide care that is almost certainly associated with higher morbidity and mortality. In 2009, Barry M. Straube,
      • Straube B.M.
      Reform of the US health care system: care of undocumented individuals with ESRD.
      MD, who at that time was the Chief Medical Officer and Director of the Office of Clinical Standards and Quality of the Centers for Medicare & Medicaid Services, wrote an editorial in this journal addressing the reform of the US health care system and care of undocumented individuals with ESRD. Acknowledging the stalemate among stakeholders, Dr Straube called on the renal community to obtain more data and information to help craft national and state policies. Specifically, he recommended more evidence-based comparative analysis and cost-effectiveness analysis to better understand the possible solutions. On account of the exclusion of undocumented patients from US Renal Data System reporting and the lack of state-level data, comprehensive national data focusing on these patients are not available for study.
      Linden et al
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      hypothesize that undocumented immigrants with ESRD are younger and healthier than the general dialysis population and therefore are ideal transplant candidates. They surveyed 45 undocumented immigrant dialysis patients who were predominately male, relatively young with an average age of 43.8 years, and predominately Hispanic. The immigrants had been in the United States for an average of 12.2 years and most likely developed progressive kidney disease while in the United States. Half the patients were still employed and when asked about transplant, they reported positive attitudes toward transplant and most could identify potential donors. These findings are not surprising given the known characteristics of the adult immigrant population. For example, according to Pew Research Center estimates, the median age of US-born adults in 2009 was 46.3 years; of legal immigrants, it was 45.9 years; and of undocumented immigrants, it was 35.5 years.
      • Passel J.S.
      • Taylor P.
      Unauthorized Immigrants and Their U.S.-Born Children.
      The nation's undocumented immigrant population also is predominantly Hispanic (76%), male (60%), and employed (94% of working age men).
      • Passel J.S.
      • Cohn D.
      A Portrait of Unauthorized Immigrants in the United States.
      The present study's finding of duration of residence in the United States also is consistent with national statistics, which estimate that >60% of undocumented immigrants have been in the United States longer than 10 years and only 15% have been in the United States less than 5 years.
      Pew Research Center
      Unauthorized Immigrants: Length of Residency, Patterns of Parenthood.
      Given the known lack of national data for undocumented immigrants with ESRD, Linden et al
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      provide a valuable snapshot of this population. Their study supports the hypothesis that this ESRD population is similar to the national portrait of undocumented immigrants and does not support the notion that this population immigrated to the United States to receive dialysis care. On this point, more evidence also is provided by the experience in California: despite offering maintenance outpatient dialysis to undocumented immigrants, the number of undocumented immigrants on dialysis therapy in California has been fairly steady since 2001.
      • Zarembo A.
      • Gorman A.
      Dialysis dilemma: who gets free care?.
      How can this study by Linden et al
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      help craft national and state policies? It is well known that kidney transplant is cost-effective and results in better outcomes than other forms of renal replacement therapy and therefore is the treatment of choice for many patients with ESRD.
      • Laupacis A.
      • Keown P.
      • Pus N.
      • et al.
      A study of the quality of life and cost-utility of renal transplantation.
      Some have argued that kidney transplant may be the only tenable long-term option for the treatment of ESRD in low-income countries.
      • Garcia G.G.
      • Harden P.
      • Chapman J.
      The global role of kidney transplantation.
      As would be predicted from the national portrait of the undocumented immigrant population, Linden et al
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      provide evidence that undocumented immigrants are excellent transplant candidates due to better overall health status, younger age, and availability of potential donors. Despite the potential cost savings and optimization of treatment, very few kidney transplants have been performed in undocumented immigrants in the United States. Of the 2 main dialysis treatment strategies currently used for undocumented immigrants in the United States, the emergent dialysis strategy is the least effective method in terms of cost and clinical outcomes compared with maintenance outpatient dialysis or transplant.
      • Laupacis A.
      • Keown P.
      • Pus N.
      • et al.
      A study of the quality of life and cost-utility of renal transplantation.
      • Sheikh-Hamad D.
      • Paiuk E.
      • Wright A.J.
      • Kleinmann C.
      • Khosla U.
      • Shandera W.X.
      Care for immigrants with end-stage renal disease in Houston: a comparison of two practices.
      Of course, recognizing that transplant is cost-effective ignores the complexity of the problem. The availability of donor organs is limited, and there would be resistance to allowing undocumented immigrants onto the United Network for Organ Sharing wait list.
      • Bernstein N.
      For illegal immigrant, line is drawn at transplant.
      • Gupta C.
      Immigrants and organ sharing: a one-way street.
      Even when presented with a live kidney donor, there are several unanswered questions. Who will pay the cost of the surgery for the donor and recipient? Who will pay for the ongoing costs of the immunosuppression and complications?
      There are no obvious solutions to breaking the current stalemate in addressing this problem. The Patient Protection and Affordable Care Act of 2010 ignored the health care of undocumented immigrants and will not provide relief. The prospect of immigration policy reform on a national level seems dim at the present time. Undocumented immigrants are voiceless and powerless in this debate. Unfortunately, except for a few advocacy groups and a position paper by the Renal Physicians Association, the nephrology community has remained virtually silent and provided very little leadership or vision in addressing this problem.
      Renal Physicians Association
      RPA position on dialysis for non-citizens.
      Although the availability of more data and cost-effectiveness analysis would be helpful, it does not seem that rational decisions about cost-effectiveness are guiding federal and state policy regarding these vulnerable patients. Politics and ideology obviously are clouding the debate. A number of physicians on the front lines of caring for these patients have expressed their anguish at having to participate in suboptimal and costly care.
      • Nzerue C.
      Between a rock and a hard place.
      • Raghavan R.
      • Nuila R.
      Survivors—dialysis, immigration, and U.S. law.
      Although some rationalize this strategy as a reality of the financial crisis in modern medicine, the argument seems false considering that the emergent dialysis strategy is not cost-effective, provides suboptimal care, and unfairly burdens safety-net hospitals. The suggestion that repatriation is a viable option is false in most cases. As mentioned, most undocumented immigrants have been in the United States for many years and no longer are eligible for employer-based health insurance in their home countries, and even if they were, the safety-net system in several countries, including Mexico, does not cover dialysis.
      • Sack K.
      For sick illegal immigrants, no relief back home.
      • Garcia-Garcia G.
      • Monteon-Ramos J.F.
      • Garcia-Bejarano H.
      • et al.
      Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL).
      Each year the nephrology community celebrates World Kidney Day in early March, a day to raise awareness about kidney disease and encourage transplant as the optimal treatment for kidney failure. It will be difficult for the US nephrology community to be at the forefront of these global renal initiatives while remaining silent about undocumented immigrants within our own borders. It is obvious that there are no easy solutions. Nevertheless, it is time to obtain more data from the stakeholders and negotiate these solutions. The nephrology community, including patient advocacy groups, professional societies, and the academic community, should encourage and facilitate dialogue among all stakeholders. A number of states such as California and New York seem to have made pragmatic and compassionate decisions and have decades of experience in providing ESRD care to undocumented immigrants in a cost-effective and humane manner. Kidney transplant and peritoneal dialysis are cost-effective strategies that could reduce the waste associated with emergent dialysis. The year 2012 marks the 40th anniversary of the legislation that authorized the Medicare ESRD program, providing nearly universal coverage for dialysis—a remarkable achievement and a result of the advocacy by the nephrology community. The time has arrived again for the nephrology community to address a pressing dilemma by advocating for cost-effective, rational, and compassionate solutions.

      Acknowledgements

      Financial Disclosure: The authors declare that they have no relevant financial interests.

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