Foolish Choices Cost Lives and Money

Jun 09 2011 Published by under MedicoLegal Concerns

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The June 9 issue of New England Journal of Medicine includes a Perspective piece from a nephrologist and hospitalist at the county hospital in Houston, TX. They discuss an issue well-known to those of us in the nephrology community, the care of illegal immigrants with kidney failure. Kidney disease strikes a disproportionate number of ethnic minorities, including those of African, Hispanic, and Native American Ancestry.

US citizens qualify for public funding for their dialysis and transplants, either through the Medicare or Medicaid programs. Federal law prohibits the use of federal funds for non-emergency services for undocumented residents. Raghavan and Nuila describe the plight of these people:

Santiago is in the ER again. He sits in a special row of 20 patients, all of whom are waiting for one result: the potassium. Is it high enough today? Two days ago he was here, and it was only 6 meq per liter. We discharged him. Right now his chest hurts, and he is short of breath. Nothing new, and Santiago knows that if he's to be dialyzed today, these symptoms don't matter. Only the potassium matters.

Thrice weekly hemodialysis, the current standard-of-care for citizens, costs $72,000 per patient per year. Some would argue that this regimen is inadequate, that we should be providing more dialysis to improve patient outcomes, but many of these patients can work and live reasonable lives. Emergency dialysis for undocumented residents places the lives of these people at risk, as well as resulting in ER visits and hospitalizations for emergencies that must be paid for by our public hospitals (using local and state tax dollars and subsidized by increasing charges to other patients). Total costs average $200,000 annually for each of these emergency-dialysis patients.

My direct experience deals with the children without papers, who came to this country with their parents. Sometimes the families can save and fund-raise and get their children transplanted, although then they must bear the burden of the costs of immunosuppression for the rest of their lives. Sometimes good parents allow their children to become wards of the state so they can get the medical care that will give them better lives.

The examples that Raghavan and Nuila provide illustrate the problems of current policy. People who came to this country illegally, but to work hard to support families, can no longer work because of the inadequate care they receive for their conditions. This inadequate care not only prevents them from contributing to the economy via their work, purchases, and sales taxes, but ends up costing the public more than if we provided standard in-center dialysis. The authors admit that this issue "lies at the intersection of debates over the soaring cost of health care and the need for immigration reform."

Do we have an ethical duty to provide the same standard of care for all sick patients within our borders? Or would mandating the providion of health care (and of maintenance-dialysis treatments) create an incentive for illegal immigration and worsen the current situation?

There is no easy solution. But with this particular disease, there are cheaper, more compassionate alternatives...

They make an excellent case for the foolishness of our current choices. Should we let these people die of their disease? Should we continue to provide our current torture care at almost 3 times the cost of standard care? Or can we come up with a more effective and cost-effective scheme for dealing with this problem?

Note: This article is not live on the NEJM site as I schedule this post; I will add a direct link to the text later on June 9. And that link is now live.

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