Kill incentive to deny care to the vulnerable

Since 1965, and Congress’s enactment of Medicaid legislation, the U.S. has expressed as one of its core concerns that fundamental health care would be provided to all, regardless of economic status.

Later Medicare legislation also made clear that the poor who suffered End Stage Renal Disease would be able to get dialysis, but in so doing it also made a distinction between the poor, those who were citizens or documented aliens, and those who were not.

Doctors in practice made no such distinctions. They knew that dialysis was life-sustaining care for patients with ESRD. They knew that an ESRD patient would die within two weeks without dialysis. They provided care to their patients based on what the patient needed regardless of whether they could pay. And they did not ask citizenship questions as part of their diagnosis. That was irrelevant to the ethics of the situation, and to their Hippocratic Oath.

In 1986, Congress also made clear that everyone, regardless of their means or status, would be able to get access to emergency medical treatment. The U.S. would not have health care denied anyone who would show up at a U.S. hospital emergency room. Care provided in the emergency room would also be compensated by the government, but to the doctors providing emergency care, this was irrelevant. As a matter of ethics, patient emergent care took precedence over compensation.

Unfortunately in some states (Georgia, Texas, New Mexico), the evolution of the law has set up an incentive to deny dialysis treatment to nondocumented immigrants. Recently, Grady Memorial Hospital closed its outpatient dialysis clinic to save itself money.

This sets up a situation where nondocumented immigrants’ only choice is to show up at the hospital’s emergency room for treatment.

While Grady may then get reimbursed, recent studies make clear that managing ESRD through emergency admissions is three to four times more expensive than if the patient attends regularly scheduled outpatient dialysis treatments. It ends up costing Medicaid (both state and the federal government in partnership) more money to treat nondocumented immigrants in the emergency room than to do the right thing, and reimburse for treatment according to regular outpatient dialysis protocols.

Many feel that even if it costs more to the state to provide dialysis, core religious and U.S. values require that the state treat any and all patients with ESRD.

Isn’t there something fundamentally inhumane with making a person with ESRD go into an emergent state, suffering heart arrhythmia or other critical acute symptoms in order to get treatment?

Moreover, studies show that nondocumented immigrants do not know they have ESRD before coming to the U.S. This is not a risk they chose by coming to the U.S. They came as generations have in the past out of economic desperation and in search of a better life by offering their labor in a marketplace where there is a demand for those willing to work in undesirable jobs.

Most nondocumented immigrants work in the U.S. and pay taxes here (an estimated $250 million annually paid in taxes in Georgia), yet do not have work-provided medical insurance because their employers don’t have to provide it for them. They are taken advantage of because of their desperate circumstances and questionable status.

Economic analysis demonstrates that citizens in Georgia receive a significant per capita economic benefit from the overall economic impact of undocumented immigrants residing in the state, after accounting for all existing public expenditures resulting from their presence in the state.

So the U.S., a country of immigrants, is confronted with a defining dilemma — how to reconcile the conflict between its core religious values, ideals and principles of uplifting humanity, with its actions of bypassing those that now lay at its feet in need of care and healing, fueled by fear and ignorance, and therein oppressing humanity.

But, even to those captured by the fear that their own health care is somehow jeopardized by providing health care to others, in this case it makes sense to do what is right — treat nondocumented immigrants in dialysis clinics — because it is cheaper to treat them there than in the emergency room.

Finally, if the U.S. is to live up to its values, you know, those written on Statue of Liberty (“Give me your tired, your poor. Your huddled masses yearning to be free ...”) then we need the House bill version of health care reform. It would give nondocumented immigrants the right to purchase health insurance, just as would anyone else.

In the meantime, local communities and states should come together and do the right thing, and save money in the process.

Whether this means that nondocumented aliens with ESRD be treated at Grady’s dialysis clinic, or that all state dialysis clinics take their fair share, reimbursed by the state, or whether doctors who treat ESRD organize to ensure that these patients are adequately cared for, or whether this patient population be provided through some combination of state and nonprofit funders, the community needs to come together to do right, and save money. Right now our fears have divided us from each other and make us blind to the harm that will soon be our responsibility to bear.