It's a week-to-week challenge for Eric Wallace, MD, and his colleagues to treat patients with end stage kidney disease (ESKD) who are undocumented immigrants. Many are young people in their 20s and 30s who are working or in school; one recently was pregnant. They are not eligible for coverage under Medicare and cannot buy coverage through the Affordable Care Act on state exchanges. If they cannot buy private insurance, their only option for care is emergency dialysis, which is covered by the Emergency Medical Treatment and Active Labor Act (EMTALA).
“All of us are hoping and praying they make it to their next treatment,” said Wallace, who as medical director of home dialysis at the University of Alabama at Birmingham frequently cares for undocumented Latinx patients. He worries that a patient may have an emergency between visits and wait too long to seek help. The situation is especially heart-breaking for Wallace, whose mother came to the United States from South America as an undocumented immigrant at 18 years old and later became a citizen.
“We are treating one set of human beings differently, and they are young and exactly like my mom when she came over,” Wallace said. “You get patient and provider burnout because we are providing substandard care.”
Emergency dialysis also contributes to worse outcomes for the estimated 5000 to 7000 undocumented patients with kidney failure in the United States (1) and is about 4 times more costly than scheduled dialysis (2). These costs are paid for by the hospital or state Medicaid programs. To reduce these burdens, at least 12 states have already expanded their Emergency Medicaid programs to cover scheduled outpatient dialysis for this vulnerable group of patients (3). In August 2021, the ASN signed on to a letter from the National Kidney Foundation (NKF) urging more state Medicaid directors to make this change as well as to cover home dialysis.
“The kidney care these individuals receive is inhumane, extraordinarily expensive, and largely ineffectual,” the NKF letter states. “Our organizations believe it is imperative that state policymakers act expeditiously to follow the lead of states like Arizona and Colorado and expand Emergency Medicaid for undocumented immigrants living in the United States.”
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, Nguyen OK Association of scheduled vs. emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease. JAMA Intern Med 2019; 179: 175– 183. doi: 10.1001/jamainternmed.2018.5866 10.1001/jamainternmed.2018.5866
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; 178:188–195. doi: 10.1001/jamainternmed.2017.7039
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, Cervantes L 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: 188– 195. doi: 10.1001/jamainternmed.2017.7039 10.1001/jamainternmed.2017.7039
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Cervantes L, et al. Clinicians' perspectives on providing emergency-only hemodialysis to undocumented immigrants: A qualitative study. Ann Intern Med 169:78–86. doi: 10.7326/M18-0400
Brown J. Immigrants here illegally were waiting until near death to get dialysis. A new Colorado policy changes that. The Colorado Sun. February 25, 2019. https://coloradosun.com/2019/02/25/undocumented-immigrants-dialysis-colorado-medicaid-policy/
Jawed A. The impact of COVID-19 on undocumented immigrants needing dialysis. Kidney News 2021; 13(7):30. https://www.kidneynews.org/view/journals/kidney-news/13/7/article-p30_21.xml