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American Journal of Kidney Diseases

The United States Needs a National Policy on Dialysis for Undocumented Immigrants With ESRD

      Related Article, p. 182
      An estimated 6,500 undocumented immigrants with end-stage renal disease (ESRD) reside in the United States.
      • Rodriguez R.A.
      Dialysis for undocumented immigrants in the United States.
      The availability of standard outpatient (thrice-weekly) hemodialysis for undocumented immigrants with ESRD varies throughout the country. Although many states offer emergency-only hemodialysis (dialysis only after an emergency department evaluation), others offer standard hemodialysis.
      • Hurley L.
      • Kempe A.
      • Crane L.A.
      • et al.
      Care of undocumented individuals with ESRD: a national survey of US nephrologists.
      This considerable variation by state is due to the lack of a national policy. Undocumented immigrants with ESRD are eligible for neither the 1972 Medicare ESRD entitlement program nor full-scope Medicaid coverage. They are also specifically excluded from the provisions of the Affordable Care Act. The practice of emergency-only hemodialysis exists because hospitals can be reimbursed for these treatments under the Emergency Medical Treatment and Labor Act (EMTALA) of 1986, which mandated the provision of emergency care for uninsured individuals, including undocumented immigrants.
      • Rodriguez R.A.
      Dialysis for undocumented immigrants in the United States.
      • Raghavan R.
      New opportunities for funding dialysis-dependent undocumented individuals.
      States such as California, New York, Illinois, and Washington offer standard hemodialysis therapy using nonfederal funds. In a recent qualitative study that explored the illness experience of undocumented immigrants with access to emergency-only hemodialysis, patients described feeling distressed by the weekly accumulation of symptoms that trigger the emergency presentation to the emergency department, and many also described risking death by consuming foods high in potassium so that they would meet critically ill criteria for emergency-only hemodialysis.
      • Cervantes L.
      • Fischer S.
      • Berlinger N.
      • et al.
      The illness experience of undocumented immigrants with end-stage renal disease.
      Compared to standard hemodialysis, emergency-only hemodialysis has a higher death rate and is also nearly 4-fold more costly due to a greater number of emergency department visits and increased medicine ward and intensive care unit stays.
      • 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.
      • Cervantes L.
      • Tuot D.
      • Raghavan R.
      • et al.
      Association of emergency-only vs standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease.
      Emergency-only hemodialysis should raise serious ethical concerns due to the physical and psychological suffering associated with this practice.
      Some states that offer standard dialysis to undocumented immigrants also offer kidney transplantation, a decision likely informed by the longer and better quality of life at a lower cost of kidney transplantation compared with long-term hemodialysis therapy (Fig 1).
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2016 annual data report: epidemiology of kidney disease in the United States.
      Undocumented immigrants are excluded from Medicare transplantation benefits and transplantation is specifically excluded in EMTALA.
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      In California, some undocumented immigrants have received kidney transplants using the Medicaid program (Medi-Cal). Undocumented immigrants can be determined as a Permanent Residence Under Color of Law (PRUCOL), which then secures full-scope Medi-Cal.

      SI 00501.420 Permanent Residence Under Color of Law (PRUCOL) Pre-1996 Legislation. 2012. https://secure.ssa.gov/poms.nsf/lnx/0500501420. Accessed November 29, 2017.

      In this issue of AJKD, Shen et al
      • Shen J.I.
      • Hercz D.
      • Barba L.M.
      • et al.
      Association of citizenship status with kidney transplantation in Medicaid patients.
      conducted a retrospective observational cohort study that makes a valuable contribution to our understanding of the outcomes of undocumented immigrants who receive a kidney transplant. The authors used the US Renal Data System to compare transplantation outcomes between nonresident aliens (assumed to be undocumented immigrants) and both permanent residents and US citizens whose primary payer was Medicaid between 1990 and 2011. A total of 10,495 Medicaid-funded kidney transplantations met inclusion criteria; 8,660 (82.5%) were US citizens, 1,489 (14.2%) were permanent residents, and 346 (3.3%) were nonresident aliens. Compared with permanent residents and US citizens, nonresident aliens tended to be younger and Latino and had fewer comorbid conditions. With regard to transplant characteristics, nonresident aliens were more likely to have received a living donor transplant (40% vs 32% of US citizens and 27% of residents). Among living donors, the nonresident alien living donors were also more likely to be Latino and were younger. The authors assessed the geographic distribution of kidney transplantation offered to nonresident aliens and found that the states with the highest percentage of nonresident transplantations were also the same states that provided standard hemodialysis therapy to undocumented immigrants with ESRD. The states with the highest share of nonresident alien transplantations included California (71%), New York (9%), and Massachusetts (5%). The authors identified 2,741 graft losses over 37,000 person-years, for an incident rate for all-cause graft failure of 7.3/100 person-years. Compared with US citizens, nonresident aliens had a 52% lower unadjusted risk for all-cause graft loss, a 45% lower unadjusted risk for death-censored graft loss, and 58% lower unadjusted risk for death (P < 0.001 for all outcomes), but these findings were attenuated in the final adjusted model, which included comorbid conditions.
      Figure thumbnail gr1
      Figure 1Total Medicare end-stage renal disease expenditures per person per year (PPPY) by modality, 2004 to 2014.
      Reproduced from Saran et al.
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2016 annual data report: epidemiology of kidney disease in the United States.
      The main limitations of this study are that it is unclear whether the “nonpermanent aliens” are all undocumented immigrants residing in the United States (vs transplant tourism) and outcomes may be incomplete among nonresident aliens who left the country. However, sensitivity analysis of transplant recipients at the authors’ institution revealed that 95% of nonresident aliens were categorized correctly. Despite concerns over inability to pay for posttransplantation care and immigration issues interfering with posttransplantation care, the findings of Shen et al provide evidence that nonresident aliens have comparable outcomes to US citizens. One additional argument against allowing kidney transplantation among undocumented immigrants is a reduction in the kidney organ pool for US citizens. However, Shen et al found that nonresident aliens were more likely to have received a living donor transplant. This finding is consistent with that of Linden et al,
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      who conducted a cross-sectional survey exploring transplantation among undocumented immigrants with ESRD in New York. Of 45 undocumented patients with ESRD surveyed, 43 (96%) were agreeable to receiving a kidney transplant and 27 (60%) reported that they had a potential living kidney donor. Among these potential living donors, the majority were described as healthy family members.
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      Undocumented immigrants have limited access to organ transplantation, yet there is evidence that they may donate organs in higher numbers than they receive transplanted organs.
      • Herring A.A.
      • Woolhandler S.
      • Himmelstein D.U.
      Insurance status of U.S. organ donors and transplant recipients: the uninsured give, but rarely receive.
      • King L.P.
      • Siminoff L.A.
      • Meyer D.M.
      • et al.
      Health insurance and cardiac transplantation: a call for reform.
      • Vedantam S.
      U.S. citizens get more organs than they give.
      According to Shen et al, the number of nonresident deceased kidney donors was 4-fold that of the number of nonresident kidney transplant recipients during the same period. Undocumented immigrants with ESRD are aware of the double standard concerning organ transplantation and in a recent qualitative study, patients expressed their frustration: “you cannot donate to your loved one when you are alive, but they will take all of your organs when you die.”
      • Cervantes L.
      • Fischer S.
      • Berlinger N.
      • et al.
      The illness experience of undocumented immigrants with end-stage renal disease.
      Despite this awareness, a cross-sectional survey found that undocumented immigrants are willing to donate their organs.
      • Baru J.S.
      • Lucas B.R.
      • Martinez C.
      • Brauner D.
      Organ donation among undocumented hispanic immigrants: an assessment of knowledge and attitudes.
      In California, Donate Life California reported a 30% increase in people who signed up to be organ donors in 2016 compared to the same time in 2015; this increase is attributed to a law (Assembly Bill 60) that allowed undocumented immigrants who reside in California to apply for a driver’s license.

      Donate Life California. 2015. https://donatelifecalifornia.org/page/2/?s=AB+60+license. Accessed November 29, 2017.

      There are currently no regulatory prohibitions against undocumented immigrants receiving transplant care. The Organ Procurement and Transplantation Network (OPTN) states in its policies that “a candidate’s citizenship or residency status in the United States must not be considered when allocating deceased donor organs to candidates for transplantation.”

      OPTN. Organ Procurement and Transplantation Network Policies. 2017. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed November 29, 2017.

      However, before 2012, it was difficult to distinguish between undocumented immigrants residing in the United States and wealthy transplant tourism because all were categorized as “nonresident alien.”

      OPTN. Organ Procurement and Transplantation Network Policies. 2017. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed November 29, 2017.

      The OPTN committee created new categories for “nonresident” transplant recipients (ie, “non-US citizen/US resident” versus “non-US citizen/non-US resident”) to allow it to scrutinize centers in which >5% of transplants go to non-US residents. As such, medical need should guide care for “non-US citizens/US residents” (ie, undocumented immigrants living in the United States). However, undocumented immigrants are less likely to be listed for a kidney transplant because without public or private health insurance, they are unable to afford transplantation costs.
      • Herring A.A.
      • Woolhandler S.
      • Himmelstein D.U.
      Insurance status of U.S. organ donors and transplant recipients: the uninsured give, but rarely receive.
      • Evans R.W.
      • Applegate W.H.
      • Briscoe D.M.
      • et al.
      Cost-related immunosuppressive medication nonadherence among kidney transplant recipients.
      One might argue that providing kidney transplantation to undocumented immigrants would be an economic burden on taxpayers for uncompensated care, but emergency dialysis is a costly alternative with poor outcomes and ethical concerns. In addition, undocumented individuals collectively contribute $11.74 billion toward state and local taxes annually, with an estimated one-fifth ($2.4 billion) going toward Medicare.

      Gee LC, Gardner M, Hill ME, Wiehe M. Undocumented Immigrants' State & Local Tax Contributions. 2017. https://itep.org/wp-content/uploads/immigration2017.pdf. Accessed November 29, 2017.

      Zallman et al
      • Zallman L.
      • Woolhandler S.
      • Himmelstein D.
      • Bor D.
      • McCormick D.
      Immigrants contributed an estimated $115.2 billion more to the Medicare Trust Fund than they took out in 2002-09.
      conducted an analysis of the Medicare Trust Fund and found that undocumented immigrants contribute substantially more than they withdraw toward the Trust Fund, while United States–born citizens draw a deficit. Also, given the demographics of undocumented immigrants with ESRD, providing coverage for transplantation would allow them to rejoin the workforce. Multiple studies have demonstrated that undocumented immigrants with ESRD are more likely to be employed than US citizens with ESRD.
      • Linden E.A.
      • Cano J.
      • Coritsidis G.N.
      Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?.
      • Coritsidis G.N.
      • Khamash H.
      • Ahmed S.I.
      • et al.
      The initiation of dialysis in undocumented aliens: the impact on a public hospital system.
      Illinois was one of the first states in the country to pass a state law providing transplantation coverage through the state’s Medicaid program for undocumented immigrants with ESRD (Illinois Senate Bill 741 or the “Comprehensive Medical Legislation”), allowing for annual transplantation-related medications. The law was passed in recognition of the cost savings of kidney transplantation as compared to hemodialysis.

      Gee LC, Gardner M, Hill ME, Wiehe M. Undocumented Immigrants' State & Local Tax Contributions. 2017. https://itep.org/wp-content/uploads/immigration2017.pdf. Accessed November 29, 2017.

      In 2009, the former Chief Medical Officer for the Centers for Medicare & Medicaid Services challenged the renal community to scrutinize current policy and generate data and information to reform national and state policies.
      • Straube B.M.
      Reform of the US healthcare system: care of undocumented individuals with ESRD.
      Fortunately, states including California and Illinois have been able to put politics aside and have made pragmatic decisions about the treatment of undocumented immigrants with ESRD. As data accumulate showing that kidney transplantation is safe and cost-effective in undocumented immigrants, other states will hopefully make decisions based on data and common sense to allow undocumented immigrants to receive standard ESRD care, such as thrice-weekly hemodialysis and kidney transplantation. In recognition of the kidney organ shortage and the argument that these organs should be reserved for US citizens, the system could be modified such that kidney transplantation for undocumented immigrants in the United States could be allowed but limited to live donation. Doing so would allow undocumented patients with ESRD to continue being productive and active members of our society, as well as decrease the costs to our health care system.

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      Linked Article

      • Association of Citizenship Status With Kidney Transplantation in Medicaid Patients
        American Journal of Kidney DiseasesVol. 71Issue 2
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          Although individuals classified as nonresident aliens, including undocumented immigrants, are entitled to receive emergency dialysis in the United States regardless of their ability to pay, most states do not provide them with subsidized care for maintenance dialysis or kidney transplantation. We explored whether nonresident aliens have similar outcomes to US citizens after receiving kidney transplants covered by Medicaid, a joint federal and state health insurance program.
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