Running head: DIALYSIS FOR THE UNDOCUMENTED

Dialysis for the Undocumented

Anne Mailhot
St. Francis University
Clinical Applications, Cindy Drenning
June 18, 2016

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Abstract

The undocumented immigrant population is not eligible for federally funded health
programs, Medicaid and Medicare. In Denver, this becomes an issue for this population with end
stage renal disease (ESRD), a disease which requires thrice weekly dialysis. Emergent dialysis
becomes the only way to receive this treatment, posing financial and ethical issues, costing
nearly four times that of outpatient dialysis and the patient facing lethal levels of potassium,
severe uremic conditions, and massive fluid overload (Rodriguez, 2015). Four states currently
offer Medicaid funding for these ESRD patients: California, North Carolina, New York and
Washington (Campbell, Sanoff & Rosner, 2010). Other specific clinics have obtained funds to
cover this cost such as Riverside Dialysis Clinic in Texas, reducing emergency department
burden (Raghavan & Sheikh-Hamad, 2011). In Denver, safety-net hospitals like Denver Health
provide emergent only dialysis without full reimbursement and risk closure like Grady Hospital
faced (Williams, 2011). Non-emergent dialysis has proven to be the most cost-effective and
safest treatment for this disease.

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Dialysis for the Undocumented

Colorado ranks number 14 in the U.S. for number of undocumented immigrants. In early
2016 it was estimated that a total of 164,000 residents were undocumented, 75% of which were
from Mexico (States with most undocumented immigrants and where Colorado ranks, 2016).
This results in at least 164,000 residents that are not eligible for health coverage. This poses an
issue for those with severe health conditions that require regular maintenance such as ESRD,
which is 1.5 times higher in Hispanics than whites (Raghavan & Sheikh-Hamad, 2011).
Patients living with ESRD require thrice weekly outpatient dialysis in order to avoid
complications of poor renal filtration such as hyperkalemia, arrhythmias, uremia and volume
overload. The cost is about $70,000 per patient per year and is a service that the Affordable Care
Act of 2010 expanded to cover (Rodriguez, 2015). In Denver, CO undocumented immigrants
with ESRD are not eligible to receive outpatient dialysis due to lack of Medicaid coverage.
Instead, they can present to the emergency department (ED) where ED providers, hospitalists,
and nephrologists work together to determine if the patient qualifies for emergent dialysis. If
deemed emergent, the patient is admitted for 1-3 nights, or longer, only to return in 3-7 days to
repeat the entire admission again. This treatment rapidly inflates by about 3.7 times of the
standard outpatient yearly cost, and is costing tax payers over $200,000 per patient per year
(Raghavan & Sheikh-Hamad, 2011). The emergent presentation allows for a sicker patient
requiring more time in the hospital, more staff, more equipment and more medication. This also
poses an ethical issue for providers as any form of discrimination, including against immigration
status, is against the oath that providers take to care for a patient.
To have Medicaid and Medicare reimburse for undocumented immigrant outpatient
dialysis would certainly reduce the cost of dialyzing these patients. Medicaid and Medicare are

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federal and state funded programs that reimburse clinics, hospitals or facilities for health services
provided to patients (Medicaid, n.d.). These programs were signed into law in 1965 and cover
individuals with low income (Program History, n.d.). In 2014, there were about 1 million people
covered by Medicaid in Colorado (Downs, 2014). Total Medicaid spending in Colorado in 2014
was almost $6 million (Total Medicaid Spending, n.d.). California, New York, North Carolina
and Washington have successfully influenced Medicaid to pay for outpatient dialysis of
undocumented immigrants by qualifying ESRD and the need for dialysis as an emergent
condition. Most of these states recognize the PRUCOL (Permanent Residents Under the Color of
Law) designation which states that undocumented immigrants who reside in the U.S. and do not
have a record for contemplation of enforcing deportation by the Department of Homeland
Security are eligible for Social Security Benefits (Kansal & Voskoboynik, 2016).
There is controversy in the topic of providing federal funds to undocumented immigrants
due to the notion that not only are these people in the country illegally, but they do not contribute
to the taxes that allow programs like Medicaid and Medicare to exist. The Chief Actuary, a
governmental organizational entity responsible for estimating federal funds, estimated that a net
of $12 billion was contributed to Medicare by undocumented immigrants in 2007 with minimal
spending as a result of lack of access to these funds. It concluded that in 2009 alone, immigrants
made 14.7% of the contributions to the Trust Fund and accounted for only 7.9% of its
expenditures. This results in a net surplus of $13.8 billion opposed to the $30.9 billion deficit
from Medicare spending by the US-born. For each year that was evaluated, immigrants
generated a surplus every year between 2002 to 2009 ranging from $11.1 billion to $17.2 billion
per year (Zallman, Woolhandler, Himmelstein, Bor, & Mccormick, 2013).

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In fact, there have been several studies that show that immigrants use less health care
services than U.S.-born citizens, and undocumented immigrants account for only 1.5% of the
total medical costs in the U.S., most of which arise from emergency department visits. It is
proposed by the Immigration Policy Center that health care costs can be reduced overall when
more people pay into the health care system. Preventing undocumented immigrants from
purchasing health plans negatively impacts those who are paying into the system. Additionally,
more money is being spent on verifying resident status when someone tries to purchase health
insurance (Edward, 2014).
In states where outpatient dialysis for the undocumented has not been made eligible,
certain cities have taken it upon themselves to resolve the issue. For example, San Antonio uses
county taxes to fund scheduled outpatient dialysis at private, for-profit dialysis clinics (Kansal &
Voskoboynik, 2016). Denver has 7 for-profit and 2 non-profit dialysis centers, not including
Denver Health which is a safety-net hospital (Denver, Colorado Dialysis Centers and Clinics,
n.d.). In Houston, Riverside Dialysis Center funds outpatient dialysis for a limited number of
patients. Forty percent is funded by property taxes in Harris County and the rest from income
based sliding scale fees paid by the patient (Nuila, 2015). Currently, the Treasury Division of
Denver states that property taxes in Denver are among the lowest in the country. The funds are
being utilized to make improvements on city facilities, funding to the Department of Human
Services and to the Developmentally Disabled Fund, funding for affordable housing and
purchasing body-worn cameras for Denvers police officers (Denver Property Taxes, City and
County of Denver, n.d.). It does not claim any contributions towards medical services.
The presence of Community Health Centers (CHC) in Colorado is another point of access
in addressing the needs of the undocumented ESRD population. CHCs, established in 1982, are

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represented by The Colorado Community Health Network (CCHN) and employ over 4,000
Coloradans. These facilities served about 526,000 Colorado patients in 2014, and its estimated
that these clinics save the health care system about $1,300 per patient per year, and about $24
billion nationally per year. Denver County has 4 CHCs that provide preventative services to
patients, including undocumented immigrants or those with inability to pay (Colorado
Community Health Centers Strengthening Colorados Health and the Economy, n.d.).
Preventative care is a mainstay of reducing overall healthcare cost, and providing that care to
patients with impending kidney disease or detecting at an earlier stage could reduce the
prevalence and burden of ESRD.
It is clear that research lacks in Denver, and Colorado overall, on the economic impact of
treating undocumented ESRD patients and what solution would be best. Additionally, the
definition of an emergent condition in Colorado should be visited. Lastly, since sliding scale
payment programs already exist in the state for undocumented immigrants, this would be an area
of interest for a solution to this problem both for ESRD care and as a preventative measure.
However, there is limited data available for this in regards to this specific population.
Literature Review
Considering that undocumented immigrants being in the U.S. is controversial to begin
with, there is little research on how we can improve medical treatment of these patients in
addition to minimal advocacy for the issue. However, approaches to the topic in research have
assessed the matter from a financial perspective in addition to a medical one. In a 2010 review by
Campbell, Sanoff, and Rosner the cost of emergent dialysis was assessed in comparison to
scheduled outpatient dialysis in Texas. The study compared the two groups after a policy change
took place in 1997 where certain immigrants were grandfathered into scheduled dialysis (n = 22)

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and patients presenting after the policy change were eligible for emergent-only dialysis (n = 13)
(Campbell, Sanoff, and Rosner, 2010). The demographic data was analyzed by using the Fisher
exact test, signed rank test, and t test. The cost was analyzed with two-sample t test. Results
showed that the emergency dialysis group spent more days per year as inpatient (162 vs 10.1),
more days in the ICU (6.1 vs 1.54), more ED visits (26.3 vs 1.4), had more blood transfusions
(24.9 vs 2.2), fewer annual dialysis treatments (98 vs 154), lower measures of dialysis adequacy
(0.9 0.08 vs 1.64 0.05), and reported a greater level of pain with lower physical functioning.
The regularly scheduled group cost about $76,000 per patient per year compared to about
$285,000 per patient per year (Sheikh-Hamad, Paiuk, Wright, & Shandera 2007).
Another study by Raghavan and Sheikh-Hamad in 2011 looked at the financial aspects of
emergent dialysis for undocumented ESRD patients through chart review of 186 patients in
Houston, TX in which 48 of those patients were also randomly selected and interviewed.
Information collected included length of stay in the U.S., length of stay in Houston, country of
origin, current and past work history, highest level of education completed, knowledge of their
kidney disease prior to immigrating, if dialysis was a reason for their immigration, and if they
had gotten care for their disease 4 months before dialysis initiation. Statistical analysis of the
data was performed with SAS version 8.0 using students t test and Chi-square. Results showed
that undocumented dialysis patients were younger than their legal counterparts (42.6 12.6 years
vs 58.9 14.3 years, p < 0.01), and had less prevalence of diabetes mellitus (35% vs 68%, p <
0.01). The average education level completed for the undocumented immigrant was 6th grade
with 17% graduating high school compared to 77.2% of patients from the legal matched cohort.
Only 3% of the patients had knowledge of their disease prior to immigration, and 54% had been

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evaluated by nephrology in the 4 months prior to initiating dialysis. Ninety percent of

undocumented patients were employed prior to dialysis and 14% continued to work.
A similar survey was conducted in 2 New York hospitals, a state where undocumented
patients are eligible for outpatient dialysis. It was found that 73% of undocumented dialysis
patients did not receive pre-end-stage care, and only 4% had been aware of their disease prior to
immigration. They also found that the undocumented ESRD patients were twice as likely to be
employed than legal ESRD patients surveyed in those 2 hospitals, a rate consistent with the
statistic that 94% of working-age undocumented immigrant men are employed, therefore
contributing a great deal to their community and the economy (Rodriguez, 2015). By having
patients do emergent dialysis as opposed to scheduled care, this irregular schedule prevents many
of them from working, in turn affecting the local and national economy. The article notes that
there are 1200 Federally Qualified Health Centers (FQHC) funded by the Health Resource and
Health Agency throughout the U.S. These are centers that provide primary-type care to patients
regardless of ability to pay or immigration status (Rodriguez, 2015). In Colorado, primary health
care services to undocumented immigrants are available through Community Health Centers
(Health Coverage Options for Immigrants in Colorado [PDF], n.d.). This could be a key tool in
identifying kidney disease early and possibly slowing progression to end-stage.
Gap Analysis
The current practice of providing dialysis to undocumented ESRD patients in Denver, CO
is through emergent dialysis. One hospital that takes on this responsibility is Denver Health. This
hospital is a safety-net hospital consisting of 5,000 employees, and claims they do not provide
financial assistance to the undocumented. However, they will provide treatment to the uninsured.
The gap in this method of treatment lies in the issues discussed above: inflated cost and allowing

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patients to become lethally ill. This hospital is faced with poor reimbursement for these services,
which historically, in the case of Grady Hospital, has threatened closure of facilities that have
provided this service to the undocumented population (Williams, 2011).
The optimal practice for this disease is scheduled thrice weekly dialysis. Research
described above has repeatedly shown that patients receiving emergent-only dialysis require
more transfusions, more ED visits, more inpatient days, more ICU days, and more
hospitalizations when compared to maintenance dialysis (Hurley et. al, 2009). It also increases
the cost paid by tax payers by nearly 4 times.
The largest hurdle in providing the same care to these patients as other ESRD patients lies
within eligibility to receive outpatient dialysis. Since paying for the cost of this treatment out-ofpocket is unrealistic, these patients have to have funding from another source, such as Medicaid,
or allowed to receive dialysis at no or lower cost to Medicaid as in the case of Riverside Dialysis
Center in Houston, TX. The question that arises with this is if this would encourage more illegal
border crossing for access to medical care. However, as mentioned earlier, the majority of
undocumented patients receiving dialysis were diagnosed in the U.S. without prior knowledge of
poor kidney function. Additionally, in a group of patients surveyed in Indiana, those with
emergent-only dialysis access were not willing to relocate to other states where outpatient
dialysis was provided to the undocumented due to family ties and established lives (Kansal &
Voskoboynik, 2015).
The fact that the majority of these patients are being diagnosed at end-stage poses an
opportunity to utilize CHCs and the preventative care they provide to its fullest potential. The
rate at which patients have denied pre-end stage care clearly indicates there is a gap in these
patients accessing preventative care. This hinders the opportunity for early diagnosis of the

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disease and likely slowing progression to end-stage. Considering that the vast majority of the
undocumented immigrant population is Hispanic, this implies that there is an overall higher
incidence of ESRD in the undocumented population. Therefore, education on their increased risk
of the disease and the importance of accessing preventative care should be provided to this
group.
Another hurdle that is possibly as large as funding is advocacy. The topic of immigration
is a controversial one and bombards our political world. Perhaps the most impactful group that
can advocate for this population is the medical community. Berlinger and Raghavan discuss the
idea of advocacy by clinicians by consciously recognizing preferences or discriminations, and
stating All hospitals serving communities with undocumented populations should make time for
candid, reflective, and nonpunitive discussions of patient care challenges related to patients'
undocumented status.This could facilitate accurate information becoming available to other
parties that could be of assistance in a movement for change (Berlinger & Raghavan, 2013).
Conclusion
Patients receiving emergent-only dialysis have longer hospital admissions, more frequent
ICU stays, poorer quality of dialysis, and poorer quality of life. The majority of nephrologist
throughout the nation agree that this is an unethical way to treat these patients (Hurley et. al.,
2009). In order for patients or clinics to be able to get the funding to provide this treatment, the
medical community and government agencies will likely have to work together. Perhaps, this
will require changes to what Colorado Medicaid considers emergent or changing who
Medicaid covers, as in the case of California, New York, North Carolina and Washington.
Allocation of Denver County taxes to dialysis patients could also help facilitate funding in
treatment of these patients. Lastly, educating the undocumented immigrant population about

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CHCs in order to detect kidney disease earlier, providing better management of the disease, and
slowing progression could be implemented.

References
Berlinger, N., & Raghavan, R. (2013). The Ethics of Advocacy for Undocumented Patients.
Hastings Center Report, 43(1), 14-17. doi:10.1002/hast.126
Campbell, G. A., Sanoff, S., & Rosner, M. H. (2010). Care of the Undocumented Immigrant in
the United States With ESRD. American Journal of Kidney Diseases, 55(1), 181-191.
doi:10.1053/j.ajkd.2009.06.039
Colorado Community Health Centers Strengthening Colorados Health and the Economy. (n.d.).
Colorado Community Health Network. http://cchn.org/wpcontent/uploads/2016/06/CCHN-EIA-brochure-web.pdf

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Denver, Colorado Dialysis Centers and Clinics. (n.d.). Retrieved June 12, 2016, from
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Retrieved June 12, 2016, from http://www.houstonchronicle.com/local/graymatters/article/Undocumented-immigrants-The-ER-And-Harris-6535123.php

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Program History. (n.d.). Retrieved June 11, 2016, from https://www.medicaid.gov/aboutus/program-history/program-history.html

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immigrants with end-stage renal disease in Houston: A comparison of two practices.
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https://www.researchgate.net/publication/6338193_Care_for_immigrants_with_endstage_renal_disease_in_Houston_a_comparison_of_two_practices.
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Zallman, L., Woolhandler, S., Himmelstein, D., Bor, D., & Mccormick, D. (2013). Immigrants
Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They
Took Out In 2002-09. Health Affairs, 32(6), 1153-1160. doi:10.1377/hlthaff.2012.1223

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