Immigration Status Checks, Emergency Medicaid Utilization, and Health Care Access for Uninsured Individuals with Kidney Disease

In 2023, Florida state bill 1718 created a new policy directing hospitals that accept Medicaid to ask patients about their immigration status when seeking treatment.¹ The goal of this policy is to decrease uncompensated care by (mostly) uninsured immigrant populations. After this policy shift, use of Emergency Medicaid in Florida—the only federally funded health care to which uninsured immigrants have access—decreased significantly.² In this article, we describe the use of Emergency Medicaid, the effects of policy on dialysis access for uninsured immigrants, and possible advocacy solutions for improving equitable kidney care in the United States.

While this may have been in part due to the movement of immigrants out of Florida to states perceived as more immigrant friendly, it foretells a chilling effect on health care utilization by uninsured immigrants. This lack of utilization can have deleterious consequences for uninsured immigrants who rely on emergency care—including those who rely on KRT.

Many undocumented immigrant populations in the United States are not eligible for federal insurance, such as Medicare, and some provisions under the Affordable Care Act, but they are able to receive emergency care through Emergency Medicaid. Owing to the 1986 Emergency Medical Treatment and Active Labor Act, Emergency Medicaid allows hospitals to receive reimbursement for providing care in the setting of a medical emergency, regardless of the patient's insurance status. An emergency is broadly defined as “treatment after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in (1) placing the patient's health in serious jeopardy, (2) serious impairment to bodily functions, or (3) serious dysfunction of any bodily organ or part.”³ The Centers for Medicare & Medicaid Services and the Department of Health and Human Services Office of the Inspector General give states the authority to specify qualifying conditions and services under Emergency Medicaid.

The total cost of Emergency Medicaid relative to overall Medicaid costs is small, at 1% of all Medicaid spending. One study in North Carolina examining how Emergency Medicaid funds are used demonstrated that most of this spending is used for pregnant persons, with a small amount used for chronic diseases, such as kidney failure.⁴ In the specific case of kidney failure, where dialysis is necessary for survival, Emergency Medicaid can play a critical role for uninsured immigrants who may rely on the emergency department for care.

Twenty states in the United States provide access to dialysis for uninsured immigrant populations, largely by not excluding noncitizens in Medicaid eligibility or by including kidney failure as a condition for Emergency Medicaid eligibility.⁵ States that have changed their policies, such as Colorado, have reported a cost savings of more than $10 million a year through the provision of scheduled dialysis.⁶ In the other 30 states that fail to provide state-wide access to dialysis for uninsured immigrant populations, provision of dialysis is institutionally dependent.⁷ Institutions that provide this care are regularly left to shoulder the financial burden of this unreimbursed care or must identify charity-funded private health insurance or municipally funded off-marketplace insurance pools to provide financial support. In its absence, the only option is often emergency-only hemodialysis or dialysis only when critically ill. This practice is associated with significant and disastrous psychosocial effects for patients, their care partners, and their clinicians. It has significant system-wide effects as well: Emergency-only hemodialysis is associated with a 14-times higher risk of mortality in 5 years and is also four times as expensive compared with provision of outpatient thrice-weekly dialysis.³ Clinicians who provide substandard care to patients with kidney disease have described several drivers of burnout including emotional exhaustion from witnessing needless suffering and high mortality as well as moral distress from propagating injustice. In many areas of Florida, emergency dialysis remains the only option for uninsured immigrants.

The effects of the public charge ruling on immigrant communities' access to care may offer an example of how an anti-immigrant policy affects health care utilization. Created in 1899, the Public Charge Rule was intended to deny US visas to a select few immigrants who were likely to be unable to care for themselves without becoming a public charge reliant on public benefits. In 2019, a Final Rule issued by the US Department of Homeland Security (DHS) amended DHS regulations to expand this definition to all public benefits, leading many noncitizens to delay seeking assistance because of fear that accessing benefits would affect their or their family's status in the United States.

It is estimated that this rule change caused 2.1 million essential workers to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance.⁸ For example, a 2021 survey demonstrated that 25% of undocumented Hispanic adults avoided governmental assistance programs because of immigration-related fears.⁸ This fear may have contributed to lower rates of coronavirus disease 2019 vaccination because one third of undocumented adults reported being concerned about having to present identification to get vaccinated.⁹ Although the definition of public charge has now been restored to its narrower definition by a 2022 Final Rule issued by DHS, there remains fear and anxiety regarding use of public benefits among immigrant groups.

The recent attempts in Florida to curb health care spending for noncitizens will have adverse consequences for those with chronic diseases, including kidney failure. As has been demonstrated in other states where the uninsured rely on emergency-only hemodialysis, the result of curbing care for those in need of KRT will lead to greater intensity of care and higher costs. In areas where the uninsured rely on emergency-only dialysis, there are more intensive care unit admissions and utilization of the emergency department, leading to higher costs and mortality related to sequelae of delays in care.³ By intimidating those from seeking care, state governments risk more urgent and life-threatening hospital admissions. Ultimately, creating barriers to care for noncitizens will be more costly to the taxpayer.

Furthermore, one common refrain in favor of denying care for noncitizens is that immigrants with chronic diseases come to the United States for care. However, multiple studies have demonstrated most undocumented people with kidney failure had been in this country for 5 years or longer before receiving their diagnosis.¹⁰ As such, concerns about availability of dialysis care driving immigration of individuals with kidney failure are unfounded.

The recent policy in Florida is a warning signal of policies that may be enacted across other states with a high population of uninsured immigrant groups. Putting off access to care will lead to more urgent and life-threatening complications and higher rates of preventable hospitalizations, higher health care costs, and, most seriously, higher rates of mortality. More importantly, the intended effect of this policy on health care access is contradictory under federal law, as access to emergency care is a right under the Emergency Medical Treatment and Active Labor Act.

To ensure that the kidney community—both in affected states and nationally—is not providing substandard care on the basis of nonmedical factors, we suggest the following advocacy efforts:

• Alleviate patient anxiety through education at the time of care. Remind patients that they do not have to reveal their immigration status as it is not necessary for clinical care and using Emergency Medicaid will not affect the risk of deportation.

• Investigate if institution(s) have mechanisms to provide outpatient dialysis, thus avoiding emergency care entirely. States without state-wide access may use multiple institutional methods to avoid emergency care, including institutional contracts with outpatient dialysis facilities, use of charity care, or direct admission to inpatient dialysis units.⁷

• Encourage inpatient and emergency department social workers and care managers to apply for kidney charity care that alleviates the costs of private insurance premiums for patients with kidney failure.

• Work with local advocacy groups to raise awareness of this issue and to educate patients of their rights outside the hospital, to prevent avoidance of care.

• Advocate for state-wide change to stipulations under Emergency Medicaid. Currently, 20 states fund outpatient dialysis through Emergency Medicaid by stipulating kidney failure as an emergency condition using methods described elsewhere.¹¹

• rAdvocate for federal policy for uninsured immigrant groups with kidney failure through a presidential executive order (such as including Deferred Action for Childhood Arrival recipients in Marketplace exchange plans) or through Congress. Advancing this issue on a national level requires consistent and thoughtful touchpoints with policy leaders, requiring many of the same advocacy strategies used on the state level. Any policy change on a federal level would exponentially raise standards of care and drastically lower mortality, while lowering costs.

Florida's immigration bill requiring hospitals to include citizenship questions on patient intake forms has severely affected utilization of essential medical services by uninsured immigrants and led to deleterious consequences for those with kidney failure. Health care professionals, particularly nephrology stakeholders, can mitigate the harmful effects of these policies through advocacy at the individual, institutional, and various governmental levels. Now is the time to stand up and protect the health and dignity of all individuals with kidney disease, regardless of their immigration status.

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/JSN/E980.

Funding

None.

Author Contributions

Conceptualization: Lilia Cervantes, Ryan Murray, Katherine Rizzolo.

Supervision: Ryan Murray.

Visualization: Katherine Rizzolo.

Writing – original draft: Lilia Cervantes, Katherine Rizzolo.

Writing – review & editing: Prakrati Acharya, Lilia Cervantes, Eric Kerns, Ryan Murray, Priti Patel, Katherine Rizzolo, Prachi Sharma, Jade Teakell.