Dialysis for Undocumented Immigrants: Challenges and Solutions

Undocumented immigrants with ESKD have traditionally had very limited options for dialysis care. They are not eligible for Medicare, they are typically not able to afford private insurance, and they are not eligible for assistance through the Affordable Care Act (ACA). A handful of states provide coverage through Medicaid programs. For patients in the state of Texas, this is not an option. Consequently, these patients have no options for scheduled dialysis care and must present to the emergency department (ED) for evaluation for emergent dialysis. As a result of federal policy, inpatient dialysis units are not able to provide scheduled dialysis, so these patients can only receive dialysis when a life-threatening indication develops. Such practice exposes these patients to adverse health outcomes (including increased mortality) and impaired quality of life, as well as creating a great deal of stress on all levels of the healthcare system and providers, including trainees. As the primary safety-net hospital for Dallas County, Parkland Hospital has cared for the vast majority of undocumented immigrants with ESKD in North Texas, and the expected array of problems has been observed. Over the past several years we have engaged in several ongoing team-based, multidisciplinary efforts to improve quality of care for this population. Through allocation of resources, collaboration with other healthcare divisions, development of educational materials, and the creation of partnerships with organizations outside our institution, we have observed improvements in the care of our patients, including increased access to scheduled dialysis, decreased catheter-related complications, and decreased mortality. Although much work remains, we have been gratified by the improvement in patient care and hope that our story can serve as an example for others faced with similar challenges and spark discussion for needed broader policy changes.Undocumented immigrants with ESKD have limited options for dialysis care. They are …