By Bill Peckham
RenalWEB links to what promises to be a more hopeful story on the dialysis situation at Atlanta's Grady Hospital. On reading the article, however, it is clear that there is still a way to go for a solution. I first heard about the situation at Grady in September. Back then they had 60 patients who were insurance never, Medicare/Medicaid never. It comes down to a state decision as to whether routine dialysis is a covered service under Medicaid or whether it is uncovered.
The Atlanta Progressive has done the most complete reporting on the situation (my emphasis):
As previously reported by APN, Grady sent letters to uninsured patients informing them of the closure and provided them a list of nearby private dialysis providers along with three options for future care: return to their country of origin, move to another state where they may qualify for emergency Medicaid services, or seek treatment through an emergency room.
As is often said if you show up at an emergency room with a medical emergency, you will get medically stabilized regardless of your insurance situation; the hospital will probably get some payment through Medicaid or a state level Medicaid-like-program of federal healthcare cost sharing.
Given that universal emergency room entitlement, most states allow Medicaid to pay for routine dialysis. Correctly, seeing dialysis, even routine outpatient dialysis, as sequential emergencies. Point of fact, as soon as you finish your dialysis treatment you will die unless you get dialysis again soon, so when you need dialysis it is an emergency or a day or three away from being an emergency. The problem of course is political. It is politically very unpopular to pick up the healthcare tab for illegal immigrants who are the majority of people who do not routinely qualify for Medicaid. And second point of fact, dialysis is not any where close to being universally available in our hemisphere, let alone in this world.
The reason that there are dialyzors from all over the world, in the United States without citizenship and/or insurance, is because dialysis is not widely available in their home country (e.g. central America, sub Saharan Africa) or in the US, dialysis is better (e.g. Mexico, Philippines). As individuals we understand the impulse, but as a society we are worried for obvious reasons. We can not, as a country, be the world's dialysis provider.
There is the issue of moral hazard. If we provide dialysis, people will come here to receive it. Far less than half the population of the world has any access to dialysis or transplantation. As a country we have to be clear eyed and direct aid where it will do the most long lasting good for the most people. There are huge areas of the globe where people need drinking water; on our national aid priority list, dialysis can't come before drinking water.
Right now in Haiti, struggling to get its footing after the devastating earthquake, the question of dialysis is in the news. Our impulse is to help, so we applaud the efforts of the dialysis community to fund emergency services. Yet before the quake, I believe there was a single dialysis unit in Port-au-Prince serving the entire country of 9 million Haitians. With a population of 9 million, by US standards there should have been 10,000 Haitian dialyzors (if not more, given risk factors for CKD). Is the US dialysis community going to stay in Haiti, after the next disaster moves Haiti out of our collective consciousness?
Certainly I hope the equipment on the USNS Comfort is put to good use. There will undoubtedly be people with an acute need for dialysis that will benefit greatly. They will have a chance to live and rebuild. And certainly the previous dialysis infrastructure should be rebuilt and enhanced, to the degree the community can sustain. But the need is greater than we, the United States, can sustain. That feels nearly as hard to accept as the text messages from under the rubble, sending out unanswered calls for help. It is hard to accept.
We want to help. We know dialysis. But right now, right there, dialysis isn't the right answer. Not when we can't help all the dialyzors of Georgia, and Florida, and ...
As always, you paint a clear and concise point Bill.
Thanks for your thoughtfulness in our small world of renal failure. Your ability to round up the facts and portray them in an intellectually honest way is most appreciated.
cheers,
Jonathan
Posted by: Jonathan Finger | January 22, 2010 at 09:20 AM
Right on Bill
Posted by: Richard St Amour | January 24, 2010 at 08:41 AM