“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

                                                – Hippocratic Oath (Modern version)

While the fundamentals of the Hippocratic oath are revered by most medical professionals, they seem to fall short in addressing the challenges of today’s world of medicine. The rising costs of healthcare and new technology has led to a greater need for considering economic issues when delineating care. As a result, the field of medicine can be affected by commercial industry, government, and economics. The healthcare of undocumented immigrants has been an ongoing struggle. A recent AJKD Policy Forum by Rajeev Raghavan discusses the challenges faced by medical organizations and healthcare providers in caring for undocumented immigrants with kidney disease, and proposes potential humane and cost-effective approaches to improve care for this population.

From advocacy to public policy: a proposed scheme to improve the lives of undocumented immigrants with kidney disease. These are 4 steps that can be done simultaneously to improve the lives of the vulnerable patients with advanced kidney disease, including noncitizens, migrants, undocumented immigrants, or asylum seekers. Figure 1 from Raghavan, AJKD © National Kidney Foundation.

Undocumented immigrants are estimated to constitute 3% of the U.S population (approximately 11 million). Many undocumented adults lack health insurance, constituting 27% of the uninsured. They tend to seek medical care through emergency rooms where they are guaranteed medical care. However, in the current political scenario, many are inclined to forgo essential medical care due to the fear of deportation. Older patients and those with chronic illnesses fail to receive regular care, making chronic conditions worse, and consequently more expensive to treat.

While nearly all US citizens have access to dialysis and transplantation, undocumented immigrants are ineligible for Medicare. Over 30% of undocumented immigrants with ESRD receive hemodialysis (HD) only for emergent and life-threatening complications. Emergent hemodialysis has been reported to impair patients’ quality of life and also pose significant healthcare cost burden ($285,000-$400,000 per person annually) compared to routine thrice-weekly dialysis. Some states like Texas and California have policies, funding resources, or charitable outpatient centers that allow these patients to receive regular thrice-weekly dialysis.

It is notable that most undocumented immigrants with ESRD are young and relatively healthy and about 60% of them have a potential kidney donor. However, despite the known health and economic benefit of living kidney transplantation to both patients and society, these patients face multiple obstacles to obtaining a kidney transplant. Barriers include insurance related issues, shortage of decreased donor organs, and United Network for Organ Sharing policies regarding noncitizens, to mention a few. The major barrier to peritoneal dialysis is inadequate space for storage of supplies. It is unfortunate that end-of-life care and hospice services are also not reimbursed for these patients.

Undocumented Immigrants and Global Renal Replacement Therapy. Table 1 from Raghavan, AJKD © National Kidney Foundation.

In this age of globalization and mass migrations, with a rising incident ESRD population, it is prudent to develop policies regarding care of undocumented immigrants with CKD and ESRD. Data clearly suggest that regular thrice-weekly HD and transplantation are more cost-effective than emergent HD in undocumented immigrants. Additionally, as the majority in this population are employed, their lost wages are a negative impact on the national economy.

Raghavan suggests various approaches that may help mitigate the healthcare and economic burden that complicate caring for undocumented immigrants. The first step would be to accept them as part of the community, since they have already arrived here. The American College of Physicians suggests that undocumented immigrants should be eligible to purchase private insurance and subsidies as well, without which insurance costs are unaffordable.

The Renal Physicians Association in 1999 published a consensus statement on the care of undocumented immigrants with kidney failure. More recently, the Coalition for Kidney Care for Non-Citizens proposed a multidisciplinary approach to care of these patients, emphasizing the following:

• Ethical obligation among healthcare professionals to provide care to patient irrespective of social or political differences
• Advocacy for public and charitable funding programs
• Patient confidentiality with respect to citizenship status
• Even distribution of healthcare resources

In summary, Raghavan elaborately described the various aspects of healthcare provision to undocumented immigrants with kidney disease. There appears to be a dire need for developing a global statement on how to improve care for undocumented patients with kidney disease. This is a complicated medical, ethical, and even political decision that likely does not have a uniform and universal solution. But for now, we can start by reminding ourselves that the Hippocratic Oath applies a physician’s care to all fellow human beings regardless of their citizenship.

– Post prepared by Ritu Soni, AJKDBlog Contributor

To view the Raghavan Policy Forum (Freely Available), please visit AJKD.org.

Title: Caring for Undocumented Immigrants With Kidney Disease
Author: Rajeev Raghavan
DOI: 10.1053/j.ajkd.2017.09.011