http://www.nytimes.com/2009/11/21/health/policy/21grady.html?pagewanted=1&hpATLANTA — Each had crossed the border years before, smuggled across the desert by a coyote, never imagining the journey would lead to a drab and dusty clinic on the ninth floor of Atlanta’s Grady Memorial Hospital.
Some knew before the crossing that they had diabetes or lupus or high blood pressure, but it was only after they arrived that their kidneys began to fail. To survive, they needed dialysis at a cost of about $50,000 a year, which their sporadic work as housekeepers, painters and laborers could not begin to cover.
And so they turned to Grady, a taxpayer-supported safety-net hospital that would provide dialysis to anyone in need, even illegal immigrants with no insurance or ability to pay. Every Tuesday, Thursday and Saturday morning, the 15 or so patients would settle into their recliners, four to a room, and while away the monotonous three-hour treatments by chitchatting in Spanish.
That all changed on Oct. 4, when the strapped public hospital closed its outpatient dialysis clinic, leaving 51 patients — almost all illegal immigrants — in a life-or-death limbo.
For Grady, which has served Atlanta’s poor for 117 years, it was an excruciating choice, a stark reflection of what happens when the country’s inadequate health care system confronts its defective immigration policy.
Like other hospitals, particularly public hospitals, Grady has been left to provide costly treatments to nonpaying illegal residents who most likely could not have obtained such care in their home countries. American taxpayers and health care consumers have borne the expense.
Over time, the mounting losses have compromised Grady’s charitable mission, forcing layoffs, increases in fees and the elimination of services.
“Years and years of providing this free care has led Grady to the breaking point,” said Matt Gove, one of the hospital’s senior vice presidents. “If we don’t make the gut-wrenching decisions now, there won’t be a Grady later. Then, everyone loses.”
But for the dialysis patients, the sudden end to their reassuring routine has prompted a panic.
“We didn’t know what to do,” said Ignacio G. Lopez, 23, who had been sustained by the clinic for more than three years. “We can pass away if we stay like two weeks without dialysis. They were just sending us out to die.”
The chairman of Grady’s recently reconstituted board, A. D. Correll, has said the hospital will not let that happen.
“We made a commitment right up front that people are not going to die on the street because of these actions,” said Mr. Correll, a former chairman of the Georgia-Pacific Corporation and a prominent civic leader here.
Soccer and Telenovelas
In fact, the future for many of the patients remains uncertain. Like most of the country’s estimated 11 million illegal immigrants, they have little access to continuing health care, a reality not addressed by the legislation now under discussion in Washington.
Across the years, the Grady dialysis patients had forged a community, a family, really, of people who share a history and language, as well as a life-threatening condition. As the machines cleansed the toxins from their blood, they would talk about the scarcity of work, the ruthlessness of their disease, and their hopes for a transplant. Some would sleep, while others crooned folksongs to drown out the snores.
Any given morning might find Mr. Lopez bickering with Fidelia G. Perez about whether to watch their soap operas, or telenovelas, in English or Spanish. From another chair, Rosa Lira, a frail grandmother, would look up from her prayer book to boast of the previous night’s exploits by Club America, her favorite Mexican soccer team. Rosa Palma de Gamez, from El Salvador, would grin when Ismael Sagrero arrived with his trademark greeting — “Hola-hola!” — which had become his nickname.
Now the patients are trying desperately to figure out their next steps.
With limited exceptions, illegal immigrants are ineligible for public insurance programs like Medicaid and Medicare and often cannot afford private coverage. When major illness strikes, they have few options but to present themselves at emergency rooms, which are required by federal law to treat anyone whose health is deemed in serious jeopardy.
Officials at Grady, which will provide more than $300 million in uncompensated care this year, estimate that as many as a fifth of its uninsured patients are illegal immigrants. Although the numbers are elusive, a national study by the RAND Corporation concluded that illegal immigrants account for about 1.3 percent of public health spending.
The recession has prompted some state and local governments to pare programs that benefit undocumented workers. And although illegal immigrants may account for about 7 million of the country’s 46 million uninsured, the health care bills being negotiated by Congress exclude them from expansions of subsidized public insurance. (The House bill that passed on Nov. 7 would allow illegal immigrants to buy policies at full cost on government-run exchanges, while legislation being considered in the Senate would forbid it.)
Calling it “a horrible situation,” Mr. Correll said that governments at all levels had decided that immigrants were not their problem. “But somehow,” he said, “they’ve become Grady’s problem, which seems totally unfair.”
Some of the Grady dialysis patients have chosen to return to their countries, encouraged by the hospital’s offer of free airfare, cash payments, three months of paid dialysis and assistance in seeking insurance or other long-term remedies. Others are trying their luck in states where Medicaid policies may be less restrictive.
But most remain in Atlanta, taking full advantage of a last-minute offer by the hospital, in response to a lawsuit, to pay for three months of dialysis at commercial clinics. They are hopeful that the reprieve will buy time for the lawsuit to progress or for private dialysis providers to take them as charity cases.
What they fear, however, is that their already fragile lives will soon be reduced to a frenzied search for their next fix of dialysis, likely provided by an emergency room after a descent into crisis.
Looking for a Better Life
They need only look to Ms. Perez to see what the future may hold.
After hearing that the clinic would close, Ms. Perez, 32, set out for Alabama on Sept. 6 because cousins told her they might be able to procure dialysis there. Grady was not yet offering its deal for three months of treatment, and instead gave her $1,300, enough to cover dialysis for a week or two.
Ms. Perez said the money was quickly spent on rent, food and transportation. After going without dialysis for 16 days, she walked into the emergency room of a hospital near Birmingham, which determined that the potassium levels in her blood were high enough to require immediate filtration. Eight days later, she did the same at another Birmingham hospital.
“They said this was the first and last time they would help me,” she said. “They told me I didn’t have any right to be there.”
She went back to the first hospital, where she was dialyzed again, and then found a third hospital that was willing to provide three treatments. A doctor there tried to find a private dialysis clinic that would accept her but came up empty, she said.
So she returned to Atlanta on Oct. 11, and underwent one more emergency treatment before agreeing to fly home to Mexico with assistance from Grady and a California company, MexCare, that the hospital has hired to help repatriate interested patients.
Ms. Perez’s parents live in Mexico and can care for her, but in many cases the patients’ families and sources of support are in the United States. Some do not want to uproot their American-born children, or abandon their spouses or jobs. Often they do not trust the quality or availability of dialysis in Latin America.
Like other patients, Adolfo D. Sanchez, 31, said he had been astonished to learn when his kidneys failed in 2004 that Grady would provide him with ongoing dialysis without charge. A subsistence farmer in Mexico, he said he had paid a coyote $1,500 in 2001 to lead him on an eight-day trek across the Arizona border to Phoenix and then to Atlanta, where his sister had settled.
Three years later, while working construction, he found he could not keep down the small tacos he ate for lunch. A local clinic referred him to Grady, which diagnosed his kidney failure and placed him on dialysis.
“No place in Mexico would have offered dialysis for free,” he said, sitting in the spare apartment he shares with his girlfriend and their 13-year-old son. “It was better to be here. I am really grateful that this is possible in this country, because if I were in my country I would already have died”
Bertha A. Montelongo, a 59-year-old widow who said she entered the United States illegally in 2005, started having seizures and shortness of breath about a month after arriving in Atlanta.
“I came to look for a better life,” she said, “but then I became sick, and that was it.”
A diabetic, Ms. Montelongo has survived for four years on dialysis, but lost her vision last December. That has made her dependent on her daughter, who baby-sits and sells homemade tamales; her son-in-law, an out-of-work landscaper; and her granddaughters. They live in a rented house in the suburbs where the mantel is lit with votives.
For a blind woman, returning to Mexico, where few family members remain, is not an option, Ms. Montelongo and her family said.
“All the people here on dialysis think the same thing,” said her daughter, Letecia. “They all think that if they go back to Mexico, they will die sooner. In Mexico, it’s different. There, you have to pay.”
Creating a Crisis on Purpose
It has been different for the 25 or so United States citizens who were patients at the dialysis clinic. They were either already on Medicare or about to become eligible, and are thus being readily treated by private dialysis clinics. After a three-month waiting period, the federal insurance program covers anyone with end-stage renal disease, regardless of age, and pays 80 percent of the cost of dialysis.
But illegal immigrants are not eligible for Medicare, and legal immigrants must wait five years to qualify. A few states use emergency Medicaid programs to cover ongoing dialysis for certain illegal immigrants, but Georgia discontinued the practice in 2006.
That sent waves of uninsured dialysis patients from across the region to Grady, which is supported by direct appropriations from Fulton and DeKalb Counties, ostensibly to care for their own residents. The hospital lost $3.5 million on the dialysis clinic last year, said Mr. Gove, the Grady spokesman. Its 88 dialysis patients accounted for a 10th of total losses at a hospital with more than 800,000 patient visits a year, he said.
The board acted, Mr. Correll said, because Grady’s dialysis equipment had become obsolete, requiring heavy investment. It was evident, given that so many patients were undocumented and uninsured, that the losses would never stop.
“It was just financially hopeless,” Mr. Correll said. “For every vacancy that opened up, another nonpaying patient would walk in the door, so it was going to last forever.”
Mr. Correll said the hospital “had to precipitate a crisis” in the hope that other hospitals, dialysis centers and governments might pitch in.
Each of the remaining patients has signed an agreement stipulating that Grady will pay for private dialysis provided by Fresenius Medical Services for no more than three months, Mr. Gove said. The patients agreed to work with the hospital during that period to devise long-range plans for their care, possibly including repatriation.
What Grady has not told the patients is that its contract with Fresenius, which sets a price of $280 per treatment, covers their care for up to one year. Mr. Gove said the contract gave Grady the flexibility to continue paying for patients who fail to make other arrangements by Jan. 3. But he said the hospital’s offer to arrange repatriation would end at that point.
“As patients, they are ultimately responsible for their care,” Mr. Gove said.
The hospital’s agreement with MexCare, obtained through a state open records request, calls for Grady to pay $18,000 for every patient relocated — $6,750 in travel expenses and escort fees, a $750 administrative fee, and payment for 30 dialysis treatments at $350 each.
Two years ago, the Grady board, then dominated by political appointees, undercut its chief executive’s plan to close the dialysis clinic. The new board, now led by business leaders, hopes to save the hospital by convincing corporations and other potential donors that its fiscal discipline is worthy of support.
Mr. Correll said closing the dialysis clinic was “important to the future financial and operational success of Grady, because people have confidence now that the board will make a tough decision if it has to, and do it in the most humane way possible.”
When Mr. Lopez first showed up at Grady in 2006, five years after he had crossed into Arizona at age 15, his disease had turned his skin a pallid gray. The doctors told him he was lucky he had not waited another day.
The charge for the initial hospital stay ran to $40,000; he said his stack of bills now totaled more than $100,000. “I try to pay little by little,” he said, “but I’m never going to finish.”
He said he had never expected such generosity from American health care, calling it “very humane.” After each dialysis treatment at Grady, he said he would thank the nurses.
“You saved my life,” he would tell them. “One more time, you saved my life.”
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