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Dialysis dilemma: Who gets free care?

In California, officials say not treating illegal migrants has high cost.

October 29, 2008|Alan Zarembo and Anna Gorman | Gorman and Zarembo are Times staff writers.
  • Marguerita Toribio, an illegal immigrant, is prepped for dialysis at the St. Joseph Hospital Renal Center in Orange. She has undergone the procedure about 2,000 times in 17 years, and U.S. taxpayers have covered the entire cost of her treatment in California: more than $500,000 and rising, not including a kidney transplant in 1993.
Marguerita Toribio, an illegal immigrant, is prepped for dialysis at the… (Mark Boster / Los Angeles…)

Roughly 2,000 times over the last 17 years, Marguerita Toribio, an illegal immigrant from Mexico, has climbed into a cushioned recliner for the three-hour dialysis treatment that keeps her alive.

She has never seen a bill.

U.S. taxpayers have covered the entire cost of her treatment in California: more than $500,000 and rising, not including a kidney transplant in 1993.

The kidney failed when Toribio briefly moved to North Carolina, which refused to pay for her anti-rejection drugs. She needed to go back on dialysis three days a week to clear toxins from her blood, but North Carolina didn't cover that either.

The best a social worker could offer was a prepaid plane ticket back to California.

"When I came back here, I said, 'There is no way I'm leaving for another state again,' " said Toribio, now 29, before a technician poked two needles into her arm at the St. Joseph Hospital dialysis center in Orange.

Health services and other benefits available to illegal immigrants can vary by the state. Welfare, prenatal care or in-state college tuition might be available in one place and inaccessible across a state line.

The disparities reflect the nation's conflicting attitudes toward its estimated 12 million illegal immigrants. With limited federal guidance, states often are left to make their own decisions, frequently shaped by political winds.

Dialysis offers a striking example of the dilemmas -- and the occasional absurdities -- that result.

The number of patients is not large. In California, illegal immigrants account for about 1,350 of the 61,000 people on dialysis. Their treatment cost taxpayers $51 million last year.

But dialysis stands out because it is often a lifetime commitment. The investment in a single patient over time can easily top $1 million.

Many states draw the line at illegal immigrants. But officials in California, New York and a few other states figure that not treating patients whose kidneys are failing costs more.

That is because patients without regular dialysis frequently end up in emergency rooms, on the brink of death. At that point, federal law requires that they receive dialysis until they are stable enough to be released -- usually only to deteriorate again within weeks and return to the ER.

It's like "rescuing a person from drowning, giving someone a good meal and then pushing them over the side," said Dr. Laurence Lewin, a kidney specialist in Orange County.

Repeated rescuing not only threatens patients' long-term health, it generally costs more than routine care, some experts argue. In Texas, where illegal immigrants generally can't get routine care, some have cycled through the emergency room at El Paso's Thomason Hospital more than 100 times for life-saving dialysis, said kidney specialist Dr. Azikiwe Nwosu.

Such patients are at increased risk of heart attacks and infections.

"Its heartbreaking," said Dr. Claudia Zacharek, a kidney specialist who until recently worked in Galveston, Texas. "Your hands are tied."

In grappling with what services to provide for illegal immigrants, some states tip toward the need to care for the sick. Others see free healthcare as a de facto endorsement of their presence.

Congress tried to establish a balance. In 1986, it barred illegal immigrants from the federal health benefits generally available to the poor, with one notable exception: emergencies. The federal government agreed to share the cost of caring for poor illegal immigrants through state-run Emergency Medicaid programs.

The problem is that the federal definition of an emergency is open to interpretation: an acute condition that, without immediate care, would seriously jeopardize a patient's health or impair bodily functions, parts or organs.

When does an emergency start? When does it end?

Debates have flared over chemotherapy, life-support and dialysis. In 2002, Arizona Sen. John McCain, the Republican presidential nominee, cosponsored a bill to provide dialysis and other chronic care needed to prevent expensive ER visits.

It failed. What's left is an ambiguous policy that the federal government itself has struggled to clarify.

"We do not pay for chronic care for illegal immigrants," Mary Kahn, a Medicaid spokesperson, said when asked about the issue in early 2007.

If California and other states were using federal funds to help provide routine dialysis, she said, they were mischaracterizing it as an emergency treatment.

More recently, she acknowledged that the federal government has knowingly been sharing the cost in California for years. It has long been left to the states to decide whether to provide routine dialysis, she said.

Many states, including Texas, Colorado and New Mexico, take the position that kidney failure does not automatically qualify as an emergency because patients can survive for weeks without dialysis before toxins accumulate to fatal levels.

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