• 1.

    Tai DBG, et al. The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States. Clin Infect Dis 2021; 72:703706. doi: 10.1093/cid/ciaa815

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Gostin LO. Is affording undocumented immigrants health coverage a radical proposal? JAMA 2019; 322:14381439. doi: 10.1001/jama.2019.15806

  • 3.

    Rodriguez R, et al. Estimating the prevalence of undocumented immigrants with end-stage renal disease in the United States. Clin Nephrol 2020; 93:108112. doi: 10.5414/CNP92S119

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Hartnett KP, et al. Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019-May 30, 2020. Morb Mortal Wkly Rep 2020; 69:699704. doi: 10.15585/mmwr.mm6923e1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Cervantes L, et al. Association of emergency-only vs standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease. JAMA Intern Med 2018; 178:188195. doi: 10.1001/jamainternmed.2017.7039

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Cervantes L, et al. The illness experience of undocumented immigrants with end-stage renal disease. JAMA Intern Med 2017; 177:529535. doi: 10.1001/jamainternmed.2016.8865

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Cooper LA, Williams DR. Excess deaths from COVID-19, community bereavement, and restorative justice for communities of color. JAMA 2020; 324:14911492. doi: 10.1001/jama.2020.19567

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Riley AR, et al. Excess death among Latino people in California during the COVID-19 pandemic. medRxiv [preprint published online ahead of print January 25, 2021]. doi: 10.1101/2020.12.18.20248434; https://www.medrxiv.org/content/10.1101/2020.12.18.20248434v2

    • Search Google Scholar
    • Export Citation
  • 9.

    Weinhandl ED, et al. Initial effects of COVID-19 on patients with ESKD. J Am Soc Nephrol [published online ahead of print April 8, 2021]. doi: 10.1681/ASN.2021010009; https://jasn.asnjournals.org/content/early/2021/04/07/ASN.2021010009

    • Search Google Scholar
    • Export Citation
  • 10.

    Cervantes L, et al. Qualitative interviews exploring palliative care perspectives of Latinos on dialysis. Clin J Am Soc Nephrol 2017; 12:788798. doi: 10.2215/CJN.10260916

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    National Immigration Law Center. Understanding the impact of key provisions of COVID-19 relief bills on immigrant communities. April 1, 2020; 1-15. https://www.fullerton.edu/tdrc/_resources/COVID19-NILC%20Relief%20Bills%20on%20Immigrant%20Communities.pdf

    • Search Google Scholar
    • Export Citation
  • 12.

    Heyman JM, et al. Healthcare access and barriers for unauthorized immigrants in El Paso County, Texas. Fam Community Health 2009; 32:421. doi: 10.1097/01.FCH.0000342813.42025.a3

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Jordan M. Farmworkers, mostly undocumented, become ‘essential’ during pandemic. The New York Times Published April 2, 2020. Updated April 10, 2020. https://www.nytimes.com/2020/04/02/us/coronavirus-undocumented-immigrant-farmworkers-agriculture.html

    • Search Google Scholar
    • Export Citation
  • 14.

    Podewils LJ, et al. Disproportionate incidence of COVID-19 infection, hospitalizations, and deaths among persons identifying as Hispanic or Latino—Denver, Colorado March-October 2020. Morb Mortal Wkly Rep 2020; 69:18121816. doi: 10.15585/mmwr.mm6948a3

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Erickson KF, et al. Employment among patients starting dialysis in the United States. Clin J Am Soc Nephrol 2018; 13:265273. doi: 10.2215/CJN.06470617

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Jordan M, Dickerson C. ‘Plz cancel our cleaning': Virus leads many to cast aside household help. The New York Times March 25, 2020. https://www.nytimes.com/2020/03/25/us/coronavirus-housekeepers-nannies-domestic-undocumented-immigrants.html

    • Search Google Scholar
    • Export Citation
  • 17.

    Page KR, et al. Undocumented U.S. immigrants and COVID-19. N Engl J Med 2020; 382:e62. doi: 10.1056/NEJMp2005953

The Impact of COVID-19 on Undocumented Immigrants Needing Dialysis

  • 1 Areeba Jawed, MD, is Assistant Professor of Medicine, Division of Nephrology and Supportive Care, Wayne State University School of Medicine, Detroit, MI.
Full access

There is mounting evidence of the disproportionate impact of the COVID-19 pandemic on racial and ethnic minorities within the United States (1). Undocumented immigrants represent one of the most marginalized segments of society with access to fewer healthcare resources and thus worse health-related outcomes (2). There are approximately between 5500 and 8857 undocumented immigrants receiving dialysis in the United States based on recent data (3). Undocumented immigrants do not qualify for regular outpatient-scheduled dialysis under Medicare or non-emergency Medicaid, and a majority of undocumented immigrants with chronic kidney disease receive emergent dialysis covered under the Emergency Medical Treatment & Labor Act (EMTALA) (3).

Higher risk of exposure due to nature of emergency dialysis

Due to concerns related to COVID-19 exposure, emergency room (ER) visits among the general population declined by 42% during the early COVID-19 pandemic (4). However, undocumented immigrants are left with no choice but to visit the ER when confronted with life-threatening emergencies related to lack of scheduled dialysis. In one study, undocumented immigrants needing emergent dialysis visited the ER an average of 6 times in 1 month (5). Multiple ER visits often requiring hospitalization, including in the intensive care units, may result in an increased risk of COVID-19 exposure, which needs to be addressed in future studies. The mental and social well-being of these patients, already impacted by the nature of emergent dialysis (6), is likely to decline further when they are forced to visit the ER amid pandemic anxiety, limited supplies of personal protective equipment, uncertainties regarding disease course, and unknown risks.

Potentially worse outcomes with COVID-19-related disease

Data specific to outcomes of COVID-19-related disease in undocumented immigrants on emergent dialysis have not been reported. However, in the general population, Latino individuals are more likely to become infected, hospitalized, and die from COVID-19 compared with White individuals (7), and much of these differences are concentrated in immigrants (8). Hispanic ethnicity is also associated with higher rates of COVID-19 hospitalization and higher excess mortality in Medicare beneficiaries on dialysis (9). Hispanic Latinos constitute the majority of undocumented immigrants. One can postulate that with overall higher mortality and morbidity with emergent dialysis, these patients are likely to have worse outcomes with COVID-19 compared to citizens on dialysis, based on ethnicity and lack of scheduled dialysis (5, 10).

Barriers to seeking medical care

The pandemic has highlighted disparities in the healthcare system, including access to basic healthcare. An estimated 7 million undocumented immigrants are without healthcare insurance after being excluded from the Affordable Care Act. Recent policy initiatives that expand access to COVID-19 treatment, such as the Families First Coronavirus Response Act; the Coronavirus Aid, Relief, and Economic Security Act; and the proposed Take Responsibility for Workers and Families Act, do not alter Medicaid eligibility, thereby excluding undocumented immigrants (11). Historically, due to lack of insurance coverage, these patients and their families have become reliant on the ER for primary care needs. Given the current strain on the healthcare system, patients are being asked to avoid ER visits; however, without access to primary care or mobile testing sites, these patients are placed in limbo. Although most COVID-19 patients can successfully be managed at home, lack of access to primary care may result in unnecessary ER visits as patients struggle with seeking help to diagnose and manage COVID-19-related diseases, adding further emotional strain for these patients.

The fear of deportation, the experiences of stigma, and racial discrimination may limit the willingness of undocumented immigrants to seek the healthcare they need (12). Despite the suspension of the US Citizenship and Immigration Services' (USCIS) new Inadmissibility on Public Charge Grounds rule, which negatively views use of public assistance when considering applications for permanent residence, there is still widespread fear of its application, which may delay patients from seeking emergent dialysis. Patients themselves may also be worried about the risk of coronavirus exposure through the ER and the risk of serious adverse events, such as volume overload, hypoxia, and fatal arrythmias, by increasing the interval days between dialysis treatments.

Social conditions contributing to increased risk of disease

The pandemic resulted in widespread stay-at-home orders across the states to limit disease spread; however, undocumented immigrants make up a disproportionate share of essential workers, which increases their risk of acquiring COVID-19 and limits their ability to work from home (13). Low-income immigrant families frequently have precarious living conditions with multiple family members sharing living arrangements to save money, which makes it challenging to self-isolate in the setting of COVID-19 exposure. Based on a recent analysis, Latino patients with COVID-19 compared with non-Latino individuals were more likely to report working while ill, exposure to someone with COVID-19 in the household, and living with multiple household members (14), which further contributes to increased morbidity and mortality from COVID-19 disease.

Economic strain

Being on dialysis is known to be associated with decreased likelihood of employment (15), with vulnerable groups having an even lower employment rate. Many undocumented immigrants are employed in the service industry and have lost their source of income during the pandemic (16). Furthermore, they will not qualify for federal relief funding in the face of rising unemployment and financial hardship. Immigrants are known to support large families within the United States and may also send resources to families overseas, and thus they are at risk for declining health as they have fewer resources to spend on medications and other healthcare-related needs (17).

The pandemic has highlighted deep-rooted inequities in healthcare access and delivery. Undocumented immigrants receiving emergent dialysis are one of the most vulnerable segments of our population, and efforts should be made to highlight their contributions to our society. A transition from emergent dialysis to scheduled outpatient hemodialysis should be part of the larger efforts to curtail COVID-19 spread and address healthcare disparities during the pandemic and beyond.

References

  • 1.

    Tai DBG, et al. The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States. Clin Infect Dis 2021; 72:703706. doi: 10.1093/cid/ciaa815

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Gostin LO. Is affording undocumented immigrants health coverage a radical proposal? JAMA 2019; 322:14381439. doi: 10.1001/jama.2019.15806

  • 3.

    Rodriguez R, et al. Estimating the prevalence of undocumented immigrants with end-stage renal disease in the United States. Clin Nephrol 2020; 93:108112. doi: 10.5414/CNP92S119

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Hartnett KP, et al. Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019-May 30, 2020. Morb Mortal Wkly Rep 2020; 69:699704. doi: 10.15585/mmwr.mm6923e1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Cervantes L, et al. Association of emergency-only vs standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease. JAMA Intern Med 2018; 178:188195. doi: 10.1001/jamainternmed.2017.7039

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Cervantes L, et al. The illness experience of undocumented immigrants with end-stage renal disease. JAMA Intern Med 2017; 177:529535. doi: 10.1001/jamainternmed.2016.8865

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Cooper LA, Williams DR. Excess deaths from COVID-19, community bereavement, and restorative justice for communities of color. JAMA 2020; 324:14911492. doi: 10.1001/jama.2020.19567

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Riley AR, et al. Excess death among Latino people in California during the COVID-19 pandemic. medRxiv [preprint published online ahead of print January 25, 2021]. doi: 10.1101/2020.12.18.20248434; https://www.medrxiv.org/content/10.1101/2020.12.18.20248434v2

    • Search Google Scholar
    • Export Citation
  • 9.

    Weinhandl ED, et al. Initial effects of COVID-19 on patients with ESKD. J Am Soc Nephrol [published online ahead of print April 8, 2021]. doi: 10.1681/ASN.2021010009; https://jasn.asnjournals.org/content/early/2021/04/07/ASN.2021010009

    • Search Google Scholar
    • Export Citation
  • 10.

    Cervantes L, et al. Qualitative interviews exploring palliative care perspectives of Latinos on dialysis. Clin J Am Soc Nephrol 2017; 12:788798. doi: 10.2215/CJN.10260916

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    National Immigration Law Center. Understanding the impact of key provisions of COVID-19 relief bills on immigrant communities. April 1, 2020; 1-15. https://www.fullerton.edu/tdrc/_resources/COVID19-NILC%20Relief%20Bills%20on%20Immigrant%20Communities.pdf

    • Search Google Scholar
    • Export Citation
  • 12.

    Heyman JM, et al. Healthcare access and barriers for unauthorized immigrants in El Paso County, Texas. Fam Community Health 2009; 32:421. doi: 10.1097/01.FCH.0000342813.42025.a3

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Jordan M. Farmworkers, mostly undocumented, become ‘essential’ during pandemic. The New York Times Published April 2, 2020. Updated April 10, 2020. https://www.nytimes.com/2020/04/02/us/coronavirus-undocumented-immigrant-farmworkers-agriculture.html

    • Search Google Scholar
    • Export Citation
  • 14.

    Podewils LJ, et al. Disproportionate incidence of COVID-19 infection, hospitalizations, and deaths among persons identifying as Hispanic or Latino—Denver, Colorado March-October 2020. Morb Mortal Wkly Rep 2020; 69:18121816. doi: 10.15585/mmwr.mm6948a3

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Erickson KF, et al. Employment among patients starting dialysis in the United States. Clin J Am Soc Nephrol 2018; 13:265273. doi: 10.2215/CJN.06470617

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Jordan M, Dickerson C. ‘Plz cancel our cleaning': Virus leads many to cast aside household help. The New York Times March 25, 2020. https://www.nytimes.com/2020/03/25/us/coronavirus-housekeepers-nannies-domestic-undocumented-immigrants.html

    • Search Google Scholar
    • Export Citation
  • 17.

    Page KR, et al. Undocumented U.S. immigrants and COVID-19. N Engl J Med 2020; 382:e62. doi: 10.1056/NEJMp2005953

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