Monday, January 18, 2010

The Undocumented ESRD Population

Although it is difficult to provide exact number, there are approximately 11 million illegal immigrants residing within the United States. Many of these individuals come from Mexico and other Latin American countries; since there appears to be a higher rate of kidney disease in Hispanics when compared to whites, it is not surprising that there exists a significant population of undocumented immigrants with ESRD. While the landmark 1972 Social Security Act provided dialysis for all those who need it, the law applies only to legal U.S. residents. What happens to undocumented ESRD patients in the U.S.?

Again, it is difficult to provide concrete statistics regarding a population which is essentially defined as being unmonitored, but it is clear that many individuals stay within the U.S. and somehow manage to obtain the life-sustaining dialysis treatments they need here. A recent AJKD paper by Hurley et al reported the results of a survey mailed out to ASN members, and 65% of respondants claimed that they had participated in the care of undocumented immigrants with ESRD, with 61% reporting an increasing prevalence of undocumented ESRD patients in recent years.
Who is paying for these dialysis treatments? As we all know, dialysis is expensive (I've heard $50,000 a year tossed around as a figure), and most undocumented immigrants simply do not have this type of income. Some do manage to obtain health insurance, and can pay for their treatments in this way. However, many don't, in which case it's often up to taxpayers (in some states, Medicaid will pay for dialysis treatments as an "emergency expense"), hospital systems, and dialysis organizations to pick up the tab. A well-publicized outpatient dialysis unit at Grady Hospital in Atlanta (see this excellent New York Times article) was losing approximately $3 million a year, in large part due to caring for a large number of undocumented ESRD patients whose treatments were not being reimbursed. The hospital seriously considered closing the unit, which would have left over 50 patients without access to the life-sustaining therapy they so desparately need, but ultimately decided to continue to operate the dialysis unit at a loss.

An article in this month's AJKD by Campbell et al summarizes the ethical dilemmas associated with care of the undocumented ESRD population quite nicely. The paper also states the current position of the Renal Physicians Association, which can be summarized as follows: all health care professionals have an ethical obligation to treat the sick (including ESRD), the federal government has an ethical responsibility to provide life-sustaining care for anybody within the U.S. borders, and because nephrologists are bound by physician-patient confidentialty agreements, they should not feel compelled to report illegal U.S. residents to the authorities.

This is a complex issue, and one which will doubtlessly need to be addressed in a more comprehensive manner in the future.


Anonymous said...

I am in Parkland Hospital in Dallas and the undocumented pts are a big part of our emergent HD pt population. We do not have a chr HD center like Grady does, but all of them show up in the ER and then as a renal fellow you have to evaluate them and dilayze for emergent indication. Atleast one shift, if not more each day in our acute HD unit is filled with them. It is a big issue atleast in Texas. Since ours is a county hospital a lot of the private hospitals will tell these pts to come to our hospital in case they fell sick which they chronically are since they do not get adequate HD. Less and less states are now dialyzing these pts in chr centers. I think Arizona, Carolinas and Illinois are ones which will reimburse for their treatments.

nathanhellman said...

Great comments--one of the aspects of the Renal Physicians Association statement that I didn't mention was that they called for ALL states to share in the burden towards treatment of undocumented immigrants requiring dialysis. As it is, states such as Texas, California, Arizona, etc are likely providing many more non-reimbursable treatments than others due to the high illegal immigrant population there.