Perspective
Survivors — Dialysis, Immigration, and U.S. LawRajeev Raghavan, M.D., and Ricardo Nuila, M.D.
N Engl J Med 2011; 364:2183-2185June 9, 2011
ArticleReferencesSantiago is in the ER again. He sits in a special row of 20 patients, all of whom are waiting for one result: the potassium. Is it high enough today? Two days ago he was here, and it was only 6 meq per liter. We discharged him. Right now his chest hurts, and he is short of breath. Nothing new, and Santiago knows that if he's to be dialyzed today, these symptoms don't matter. Only the potassium matters.
One of us is the nephrologist on service, and the other is the hospitalist taking admissions. We both trained here as medical students and have continued to work in the county hospital system as faculty members. Some of these patients remember us as residents. Now they recognize us as the gatekeepers, the people deciding which patients go home and which sit in the chair. We know them, too. There's Juan, who is 67 years old and lives 50 miles away in Hempstead. His children take turns bringing him in. There's Maria; she's 38, a mother of three. She began dialysis 5 years ago, initially just once a month; now it's twice every week. Hugo is back. He was admitted for line sepsis last month and spent 2 weeks in-house receiving antibiotics and a new catheter. He was referred for an arteriovenous fistula 6 months ago, but the waiting list is more than a year long. Hugo was brought to the United States at the age of 5; he works in an upscale restaurant and speaks perfect English. Some of the patients appear miserable, but most are like Santiago — they are just waiting patiently for a doctor to quantify their malaise.
Santiago emigrated from Mexico at the age of 20. He had no papers and no job, but he had a family to support, so he hired a smuggler to help him cross the border. He worked in construction from his first day here and helped to build Houston's highways, until one day he became inexplicably ill. He presented to our county hospital, where on his first encounter with a doctor, he was found to have a serum creatinine concentration of 15 mg per deciliter. An ultrasound and laboratory tests confirmed the diagnosis: irreversible kidney failure. A tunneled hemodialysis catheter was inserted into his right internal jugular vein, and the demands of his new life were explained: you are to come to the emergency room every time you feel sick. And every fourth day for 5 years now, Santiago has come to our ER.
More than 11 million undocumented residents live in the United States, and 6000 of them have end-stage renal disease (ESRD).1 This number seems small in the context of the 400,000-plus Americans currently undergoing dialysis,2 but the direct and indirect costs are not small. The annual cost of hemodialysis is approximately $72,000 per patient.2 Through the End Stage Renal Disease program, passed by Congress in 1973, all U.S. citizens with advanced kidney failure qualify for Medicare or Medicaid to defray these high costs.1 The Consolidated Omnibus Budget Reconciliation Act (COBRA) passed in 1986 explicitly prohibits the use of federal funds for covering undocumented residents for nonemergency services such as dialysis.3 Some states such as California and Massachusetts use state-allocated Medicaid or county taxes to pay for thrice-weekly hemodialysis for undocumented residents. Most states — including ours, Texas — do not. Here, undocumented residents with ESRD depend on public safety-net hospitals for emergency dialysis. That is to say, even though we know when these patients become ill, we must wait until their lives are at risk before we provide dialysis.
Nephrology guidelines recommend initiating dialysis when the estimated glomerular filtration rate (GFR) falls below 15 ml per minute in patients with diabetes or 10 ml per minute in patients without diabetes. Because of a lack of resources, we often delay initiation of dialysis in undocumented residents until the GFR is much lower or a patient requires emergency treatment. Our inpatient dialysis unit has 12 chairs, and priority is given to admitted patients. The line in the ER begins to swell by 6 a.m. Over the years, we've had some small victories — a special row of chairs, blood for laboratory tests drawn at triage, EKGs performed in assembly-line fashion — which have helped us maximize the provision of hemodialysis. Still, our capacity is grossly insufficient to meet the demands of the more than 180 undocumented residents (and counting) who depend on emergency dialysis in our city.3
Emergency dialysis is good for nobody. It places patients' lives at risk, and it results in more ER visits, more hospitalizations, and more blood transfusions than does scheduled dialysis. In total, these excesses result in costs of more than $200,000 per emergency-dialysis patient annually.4 Furthermore, the community loses these patients' labor, and they lose out on wages, because of their irregular dialysis schedules and poor health. These effects are apparent in our population of patients, the majority of whom immigrated to the United States to work. In our experience, very few patients immigrate to this country because of their illness. Most are like Santiago: they are survivors.
This issue lies at the intersection of debates over the soaring cost of health care and the need for immigration reform. Do we have an ethical duty to provide the same standard of care for all sick patients within our borders? Or would mandating the provision of health care (and of maintenance-dialysis treatments) create an incentive for illegal immigration and worsen the current situation?
There is no easy solution. But with this particular disease, there are cheaper, more compassionate alternatives: dialyzing at home using peritoneal dialysis, kidney transplantation, or funding of maintenance hemodialysis. Resources in our city have allowed for 100 undocumented residents to receive thrice-weekly hemodialysis treatments in a county-funded clinic.3 Patients undergoing dialysis in this clinic are healthier and happier than those who must receive emergency treatment, and many of them have returned to work.3 Like the undocumented residents cared for in other centers, our patients are young, with an average age of 43 years.3 These patients are excellent candidates for transplantation, and many have potential donors. However, the out-of-pocket costs for transplantation and immunosuppressive medications make this option untenable, despite the potential savings for taxpayers.5
In order for any of these options to work, dialysis coverage for this patient population must be standardized throughout the country. Standardization would alleviate the burden that is unfairly placed on taxpayers in areas where the most undocumented residents live, such as California and Texas.3 In states like ours, standardization of care would improve these patients' health and allow them to return to work.
Santiago would love to work, but he can't work like this — not with his body so weak. On the days he qualifies for dialysis, he arrives here by bus at 5 a.m. and leaves in the evening, exhausted. When he doesn't qualify, he comes back the very next day. Today he waits. It's July in Houston — the heat index is 110°F — and Santiago is wearing his blue hoodie. He's cold. By any moral or medical standard, he should already be upstairs, but he “looks stable,” and so we wait for the potassium. There are mouths to feed and bills to pay, but though Santiago would like nothing more than to work, his body tells him he can't, and so he rests. And in 2 days, he will begin the process again.
The names of the patients and other identifying details have been changed to protect their privacy.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Department of Medicine (R.R., R.N.), the Division of Nephrology (R.R.), and the Department of Family and Community Medicine (R.N.), Baylor College of Medicine, Houston
http://www.nejm.org/doi/full/10.1056/NEJMp1101195
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