The Senate’s Christmas Eve vote makes historic legislation to transform our health care system likely. Politicians, who rightly note that this legislation would affect nearly all Americans, could also point out that the people least affected may not be Americans at all, but those in the country illegally. Under the House bill, illegal immigrants could buy coverage in the bill’s insurance exchange but would be ineligible for federal subsidies; under the Senate version, even that would not be not permitted. The implications are staggering. While the Senate bill would extend insurance coverage to 31 million people, the Congressional Budget Office projects that as many as 23 million people would still be uninsured in 2019, about 8 million of whom would be illegal immigrants.
We don’t need to wait until 2019, however, to witness the human tragedies and policy nightmares at the heart of health care for undocumented immigrants. The closing of the outpatient dialysis unit at Grady Memorial Hospital in October 2009 captures it all.
Grady Memorial, a public hospital and fixture in Atlanta for over 100 years, provides care to the poor and essential services to the whole community, including a Level 1 trauma center and ambulance fleet. It has been seriously in the red for over a decade. Major steps have been taken recently to keep Grady’s doors open, most controversially the decision to close the outpatient dialysis unit. At the time of the decision, the unit, which was using outdated equipment that needed to be replaced, was losing between $2 million and $4 million annually. Two-thirds of its then remaining patients were undocumented immigrants. When the dialysis unit finally closed, there were about 50 patients left, almost all undocumented.
That undocumented immigrants were left behind is hardly surprising. End stage renal disease is the one and only area of medicine where most Americans already have guaranteed coverage. The Social Security Amendment of 1972 ensures access to kidney dialysis, but applies only to U.S. citizens. Another law requires hospitals that receive federal funds to provide emergency care, including dialysis, to any patient regardless of immigration status who presents with a life-threatening condition. At the same time, special federal funds that are used to offset this emergency care cannot be used to provide illegal immigrants with “maintenance dialysis”-regular dialysis treatments that prevent the life-threatening complications of renal failure and keep patients out of emergency rooms. Against this incoherent federal backdrop, a few states fund maintenance dialysis for undocumented immigrants, but a majority, including Georgia, do not.
Disagreements continue about whether closing the outpatient dialysis unit was necessary to save Grady Memorial, and about whether the hospital did everything it should have done to assist patients in finding maintenance dialysis care elsewhere. The hospital has offered to pay for private dialysis for up to one year and to help some patients return to their home countries for care there.
Even with these measures, however, it is likely that some of the unit’s former patients will die for lack of maintenance dialysis and that others will suffer the heartbreak of separation from loved ones. But the tragedy facing these patients and their families, and the tragic choice the Grady Memorial leadership felt it had to make, are hardly unique. A recent study estimates that about 5,500 undocumented immigrants with end stage renal disease currently live in the United States.1 No national data are available about how many of these people are able to secure the lifeline of maintenance dialysis, and how many die for lack of it, but in another recent survey, only 50 percent of nephrologists responded that undocumented immigrants had access to maintenance dialysis.2
Clinicians who understand that refusing to provide life-sustaining care goes against the moral foundations of their profession are constantly forced to confront the realities underlying these dry statistics. In some cases like Grady Memorial’s, institutional decisions are based on financial assessments of the burdens of providing uncompensated treatment to undocumented immigrants, and the impact these costs have on the capacity to provide care to other patients. Depending on the facts, such local decisions may be ethically justifiable, but the same cannot be said for the public policies against which these agonizing choices must be made.
Americans who object to providing health care to those who are in this country illegally make the principled point that people who violate the immigration laws of this country have forfeited any moral claim to assistance and should not benefit from their illegal behavior. They also argue that providing those here illegally with access to regular health care will as a practical matter have the undesirable effect of increasing illegal immigration.
The principled argument in favor of including illegal immigrants in health reform is that decent health coverage is a basic human right. A just nation should support that right for everyone, regardless of why or how a person is in the country. There are also practical reasons to support including undocumented immigrants in health reform. Ethics aside, there is no pragmatic way to deny emergency care to illegal immigrants. As the dialysis story illustrates, in many cases, it is difficult if not impossible to make coherent distinctions between emergency and regular care that make financial and medical sense.
While the practical arguments on both sides are important, this is one debate that can and should be settled on principled grounds. The problem of illegal immigration should be solved by immigration policy, not health policy. People who are in this country illegally have broken our laws, but the magnitude of their crime does not justify depriving them of the basic right to health care coverage while they are in our midst. The most extraordinary thing about health reform is that it finally enshrines the principle that America is committed to universal access to health care. It will take time, but eventually, as with other American declarations of rights, universal will come to mean universal. The House’s proposal for illegal immigrants is a good first step.