Barriers to providing optimal dialysis care for undocumented immigrants: Policy challenges and solutions

Abstract

Access to hemodialysis for undocumented immigrants with end stage renal disease (ESRD) is widely variable across the United States and highly dependent upon state policy. Some states have enacted policies to provide coverage for standard dialysis to undocumented immigrants, while other states do not provide coverage. Patients living in some states which do not provide coverage rely on emergency federal coverage through the Emergency Medical Treatment and Active Labor Act. However, this act requires that patients present with an acute, life‐threatening condition in order to receive dialysis, which is then referred to as “emergency‐only hemodialysis” (EoHD). Because EoHD requires patients to present in life‐threatening condition, patients who rely on EoHD suffer from debilitating physical symptoms and psychosocial distress. Undocumented immigrants who receive EoHD also have staggeringly higher mortality rates than those who receive standard hemodialysis. Moreover, in comparison with standard dialysis, EoHD results in greater health care utilization and higher health care costs. Therefore, EoHD represents a very low value care practice, providing substandard care at a greater cost. Policy change is urgently needed to provide undocumented immigrants with ESRD access to the standard of care; that is, three‐times weekly standard hemodialysis or peritoneal dialysis.

Dialysis for Undocumented Immigrants: Challenges and Solutions

“…Because of inconsistent, inadequate dialysis, they have endured impaired quality of life, frequent hospitalizations, high rates of access related complications, and increased mortality compared to patients on scheduled dialysis 1-3 . Similar experiences have been reported elsewhere [4][5][6][7][8][9][10] .…”

Immigration status and end‐stage kidney disease: Role of policy and access to care

“…Medicaid expansion at the state level requires a policy analysis, research on cost analysis, and then engagement of all stakeholders, including affected patients, health policy individuals, executive staff at the safety-net hospital, and state Medicaid. 53 Second, the improvement of federal funding within or outside of the ACA should be addressed. A shared responsibility at the national level needs to be addressed so that coverage does not fall disproportionately on highly burdened states.…”

“…In addition to pre‐dialysis care, the uninsured population is unlikely to be diagnosed and receive treatment of comorbidities (including cardiovascular disease, diabetes mellitus, and hypertension) or any interventions (including PD, home dialysis, or transplant). Furthermore, vascular access care is limited 53 . Eighty percent of patients are initiated on dialysis with a high‐risk catheter, and in the uninsured, only 8% have a fistula 13 .…”

“…First, several states have qualified ESKD as an emergency condition under EMTALA. In Colorado, the Department of Healthcare Policy and Financing (Colorado Medicaid) changed this stipulation in February 2019, thus expanding access to standard dialysis for undocumented immigrants with ESKD 53 . Other states, including Arizona and Washington, have done the same.…”

“…Despite the current lack of access, undocumented immigrants donate organs at a high rate: 10% of organs come from undocumented donors, though they receive <1% of donated organs 5. Undocumented immigrants are more likely to have a potential living donor and have a lower rate of transplant loss even after adjustment for demographics, comorbidities, time on hemodialysis, and transplant factors 53. Transplantation saves money compared to outpatient renal replacement therapy after 1.5-2.7 years.…”