New Opportunities for Funding Dialysis-Dependent Undocumented Individuals

Abstract

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining "who gets dialysis that day." Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation.

Strategies for Responding to Undocumented Immigrants With Kidney Disease

“…In 1972, Congress passed Public Law 92-603, Social Security Amendments of 1972, which mandated Medicare coverage for dialysis for all patients with ESRD who qualified for Social Security benefits or were the spouse or dependent of someone who did. 17 Unfortunately, this coverage did not extend to undocumented immigrants even if they contributed payroll taxes. In certain states, such as Texas, many undocumented immigrants only qualify for emergency dialysis, which is provided only when potentially deadly lab findings or symptoms exist.…”

“…27 Few immigrants have been able to get coverage for regularly scheduled dialysis under unsubsidized commercial plans, but the sustainability of this option is unknown and still leaves many without coverage. 3 Although emergency dialysis is covered by law, 29 regularly scheduled dialysis is still not the standard of care for most undocumented immigrants in the United States. 30 Research has shown the potential benefits to both patients and the country of regularly scheduled dialysis, so continued advocacy for undocumented patients with ESRD is needed to make sure they get the proper care they deserve.…”

Allograft transmission of hepatitis C during the window period: Weighing the new risks and costs in the era of donor shortage

“…Antiviral treatment for chronic HCV in posttransplant recipients costs $63 000 for a 12-week course early in disease progression and results in a sustained virologic response in >90%. 6 In contrast, hemodialysis incurs a cost of $77 000-400 000 annually. 7 Elbasvir/Grazoprevir is FDA approved for treatment of HCV genotypes 1 and 4 in patients with end-stage renal disease, achieving a sustained virologic response at 12 weeks in 95% of cases.…”

The United States Needs a National Policy on Dialysis for Undocumented Immigrants With ESRD

“…The practice of emergency-only hemodialysis exists because hospitals can be reimbursed for these treatments under the Emergency Medical Treatment and Labor Act (EMTALA) of 1986, which mandated the provision of emergency care for uninsured individuals, including undocumented immigrants. 1,3 States such as California, New York, Illinois, and Washington offer standard hemodialysis therapy using nonfederal funds. In a recent qualitative study that explored the illness experience of undocumented immigrants with access to emergencyonly hemodialysis, patients described feeling distressed by the weekly accumulation of symptoms that trigger the emergency presentation to the emergency department, and many also described risking death by consuming foods high in potassium so that they would meet critically ill criteria for emergency-only hemodialysis.…”