The following is a two part series on why undocumented immigrants with end-stage renal disease (ESRD) should be covered by Medicare. This issue needs to be discussed among all SPHers, not just HMP students. This first part will focus on background of the current situation.
Are you familiar with end-stage renal disease (ESRD)? To date, it remains the only medical diagnosis in the United States which unconditionally guarantees Medicare coverage to all citizens regardless of age. Since Congress passed the Social Security Act of 1972, state and federal funding has paid for citizens who require “a regular course of dialysis or kidney transplantation to maintain life” (Goldberg, Simmerling, & Frader, 2007). Just two major problems: 1) Undocumented immigrants with ESRD are not covered; and 2) Regardless of insurance status, ESRD patients still require weekly, life-saving dialysis treatment.
To all future hospital administrators, you should care because of a little law named Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA mandates that hospitals receiving Medicare payments provide emergency healthcare treatment, in this case emergent dialysis treatment, to those uninsured patients presenting in the ED from kidney failure. Ben Taub General Hospital in Houston, Texas, treats approximately 90 undocumented immigrants, running three shifts per day on ten dialysis chairs (Raghavan, 2012). Here is a hypothetical scenario (similar to other safety net hospitals) based on experiences at Ben Taub General Hospital:
At 6am, John enters the emergency department alongside 25 other patients with dangerously low glomerular filtration rate levels. For any citizen, such deteriorated condition would guarantee immediate dialysis treatment, but not for John. The nurse practitioner, understanding the dire circumstances of each patient, weighs each life against life. Each patient is checked-in, asked a brief medical history, and physically examined. Based on lab draw results, patients will be ranked according to level of illness-severity, determined by potassium levels in the blood. After waiting for as long as ten hours for a dialysis chair, only 15 of the 25 patients will receive the care they need for survival, the remainder will be sent home.
At 8am, the dialysis nurse manager estimates the number of spots available for emergent dialysis. This number fluctuates daily depending on inpatient admissions. John is “fortunate” enough to receive care that day and enters the dialysis suite at the nephrology clinic. Here a physician assesses each patient, writes acute dialysis orders, and begins treatment. Filtration will take between three and four hours, followed by education counseling on restriction of dietary sodium. By 3pm, those who have not yet been dialyzed, but are deemed too sick to safely discharge are either admitted to the hospital or held overnight to receive dialysis care the following day. Those deemed “too healthy” are forced to return tomorrow.
Indisputably these patients receive sub-optimal treatment for a condition that has proven treatment methods. In part two, I will identify key stakeholders in the debate and explain the economics behind the expansion of Medicare coverage for undocumented immigrants with ESRD.
Lastly, although this series will not focus on immigration policy, I must address one concern that many readers may raise. A chief issue with expanding Medicare ESRD coverage eligibility is the belief that undocumented immigrants cross our borders to freeload off our medical system. Even with EMTALA, research indicates this to be a minor incentive relative to other factors. Contrary to the prospect of emergent healthcare benefits, the overwhelming impetus for immigrating to the United States is the prospect of employment and higher wages. During a study of 186 undocumented immigrants, it was determined that more than 95% of the undocumented patients from Houston, Texas, progressed to ESRD while residing here in the United States (Raghavan & Sheikh-Hamad, 2011). Similarly, in 2004, the National Kidney Foundation published similar findings about the health behavior of undocumented immigrants from two New York City public hospitals, Nassau University Medical Center (NUMC) and Jacobi Medical Center (Coritsidis, et al., 2004).
Andy Mychkovsky is a second year HMP student at the School of Public Health.
Coritsidis, G. N., Khamash, H., Ahmed, S. I., Attia, A.-M., Rodriguez, P., Kiroycheva, M. K., et al. (2004). The Initiation of Dialysis in Undocumented Aliens: The Impact on a Public Hospital System. American Journal of Kidney Diseases, 424-432.
Goldberg, A. M., Simmerling, M., & Frader, J. E. (2007). Why Nondocumented Residents SHould Have Access to Kidney Transplantation: Arguments for Lifting the Federal Ban on Reimbursement. Transplantation, 17-20.
Raghavan, R., & Sheikh-Hamad, D. (2011). Descriptive Analysis of Undocumented Residents with ESRD in a Public Hospital System. Dialysis & Transplantation, 78-81.
Raghavan, R. (2012, May). When Access to Chronic Dialysis is Limited: One Center’s Approach to Emergent Hemodialysis. Seminars in Dialysis, pp. 267-271.