People whose kidneys have failed typically hook up to dialysis machines three times a week, flushing fluids and toxins from their blood. It’s how they avoid heart failure and death.
But for those without health insurance who are living in the country illegally, that hasn’t been an option in Colorado and most other states. Instead, those patients show up in emergency departments about once a week, in a condition so dire that federal law requires they receive emergency treatment.
That changed this month, under new policy put in place by the state Medicaid department.
Now immigrants here illegally can get dialysis at outpatient clinics, avoiding waiting until they can hardly breathe or walk, on the brink of heart failure, to get the toxins cleansed from their blood.
Medicaid, which is government insurance for people who are needy or have disabilities, will pay for the treatment — same as it covered the emergency, in-hospital dialysis for those patients.
A recent review of Medicaid claims data by the state — spurred by reports from public health officials — found it will save Colorado money to give immigrants here illegally regular dialysis rather than treat them only when they are gravely ill. It’s eight times cheaper, in fact.
Emergency dialysis was costing the state Medicaid department $20,291 per month per person, according to a Department of Health Care Policy and Financing analysis. That’s based on March 2017-June 2018 Medicaid claims from hospitals that treated 137 immigrants here illegally.
To compare, it costs $2,413 per month to give Medicaid patients regularly scheduled dialysis at outpatient clinics.
The policy change is expected to save the state Medicaid department $17 million per year.
“It’s really more responsible to all of the other citizens of Colorado,” said Dr. Tamaan Osbourne-Roberts, chief medical officer at the Department of Health Care Policy and Financing. And aside from the financial benefits, it’s “a wonderful way to provide better care to these particular folks,” and to ensure physicians can follow their oath to “help relieve pain and suffering,” he said.
Colorado is the sixth state to make the policy change, with approval from the federal Centers for Medicare and Medicaid Services. The change categorizes end-stage renal disease as an “emergency medical condition” because it could result in “serious impairment to bodily functions” or cause “serious dysfunction” to an organ.
That distinction is key. Federal law and state Medicaid rules say citizens who are in the country illegally can receive medical services only in emergencies. They are not eligible for Medicare or Medicaid.
U.S. citizens with end-stage renal disease are eligible for Medicare, no matter their age, meaning they can receive regular dialysis in clinics.
Colorado’s new policy took effect Feb. 1, about a week after the federal government shutdown ended — the shutdown caused by a political battle over immigration and whether to build a wall along the U.S.-Mexico border.
Denver Health researchers have pushed for the policy change for years, but now Denver Health is declining to give interviews on the topic.
Marc Williams, spokesman for the Department of Health Care Policy and Financing, noted Colorado isn’t the first state to ask federal regulators for permission to change the policy.
“Politics aside, it was really looking at how can we manage this population more effectively,” he said. “It’s something that as we look for ways to contain the costs in the health-care system and do things more effectively and efficiently, this is one that jumped out at us.”
Colorado’s decision about kidney care for immigrants here illegally is part of the broader political and ethical debate about health care for the estimated 10.7 million immigrants living in the country illegally. The Kaiser Family Foundation found those immigrants make up 14 percent of the U.S. uninsured population. The bulk of their health care is subsidized by taxpayers, often through emergency department visits.
Colorado’s Medicaid department spent $40.5 million on emergency care for 2,722 people here illegally in fiscal 2015, according to a department report to the legislature.
The state started researching the kidney-care change about two years ago and worked out the details with federal officials, said Matthew Colussi, section manager for the Colorado Benefits Management System.
Denver Health research in recent years has helped shape the national conversation on kidney care for immigrants here illegally.
A 2017 study of 20 Denver Health patients living in the country illegally and receiving emergency-only dialysis found they suffered from “death anxiety” as well as struggles with keeping jobs and caring for family because of regular, overnight hospital stays. The study’s author, Dr. Lilia Cervantes, published another report in 2018 noting that the death rate for people receiving emergency dialysis instead of regular dialysis was 14 times higher.
Emergency-only dialysis “should raise serious ethical concerns due to the physical and psychological suffering associated with this practice,” Cervantes wrote in a paper in the American Journal of Kidney Disease.
And Cervantes argues that suffering extends beyond the patients. In another study, published later in 2018, Cervantes and colleagues found that being unable to treat undocumented kidney patients until they were near death was so upsetting and stressful to those patients’ doctors, that it contributed to physician burnout.
An estimated 6,500 immigrants living in the country illegally have end-stage kidney disease. The Emergency Medical Treatment and Labor Act, passed in 1986, mandates emergency care for people who do not have insurance, including immigrants without legal documentation.
Colorado follows Washington, Arizona, Illinois, North Carolina and New York in changing policy to allow for regular dialysis. In 2014, Illinois began allowing Medicaid to cover kidney transplants for undocumented residents.
This story has been updated to reflect that it was Denver Health-based research that influenced kidney care policy.