The Case for Scheduled Dialysis Care for Undocumented Immigrants with End-Stage Renal Disease in US

Undocumented immigrants in the United States basically have to wait until they are on the brink of death to receive care for renal disease. In the United States, between 5500 to 8857 undocumented immigrants suffer from kidney failure. [4] Thrice weekly scheduled outpatient dialysis is the standard of care for patients with end-stage renal disease (ESRD); however, many barriers prevent this standard of care from being met. First, access to outpatient dialysis is limited. Additionally, under the 1972 Medicare ESRD entitlement program, or the Patient Protection and Affordable Care Act, undocumented immigrants are ineligible for Medicare. [2] Further, they are typically unable to afford private health insurance. Thus, it is necessary to enact policy changes to help support undocumented immigrants in receiving dialysis care.


Currently, undocumented immigrants comprise 27% of the uninsured population. [5] A few states provide coverage through Medicaid programs, including Colorado, California, and New York; however in most states, such as Texas, this is not an option. [1] Scheduled dialysis is usually reliant on public clinics or philanthropy, which varies drastically by state and region. Fortunately, undocumented immigrants are protected by the 1986 Emergency Medical Treatment and Active Labor Act, which states that patients cannot be turned away from receiving emergency services. To receive emergent dialysis, however, a patient must meet the criteria of serious illness, which include an elevated potassium level, nausea, vomiting, low oxygen saturation, worsening neurological systems, and clinical findings suggestive of heart failure. [2] Given this extensive list of requirements, undocumented immigrants with renal disease are often being denied dialysis until it is too late.


Compared with patients who receive scheduled dialysis, undocumented immigrants who do not receive scheduled dialysis have a five year mortality rate that is 14-fold higher and spend more time in the inpatient setting. [4] Coupled with critical health conditions, these patients face significant anxiety about death, high rates of hospitalization, and an overall lower quality of life. [1] Additionally, due to lack of insurance, patients are often diagnosed only after the emergence of severe symptoms.


“This patient had suffered three cardiac arrests and knew her days were numbered, and she didn't want to keep putting her children through the trauma of wondering if their mother would survive week to week,” said Dr. Lilia Cervantes, MD, FACP, about a patient suffering from ESRD in her early thirties with young children. “She ultimately decided to stop emergency dialysis and give up her sons for adoption so they could grow up in a loving family and pursue an education.” [3]


Dr. Cervantes’s patient’s case is not an isolated incident. The overall prevalence of renal disease in the United States is 13-16% of the population. [5] Demographics show that compared to the overall population with renal disease, undocumented immigrants with renal disease are typically Latino, younger, have fewer comorbid conditions, and possess a lower level of education. [4]


The most prominent causes of renal disease are diabetes mellitus and hypertension, which is key in understanding the importance of preventive care, and more significantly, undocumented immigrants’ lack of access to it. If action is taken earlier in the disease course, preventive care may manage diabetes mellitus and hypertension, which can help avoid the need for dialysis altogether. [3] Furthermore, early recognition of kidney disease can slow its progression and prevent further complications, as well as improve cardiovascular disease outcomes. [5] Early recognition can also allow the patient to see a nephrologist sooner, which improves mortality rates and potential for organ transplantation. [5] Moreover, treatments are less effective at advanced stages of renal disease.


To target the issue of undocumented immigrants lacking access to proper care, policy recommendations include increasing the accessibility of proper screening and primary care. Early kidney disease treatment as well as interventions focused on treating diabetes and hypertension are suggestive of better health outcomes. [5] Further research on disease prevention in the undocumented and disadvantaged population will require collaboration with policymakers. Additionally, since undocumented immigrants with end-stage renal disease tend to be younger and have fewer comorbidities, they are ideal candidates for organ transplantation. [5] In fact, the uninsured donate about 17% of transplanted organs, but receive less than 1%. [5] Additionally, up to 60% of undocumented dialysis patients have coordinated potential donors and family members prepared to aid post-transplant care. [3]Government-issued health insurance that covers organ transplants would be an excellent option for this population. Lastly, research has prompted the urgent need for expanding the benefits of Emergency Medicaid to standard outpatient dialysis for undocumented immigrants. Policy language should be modified to encompass all dialysis modalities as well as vascular access procedures. [4]


How will this be funded? Compared with $76,177 to $90,971 per person per year for scheduled dialysis, emergency dialysis costs $285,000 to $400,000 per person per year, making emergency dialysis extremely cost-prohibitive. [4] These changes can be funded by shifting the annual healthcare expenditure from emergency to scheduled dialysis which would reduce overall U.S. healthcare costs. Similarly, organ transplantation costs significantly less than the totality of other treatment costs, making increased organ transplantation access for undocumented immigrants a cost-effective change. [3] Furthermore, the health outcomes of these patients should be closely monitored. An increase in documentation of savings from standard dialysis care would prompt insurance companies to push for outpatient treatment as well. [4]


In summary, long work hours and labor-intensive jobs that undocumented immigrants undertake predispose them to developing chronic illnesses such as end-stage renal disease at a younger age compared to the average U.S. population, and they currently lack the resources to seek proper treatment. Apart from advocacy groups, undocumented immigrants have little voice in policy and society. For these reasons, urgent action is needed in policy to make sure we do not fail these populations.


References

1. Berger, Joseph R., et al. “Dialysis for Undocumented Immigrants: Challenges and Solutions.” Kidney360, vol. 1, no. 6, 2020, pp. 549–552., https://doi.org/10.34067/kid.0000682020

2. Cervantes, Lilia, et al. “Offering Better Standards of Dialysis Care for Immigrants.” Clinical Journal of the American Society of Nephrology, vol. 15, no. 10, 2020, pp. 1516–1518., https://doi.org/10.2215/cjn.01190120.

3. Colwell, Janet. “Getting Dialysis for Undocumented Patients.” ACP Internist, 1 Feb. 2021, https://acpinternist.org/archives/2021/02/getting-dialysis-for-undocumented-patients.htm.

4. Rizzolo, Katherine, et al. “Dialysis Care for Undocumented Immigrants with Kidney Failure in the Covid-19 ERA: Public Health Implications and Policy Recommendations.” American Journal of Kidney Diseases, vol. 76, no. 2, 2020, pp. 255–257., https://doi.org/10.1053/j.ajkd.2020.05.001.

5. Strategies for Responding to Undocumented Immigrants with Kidney Disease.” AMA Journal of Ethics, vol. 21, no. 1, 2019, https://doi.org/10.1001/amajethics.2019.86.

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