The Journal — July 2014
Tex Med. 2014;110(7):e1.
By Rohit Kuruvilla and Rajeev Raghavan, MD
Rohit Kuruvilla, Department of Medicine, and Dr. Raghavan, Department of Medicine and Division of Nephrology, Baylor College of Medicine, Houston, Texas. Send correspondence to Rajeev Raghavan MD, 6620 Main St., 11th Floor, Houston, TX 77030; email: firstname.lastname@example.org.
Providing health care to the 1.6 million undocumented immigrants in Texas is an existing challenge. Despite continued growth of this vulnerable population, legislation between 1986 and 2013 has made it more difficult for states to provide adequate and cost-effective care. As this population ages and develops chronic illnesses, Texas physicians, health care administrators, and legislators will be facing a major challenge. New legislation, such as the Affordable Care Act and immigration reform, does not address or attempt to solve the issue of providing health care to this population. One example of inadequate care and poor resource allocation is the experience of undocumented immigrants with end-stage renal disease (ESRD). In Texas, these immigrants depend on safety net hospital systems for dialysis treatments. Often, treatments are provided only when their conditions become an emergency, typically at a higher cost, with worse outcomes. This article reviews the legislation regarding health care for undocumented immigrants, particularly those with chronic illnesses such as ESRD, and details specific challenges facing Texas physicians in the future.
The undocumented immigrant population in Texas has been increasing since 2008 with a current estimate approaching 1.6 million persons.1 Although this may be attributed primarily to proximity to the US-Mexico border, favorable growth of the Texas economy and creation of low-wage jobs predicts a continued increase along this path over the next decade. Addressing the health care needs of undocumented immigrants and their families constitutes an existing problem that is solved currently by a patchwork of clinics, safety net hospital systems, and uncompensated charity care. We expect this problem to increase as this population ages and develops costly chronic illnesses such as obesity, diabetes, heart disease, kidney disease, and cancer. Unfortunately, forthcoming national health care and immigration reform legislation does not adequately address the issue of health care for this population.
Undocumented immigrants with end-stage renal disease (ESRD) represent a patient population at the center of this problem. These patients require dialysis treatments several times a week for survival. The lack of a uniform national policy to cover the cost of dialysis for noncitizens forces local health care systems into the ethical dilemma and financial challenge of providing adequate, cost-effective care for these patients. Not surprisingly, the type and frequency of dialysis treatments that an undocumented immigrant receives varies between El Paso and Houston, and even within a particular city, such as Houston.
This article reviews the past, present, and future legislation regarding health care for undocumented immigrants, while describing the challenge of managing these patients with a chronic illness, such as ESRD.
Delivering Health Care to Undocumented Immigrants
The Pew Research Center estimates that 11.2 million undocumented immigrants reside in the United States. Approximately 14% of these persons live in Texas, and this number is expected to increase.1 Primary care is delivered to this population at 1 of the 69 federally qualified health centers (FQHCs) in Texas or via safety net hospital systems.2 Both locations care for uninsured and indigent patients, regardless of citizenship. The FQHCs receive money from the federal government and are equipped to provide both primary and preventative care. Safety net hospital systems (also called "county" or "public" hospitals) tend to be located in larger cities (e.g., Houston or San Antonio) and are funded by their specific county. Although they offer a multitude of services, including specialist care and elective surgeries, a longer wait time is usually involved. One unfortunate consequence of the current system is that patients often present to the emergency room with a more advanced disease due to lack of early diagnosis or treatment. The resulting health care costs more and is often either uncompensated or inadequately compensated.
Besides the relative lack of access to specialists, undocumented immigrants face cultural and social barriers in obtaining care. One major cultural barrier is language; more than 75% of undocumented immigrants come from Spanish-speaking countries, and most are not fluent in English.1 Two social barriers often encountered are difficulty keeping medical appointments because of an irregular work schedule and fear of deportation or exposure to the law.
Between 1986 and 2013, many legislative documents have addressed the issues of health care and immigration. The Table summarizes the four most comprehensive acts, which are detailed below.
1986: Emergency Medical Treatment and Labor Act (EMTALA)
Signed in 1986, EMTALA stipulates that any person, regardless of his or her legal status, insurance status, or ability to pay, who presents to an emergency room must be medically stabilized before discharge or transfer. This law was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer. According to the law, an emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the person's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs."3
1996: Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)
The "Permanent Residents Under Color of Law" (PRUCOL) status applies to persons whom the United States acknowledges are here illegally but for whom the country is not actively pursuing deportation. Under this status, these undocumented immigrants were granted access to many public benefits. However, in 1996, PRWORA eliminated classifying undocumented immigrants as PRUCOL status, effectively terminating their access to certain benefits (eg, welfare programs and Medicaid). Some states appealed this and continue to grant PRUCOL status to undocumented immigrants.4 In California and Massachusetts, the PRUCOL status given to the undocumented immigrants allows them to receive certain health care benefits, such as scheduled dialysis. However, in Texas, undocumented immigrants are not given PRUCOL status and, hence, do not receive any public or health care benefits.
2013: Border Security, Economic Opportunity, and Immigration Modernization Act of 2013 (S 744)
Passed by the Senate in June 2013 by a vote of 68-32, this bill was awaiting approval by the House of Representatives as of May 2014. Its three primary goals are the following: to enhance border security, to renovate the immigration system by integrating the current undocumented immigrant population, and to streamline the citizenship process for highly skilled and educated persons.1 Ultimately, this bill will reduce the number of undocumented immigrants as a result of strengthened border security (adding 40,000 new agents to border patrol) and enforced hiring codes, while encouraging persons with broader educational achievement and economic potential to come into the United States through an extended visa program.
Undocumented immigrants who have lived in the United States since 2011 will be addressed as registered provisional immigrants (RPIs). After paying an initial $500 fee and any back taxes a person may owe, these immigrants may receive the RPI status if they have no criminal history. The RPI status must be extended after a 6-year probationary period. After 10 years, an RPI can apply for permanent residence, and at 13 years for citizenship. While the 13-year path to citizenship is an extended process, it affords current undocumented residents legal rights and provides them with a stable environment, relieving fears of deportation.
This act does not address health care for persons of RPI status. Hence, if this bill is signed into law, the challenge of providing care to undocumented immigrants will continue and may even increase as these persons will "come out of the shadows" and be more likely to seek primary, preventative health care and, eventually, specialist care.
2014: Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act (ACA), also named Obamacare, has been under intense scrutiny and debate since its inception. Regarding health care for undocumented immigrants, RPIs, and persons on visa, much debate has produced no conclusive answers. Obamacare was passed in 2010; it envisions complete national coverage by 2019 via a series of mandates, subsidies, and insurance exchanges. The act requires all legal residents to purchase insurance and penalizes those who do not. While Section 246 of the bill claims that “there shall be no federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States," argument has ensued on where this places RPIs and how this will affect undocumented immigrants.1
Until they receive full citizenship, neither undocumented immigrants nor RPIs will gain access to health care under the ACA as it is written today. They will be exempt from the mandatory fee imposed on uninsured citizens, and they will be unable to purchase health care insurance.
Texas and the Medicaid Expansion
The ACA can be expected to have several direct and indirect effects in Texas. Although Texas has declined Medicaid expansion, ramifications from the bill will still be present as federal insurance subsidies and the insurance trading market will be available to Texas residents. The ACA also calls for decreased reimbursements to disproportionate share hospitals (DSHs) under the assumption that most persons will be insured.5 In theory, this would reduce money available to care for undocumented immigrants and possibly place DSH (safety net hospitals) at jeopardy for hospital shutdown or withdrawal of certain services.6 Texas, with its large undocumented immigrant population and nonrecognition of PRUCOL status, is likely to feel these changes more than other states.
Undocumented Immigrants and Emergent Dialysis
All patients with ESRD require dialysis treatments to cleanse the blood of toxins and remove excess salt and water. Dialysis is either done every day by the patient at home (peritoneal dialysis) or in a center 3 times a week (hemodialysis). All dialysis patients, particularly those who are younger and healthier, are encouraged to be listed for kidney transplant. In 1973, Congress enacted a historic legislation guaranteeing federal or state funding for all US citizens diagnosed with ESRD to defray the high cost of this treatment. The cost of hemodialysis today is estimated at $87,000 per person annually.7
Undocumented immigrants with ESRD represent a population at the crux of immigration reform, health care reform, and the rising cost of chronic illnesses. EMTALA specified that an undocumented immigrant with ESRD who is medically unstable and presents to a hospital emergency room in need of emergent dialysis must be stabilized. Interpretation of EMTALA has led many hospitals, including safety net hospitals, to practice "emergent dialysis." In emergent dialysis, the patient is first evaluated in the emergency room and then only receives treatment if a life-threatening indication is present. Typical indications include shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia). This is in contrast to scheduled dialysis, which happens regularly.8
Emergent dialysis is 3.7 times more expensive per patient due to the associated costs of emergency room care (laboratory draws, studies, and physician fees) and more frequent patient hospitalizations as a result of poor health.9 Despite this high cost, this practice has been the standard of care because of the perceived notion that offering scheduled dialysis to undocumented immigrants could trigger an influx of immigrants with ESRD to the state. In the past decade, individual counties or cities have devised unique solutions to this problem. For example, all patients in San Antonio receive scheduled dialysis, paid for by the county hospital system via contract to local for-profit dialysis centers; in Dallas, patients only receive emergent dialysis. In Houston, all patients begin with emergent dialysis, but one county-funded and county-operated dialysis center accepts emergent dialysis patients when space becomes available. The Figure shows this variability in care across these three cities in Texas. This same variability in dialysis options exists across the United States for this population.
More than 400,000 US citizens receive dialysis.7 Through extrapolation of published incident rates, experts estimate that 6000 undocumented immigrants in the United States require dialysis.10 From personal communication, we estimate that more than 1000 undocumented residents in Texas require dialysis. Given the high cost of dialysis and the even higher cost of emergent dialysis, Texas taxpayers are likely paying more than $10 million to manage these patients.
Emergent dialysis is not just more costly but also forces physicians into making difficult ethical decisions, such as deciding "which patient should receive treatment." It is also associated with worse patient outcomes; the patient suffers physically from infrequent dialysis and financially from lost wages secondary to an inability to work around an irregular dialysis schedule.8
Texas has a large, growing population of undocumented immigrants. Providing comprehensive health care to this population is a challenge, and these patients rely on safety net hospital systems. Legislation from 1986 to 2013 has made it increasingly difficult for these persons with chronic illnesses to receive cost-effective, adequate care. Undocumented immigrants with ESRD receive dialysis in Texas primarily when it becomes an emergent condition. While future RPI status may grant undocumented immigrants legality, the ACA specifies that this does not grant access to health care. With a growing undocumented immigrant population in Texas, our state legislators must be aware of and address this problem before it evolves into a health care crisis.
- Passel J, Cohn D, Gonzalez-Barrera A. Population decline of unauthorized immigrants stalls, may have reversed. Washington, DC: Pew Research Center; 2013. http://www.pewhispanic.org/2013/09/23/population-decline-of-unauthorized-immigrants-stalls-may-have-reversed/. Accessed Oct. 28, 2013.
- Myers C. Affordable Care Act's effects begin showing in Texas health care system. ABC Houston. http://abclocal.go.com/ktrk/story?section=news/health&id=9098107. Accessed Oct. 30, 2013.
- American College of Emergency Physicians. EMTALA. http://www.acep.org/content.aspx?id=25936. Accessed Oct. 28, 2013.
- Gusmano M. Undocumented immigrants in the United States: US health policy and access to care. Garrison, NY: The Hastings Center; Oct. 13, 2012. http://www.undocumentedpatients.org/issuebrief/health-policy-and-access-to-care/. Accessed Oct. 20, 2013.
- Sommers BD. Stuck between health and immigration reform — care for undocumented immigrants. N Engl J Med. 2013;369(7):593-595.
- Neuhausen K, Spivey M, Kellermann AL. State politics and the fate of the safety net. N Engl J Med. 2013;369(18):1675-1677.
- USRDS 2013 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013.
- Raghavan R. One center’s approach to emergent dialysis. Semin Dial. 2012;25(3):267-271.
- Sheikh-Hamad D, Paiuk E, Wright AJ, Kleinmann C, Khosla U, Shandera WX. Care for immigrants with end-stage renal disease in Houston: a comparison of two practices. Tex Med. 2007;103(4):54-58.
- Campbell GA, Sanoff S, Rosner M. World Kidney Forum: Care of the undocumented immigrants in the United States with ESRD. Am J Kidney Dis. 2010;55(1):181-191.
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