When Lauren Kasper was starting her career as a nurse practitioner, one of her patients, a 30-year-old father who had come to the emergency room for dialysis, died “a slow, horrible death.”
The worst part, Kasper said, was that the man’s death was avoidable.
“I decided, I can’t sit here, knowing we can do something,” she said “Watching people die like this, it’s so pointless.”
The young father died of kidney failure after waiting too long to get dialysis. As an undocumented immigrant, he was not eligible for insurance under the Affordable Care Act or for Medicaid and had no way to pay for what should have been routine and regular treatment.
Although the death happened years ago, immigrants today continue to suffer from the same situation. Kasper, now a hospital administrator, and other physician advocates across Georgia are working to convince state officials to make changes to address the dangerous and costly gap in care.
Up to 800 undocumented immigrants living in Georgia at any given time require dialysis, said Dr. Shamie Das, physician at the Emory University Hospital emergency department. Many undocumented dialysis patients show up at emergency rooms with health problems like shortness of breath or even cardiac arrest due to not receiving dialysis when needed, Dr. Das said.
For people whose kidneys don’t filter blood the way they should, dialysis is a treatment that removes wastes, toxins and excess fluid from the blood. People with kidney failure who don’t receive routine dialysis not only experience multiple health problems, their mortality rate within five years of initiating treatment is more than 14 times higher than those who do, according to research.
A federal law requires hospitals to treat anyone who comes to the emergency room, even when they can’t pay for their care. Treating dialysis patients in emergency rooms can cost up to $400,000 per patient each year — or about four times what outpatient dialysis would cost if done on a regular basis, according to a 2020 article in the American Journal of Kidney Diseases. Despite the federal law requiring hospitals to provide emergency care, hospitals aren’t reimbursed and some of those costs are borne by taxpayers. Some are written off as charity care. Some contribute to rising insurance and healthcare costs, according to experts.
During the pandemic, the situation has also created additional problems for short-staffed, overloaded emergency rooms, contributing to longer wait times for all patients, as well as exposing dialysis patients to the virus.
Kasper, Dr. Das and colleagues are pushing to have Georgia cover the cost of routine dialysis. In Georgia’s Medicaid system, a program known as “Emergency Medical Assistance,” could be expanded to allow healthcare facilities to be reimbursed for routine dialysis treatments for undocumented immigrants.
The move would not only improve and even save lives, say Kasper and her colleagues, but be more cost-effective, saving public and private hospitals tens of millions a year. At least 12 states have adopted similar measures — including those like Arizona, with large undocumented immigrant populations.
Dr. Josh Mugele, emergency medicine program director at Northeast Georgia Medical Center, supports the idea. Earlier this year, paramedics brought a patient in his 20′s to one of the hospitals where he works. The man had suffered a heart attack at a shopping center. “Cardiac arrest is unusual for people in their 20s,” said Dr. Mugele. “I didn’t think immediately of him missing dialysis ... but it became apparent pretty quickly that the patient had too much potassium in his blood, a condition that occurs in renal disease. We were able to treat and resuscitate him.”
Dr. Mugele later discovered the patient lived several hours away, was undocumented, and only received occasional dialysis. He had suffered a previous heart attack. “Imagine if he continues this way,” Dr. Mugele said. “He will collapse somewhere where there won’t be bystanders.”
The emergency doctor said he has seen similar cases “dozens of times” in his three years working in Georgia.
Dr. Das and Kasper are completing research on the issue for submission to a peer-reviewed journal. They did a survey involving 90% of the hospitals in Georgia and estimate that there are 500 to 800 undocumented immigrants who are dialysis patients across Georgia at any one time.
Another voice in support of a change comes from the Medical Association of Georgia, a group representing physicians. The association passed a resolution late last year in support of pursuing a “fiscally responsible” change to state Medicaid or other government programs to cover routine dialysis for undocumented patients, said Bethany Sherrer, director of government relations and general counsel.
Dr. Liliana Cervantes cared for a patient who she then befriended until the woman died in 2014 after being unable to obtain regularly scheduled dialysis. The internal medicine hospitalist set about seeking a change in her state of Colorado. It took a few years, but the state moved in 2019 to include scheduled dialysis for undocumented immigrants under Emergency Medicaid. Now, Dr. Cervantes informally advises medical colleagues in five states seeking to do the same, including Georgia.
In her experience, she said, “every environment has policymakers who are polarized. It’s important to understand factors that would influence their decision-making. In Colorado, the most important factor was cost.” Dr. Cervantes added that “not only does emergency dialysis cost more — people are able to rejoin the workforce more quickly and contribute to the tax base if they receive regularly scheduled dialysis. So it’s a win-win for everyone.”
Kasper said she hopes Jerry Dubberly, state Medicaid division chief, makes the change without needing the state Legislature to act, but realizes the issue may require changing Georgia code. Officials at Grady Memorial Hospital said they are “in communication” with the Department of Community Health, which oversees Medicaid, about “policies in other states” that have addressed undocumented immigrants with kidney failure.
The issue is not new in Georgia, she noted: in 2010, Grady, Emory and private dialysis centers agreed to cover treatment for a small group of undocumented patients and sent a smaller group back to Mexico. Nearly half of the second group died.
But now, the problem is more acute, not only because the population of undocumented immigrants has grown, but because the emergency room has become a much-needed, limited resource each time there’s a surge in COVID cases. “I’ve seen this problem get worse during the pandemic — when we’re resource short,” said Kasper.
The situation has contributed to what Dr. Das called “moral injury,” a concept described by one researcher as “a deep emotional wound ... unique to those who bear witness to intense human suffering and cruelty.” Moral injury in healthcare workers has been described as prevalent in research on this issue, and has also increasingly surfaced during the pandemic.
“They cry. You cry. You see patients deteriorate so quickly,” Kasper said. “The ones who are still alive are in terrible condition. It’s really hard to watch.”
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