Risks outlined for undocumented immigrants who require dialysis during COVID-19 pandemic
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In a published paper, researchers argued that undocumented immigrants with kidney failure are presented with unique risks during the COVID-19 pandemic as they attempt to obtain necessary dialysis treatments.
The researchers also emphasized that these risks have broader public health implications as patients’ contacts may also be exposed to the virus.
“As cases of coronavirus disease 2019 (COVID-19) increase, we must pause to consider a particularly vulnerable community – undocumented immigrants with kidney failure,” Katherine Rizzolo, MD, of the Maine Medical Center, and colleagues wrote, noting that there are estimated to be between 5,500 to 8,857 undocumented immigrants with kidney failure living in the United States.
Rizzolo and colleagues wrote that undocumented immigrants are more likely to be younger, have a lower educational level and are less likely to receive appropriate health care prior to kidney failure.
Most importantly, the researchers contended, is that many undocumented immigrants rely on dialysis treatments through an ED (which occurs approximately six times per month). While the standard of care for patients with kidney failure is in-center dialysis three times per week or daily home dialysis, undocumented immigrants are excluded from the provisions of the Affordable Care Act related to end-stage renal disease, as well as other federally funded Medicaid programs for standard outpatient dialysis. As hospitals must treat anyone who enters with an emergency medical condition based on The Emergency Medical Treatment and Active Labor Act, the researchers wrote that many undocumented immigrants rely on “emergency-only dialysis.”
The researchers suggested that emergency-only dialysis is not a feasible option even when the country is not facing a global health crisis, as this type of dialysis is linked to lower quality of life, higher rates of mortality and places a significant burden on the health care system (estimated costs of $285,000 to $400,000 per person per year; cost reductions of $5,768 per person per month have been estimated when patients who utilize emergency-only dialysis switch to outpatient dialysis). During the COVID-19 era, these negative outcomes are magnified and each emergency treatment presents added risks including risk for exposure to the virus which, the researchers indicated, also increases risk of exposure to family members and other contacts.
“The Latino community is already at disproportionately higher risk of COVID-19 infection and death, attributed to inability to social distance in work and living environments, higher rates of comorbidities, and poor access to care,” the researchers wrote. “As such, a COVID-19 infection acquired via emergency-only hemodialysis could result in an exponential increase in the number of COVID-19 cases in the community.”
According to the researchers, not only does every hospital admission for dialysis treatment increase risk for exposure but inpatient beds, dialysis supplies (of which there is already a shortage) and nursing resources are being “unnecessarily” utilized.
“This is especially problematic in communities facing a COVID-19 surge, where nephrologists are making decisions about altering dialysis treatments to meet the needs of greater numbers of patients,” the researchers argued.
Due to these challenges, the researchers proposed alternatives to emergency-only dialysis, citing that 12 states have already allowed undocumented immigrants to receive outpatient dialysis by making changes to their emergency Medicaid coverage.
“There is no stipulation that emergency medical conditions have to be treated in the inpatient setting, and the Centers for Medicare and Medicaid Services defers to states to determine what conditions qualify as emergencies,” the researchers wrote.
They further addressed what can be done in states in which emergency Medicaid does not cover outpatient dialysis, suggesting that options for acquiring private insurance be expanded (paid for by “nonprofit entities,” or county-funded and hospital-funded outpatient dialysis centers).
According to the researchers, The Coronavirus Immigrant Families Protection Act (which was introduced on April 3), is also an important step in improving care for undocumented immigrants as it “seeks to suspend the public charge rule and immigration enforcement at sensitive locations [and]... seeks to allocate $100 million for the CDC to provide language-appropriate public health outreach materials.”
They concluded: “Bold action is required to protect immigrant populations during the COVID-19 pandemic, and should include a move toward covering outpatient dialysis in all 50 states.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
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