Policy Forum Perspective: Healthcare for Undocumented Immigrants with CKD

Undocumented immigrants represent 3% of the population in the United States and 27% of the uninsured, despite passage of the Affordable Care Act (ACA) and expansion of state-based insurance coverage. There is a need for countries to re-examine policies regarding healthcare for noncitizens with chronic illnesses, including chronic kidney disease (CKD). The issue centers on the question of providing equal access to healthcare for all persons within a country’s border, regardless of immigration status.

In the United States, policies for provision of care for undocumented immigrants with kidney failure vary from state to state, resulting in increased costs for hospital systems, reduced quality of life for patients, and frequent ethical dilemmas for clinicians regarding which patients should receive dialysis.

There have been two previous reviews of the care of undocumented immigrants dependent on dialysis. In a recent issue of the American Journal of Kidney Diseases [2-18;71)4):488-494], Rajeev Raghavan, MD, provides an update to those reviews, discusses changes in US policy, examines global patterns of kidney care for noncitizens, and offers an approach for documentation and improvement in the care of individuals in this patient population.

In 2014, the states with the highest proportion of undocumented immigrants were California (20.9%), Texas (14.7%), Florida (7.5%), New York (6.9%), New Jersey (4.4%), and Illinois (4.0%). The percentage of Mexicans in the US undocumented immigrant population has decreased since 2007, while immigration from Central American has increased.

Basic healthcare is available to undocumented uninsured patients at federally qualified health centers or safety net hospitals; care is provided at those centers without regard to citizenship status or ability to pay. The centers may provide culturally oriented care as well as local bilingual staff to overcome common barriers; building trust with the healthcare system is important in undocumented immigrants who are fearful of apprehension and deportation.

In the absence of registries or databases, it is not possible to calculate the number of undocumented immigrants with kidney failure. Using the US Renal Data System incidence rate of end-stage renal disease among Hispanics (515 per million) puts the figure at 6500 individuals. There are also few data on the causes of kidney disease in this population; available descriptive analyses suggest that these patients are younger, male, and nondiabetic, and present with small atrophic kidneys.

The 1972 End-Stage Renal Disease Amendment to the Social Security Act (Public Law 92-603) provided access to dialysis and transplantation for nearly all citizens. Because undocumented immigrants do not qualify for Medicare, there is a patchwork of options among as well as within states. Approximately 30% of undocumented immigrants who have chronic kidney failure receive emergent hemodialysis only in the presence of life-threatening laboratory abnormalities and volume overload.

Patients receiving emergent hemodialysis represent large costs to local healthcare systems: approximately $285,000 per person per year in Houston, Texas, and more than $400,000 per person per year in Denver, Colorado. State (Medicaid) and local funding provide resources for patients receiving emergent hemodialysis. In Houston, 50% of undocumented immigrants receive treatment at an outpatient center funded with city taxes. In California, undocumented immigrants who require dialysis are granted Permanent Residence Under Color of Law (PRUCOL) status, a category created by the US Court of Appeals for the Second Circuit entitling undocumented immigrants residing in the United States with benefits under the Medicaid program. PRUCOL is not an immigration status recognized by the US government.

Since 2014, following inception of the ACA, more than 200 undocumented immigrants dependent on dialysis in Texas and Illinois have been able to purchase “off-exchange” plans covering thrice-weekly dialysis in outpatient clinics. The plans are upheld by one insurance company, they do not require a social security number, and the premium is funded by a third-party payer. The sustainability of this program is in question in light of efforts to repeal, replace, or weaken the ACA. Opponents believe the plan will encourage illegal immigration; however, in California, a state with the largest undocumented immigrant population in the United States and a provision that covers nonemergent dialysis, there has been no significant increase in the population of undocumented immigrants since 2005.

Insurance barriers and a shortage of deceased organ donors contribute to the low incidence of transplantation in this patient population in spite of being younger, having a lower incidence of cardiovascular disease or diabetes, having a desire to keep working, and at least 60% having a potential donor. Living kidney donor transplantation for young undocumented immigrants with no major comorbid conditions has financial benefits to the patients as well as to society. Other benefits include increased life expectancy, the ability to return to work, potential growth of the donor pool, and an alternative to dialysis saves healthcare costs.

Only 400 undocumented immigrants underwent kidney transplantation between 1990 and 2011; >70% of those were in California and from living donors. Illinois became the first state to pass legislation in 2014 to allow undocumented immigrants to be listed for kidney transplantation. In 2016, despite some opposition and defunding by the state government, approximately 50 patients underwent transplantation in Illinois. The Gift of Hope, a nonprofit organization, provided funding for post-transplant medication.

In some states, including California and Texas, undocumented immigrants with chronic kidney failure have the option of peritoneal dialysis, which is more cost-effective than in-center hemodialysis. However, the need for infrastructure (nephrology nurse and supplies) and the lack of space to store supplies create barriers for safety-net hospitals to offer peritoneal dialysis to this patient population.

Currently, there are 39 cities, 364 counties, and four states in the United States that have statutes limiting routine reporting of documentation status of individuals seeking police or health services. The current administration has initiated steps to eliminate sanctuary status, creating the possibility that hospitals and physicians would be made to act as immigration enforcement personnel. The permanent rescinding of DACA (Deferred Action for Childhood Arrivals) would also affect the care of undocumented immigrants.

In the review’s conclusion, Dr. Raghavan said, “Nephrologists provide a life-saving intervention to dialysis-dependent undocumented immigrants, an undertaking fraught with ethical dilemmas, political undertones, and variable barriers. Despite high employment rates, undocumented immigrants face an array of cultural, linguistic, economic, and legal barriers to equitable healthcare. As countries wrestle with immigration and healthcare reform, the prospects for a uniform solution to provide comprehensive care for this population seem bleak. Continued directed research in this field along with adoption of a uniform position statement by representative organizations are key steps of advocacy that would send a worldwide message of equitable care for all community members residing within any border.”

Takeaway Points

  1. Two US national agendas are at the core of the discussion regarding care for undocumented immigrants with chronic kidney disease (CKD): immigration and healthcare.
  2. In the face of no uniform national policy, an estimated 30% to 50% of undocumented immigrants with CKD receive treatment only in life-threatening situations (emergent hemodialysis).
  3. The rate of kidney transplantation in this patient population is very low due to insurance barriers, a shortage of deceased donors, and the political climate surrounding access to healthcare.