Kidney Transplantation for Undocumented Immigrants: Time To Find a Solution
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For patients living with end stage kidney disease who require chronic dialysis, transplantation offers a better option than chronic dialysis, because it is more cost-effective, and it improves patients’ quality of life. Through the generosity of both living and deceased donors, over 24,000 kidney transplants occur in the U.S. each year.
But there’s a wrinkle: if you are one of the 10.7 million undocumented immigrants living in the U.S., you are far more likely to be a kidney donor than a kidney transplant recipient. This inequity is unjust and unjustifiable. Approximately 3% of deceased organ donors are undocumented, but only 0.2% of deceased donor kidney transplants go to undocumented immigrants. That’s less than one percent. This leads to a morally troublesome situation in which those who live and work in the U.S. can donate a kidney, but do not have access to a lifesaving kidney transplant during their life if they need one.
Few in the transplant community are conflicted about the right thing to do: Most believe that providing kidney transplantation for immigrants is appropriate regardless of their status. Indeed, official transplant policy, as set by the federal government and endorsed by the transplant community, states that medical need alone should determine transplant eligibility, not a patient’s citizenship or residency status.
Less easy are questions about how to create fair mechanisms to pay for the transplant and subsequent lifelong care. Even if transplant centers are willing and able to provide transplant services for undocumented immigrants, the cost of transplant and long-term follow-up is considerable. Medicare and many private insurance plans will not cover these expenses. And unlike many medical conditions, to care for a transplanted organ is costly and can span well over ten years, making charity funds at best an unstable solution (similar challenges hamper care for undocumented patients who need but, because of a lack of insurance, are unable to access regular dialysis).
Some might argue that the minimal tax contribution from undocumented immigrants is insufficient to justify asking a government to cover these costs. But in my home state of Texas alone, in 2021, undocumented immigrants contributed an estimated $4 billion to the federal, state, and local tax base. Others might argue that opening the transplant pool to this group would further restrict access to what is already a limited resource, implying that transplantation — a lifesaving medical treatment — should be reserved for “deserving” people with legal residence and insurance. This runs contrary to the basic tenet of “first, do no harm.”
Given the sensitive nature of the subject, published data on undocumented immigrants and transplantation is scarce, but what we do know suggests that outcomes are as good as, if not better than, the rest of the U.S. transplant population. A national study found that nonresident aliens who undergo transplantation with Medicaid have similar outcomes to U.S. citizens with Medicaid. Conversely, a study from a transplant center in California found that denying transplants based on immigration status resulted in both higher costs and worse health outcomes for an already underserved population.
Because federal regulation effectively prohibits spending federal money on the care of undocumented immigrants, the only successful solutions have come from state and local governments. For example, Illinois passed a state law that expanded Medicaid coverage to cover transplantation for undocumented immigrants.
These state-led fixes, even when effective, are a patchwork solution in an already complex system that is truly regulated at the federal level. A federal mandate to provide dialysis and transplantation irrespective of ability to pay exists for nearly the entire U.S. population via Medicare, but it excludes undocumented residents. A federal modification of the Affordable Care Act to allow for treatment of undocumented residents could help more states cover dialysis and transplantation through Medicaid programs.
Evaluating potential solutions is limited by our lack of real data about the costs, barriers, and needs for kidney transplantation among undocumented immigrants. We cannot improve what we cannot measure. We need support from the Health Services Research Administration, which is already charged with overseeing both organ donation and transplantation in the U.S. With that organization’s help, the two leading transplantation societies, the American Society of Transplantation and the American Society of Transplant Surgeons, could define the best approach, ideally with the involvement and engagement of patients, healthcare providers, insurers, and policy makers — the entire spectrum of care for patients with end stage kidney disease. A committee involving these stakeholders could identify the current and future needs for kidney transplantation. They could evaluate current policy approaches and identify ways to pay for both transplantation and long-term coverage of immunosuppressive medication.
Our basic ethics require fairness, both in justice and reciprocity. We can do better in providing a key, life-saving intervention for all people. A difficult and fraught relationship with immigrants in this country has led us to this point. But as we reexamine the transplant system in the U.S., we should also work to ensure that everybody not only can donate organs, but also can receive them.
About the Author:
Joel T. Adler, MD, MPH, is an abdominal transplant surgeon and assistant professor of Surgery and Perioperative Care at Dell Medical School at the University of Texas at Austin and a Public Voices Fellow of the OpEd Project. His research focuses on increasing equity in access to care for historically vulnerable populations through the use of technology, large-scale policy evaluations in transplantation, community-based participatory research and novel methods to improve the evaluation and waitlisting process associated with transplantation.