I thought with the impending influx of the huge group of immigrants moving toward to the U.S. border, that we should look at the real impact. This is a fairly long post but one that “needs to be told”. Matt O’Brien and Spencer Raley reported on the continually growing population of illegal aliens, along with the federal government’s ineffective efforts to secure our borders, present significant national security and public safety threats to the United States. They also have a severely negative impact on the nation’s taxpayers at the local, state, and national levels. Illegal immigration costs Americans billions of dollars each year. Illegal aliens are net consumers of taxpayer-funded services and the limited taxes paid by some segments of the illegal alien population are, in no way, significant enough to offset the growing financial burdens imposed on U.S. taxpayers by massive numbers of uninvited guests. This study examines the fiscal impact of illegal aliens as reflected in both federal and state budgets.

The Number of Illegal Immigrants in the US

Estimating the fiscal burden of illegal immigration on the U.S. taxpayer depends on the size and characteristics of the illegal alien population. FAIR defines “illegal alien” as anyone who entered the United States without authorization and anyone who unlawfully remains once his/her authorization has expired. Unfortunately, the U.S. government has no central database containing information on the citizenship status of everyone lawfully present in the United States. The overall problem of estimating the illegal alien population is further complicated by the fact that the majority of available sources on immigration status rely on self-reported data. Given that illegal aliens have a motive to lie about their immigration status, in order to avoid discovery, the accuracy of these statistics is dubious, at best. All of the foregoing issues make it very difficult to assess the current illegal alien population of the United States.

However, FAIR now estimates that there are approximately 12.5 million illegal alien residents. This number uses FAIR’s previous estimates but adjusts for suspected changes in levels of unlawful migration, based on information available from the Department of Homeland Security, data available from other federal and state government agencies, and other research studies completed by reliable think tanks, universities, and other research organizations.

The Cost of Illegal Immigration to the United States

At the federal, state, and local levels, taxpayers shell out approximately $134.9 billion to cover the costs incurred by the presence of more than 12.5 million illegal aliens and about 4.2 million citizen children of illegal aliens. That amounts to a tax burden of approximately $8,075 per illegal alien family member and a total of $115,894,597,664. The total cost of illegal immigration to U.S. taxpayers is both staggering and crippling. In 2013, FAIR estimated the total cost to be approximately $113 billion. So, in less than four years, the cost has risen nearly $3 billion. This is a disturbing and unsustainable trend. The sections below will break down and further explain these numbers at the federal, state, and local levels.

Total Governmental Expenditures on Illegal Aliens

Total Tax Contributions by Illegal Aliens

Total Economic Impact of Illegal Immigration 

Federal

The Federal government spends a net amount of $45.8 billion on illegal aliens and their U.S.-born children. This amount includes expenditures for public education, medical care, justice enforcement initiatives, welfare programs, and other miscellaneous costs. It also factors in the meager amount illegal aliens pay to the federal government in income, social security, Medicare and excise taxes.

FEDERAL SPENDING

The approximately $46 billion in federal expenditures attributable to illegal aliens is staggering. Assuming an illegal alien population of approximately 12.5 million illegal aliens and 4.2 million U.S.-born children of illegal aliens, that amounts to roughly $2,746 per illegal alien, per year. For the sake of comparison, the average American college student receives only $4,800 in federal student loans each year.

FAIR maintains that every concerned American citizen should be asking our government why, in a time of increasing costs and shrinking resources, is it spending such large amounts of money on individuals who have no right, nor authorization, to be in the United States? This is an especially important question in view of the fact that the illegal alien beneficiaries of American taxpayer largess offset very little of the enormous costs of their presence by the payment of taxes. Meanwhile, average Americans pay approximately 30% of their income in taxes.

Map: Illegal immigration costs California most, $23B, all states $89B

Now a break down of costs by state. Paul Bedford noted that the illegal immigration costs taxpayers in all 50 states a total of $89 billion, and California, where an illegal on Thursday was cleared of murdering Kate Steinle despite admitting to the shooting, pays the most at $23 billion, according to a new map of the costs.

The website HowMuch.net, working with figures from the Federation for American Immigration Reform, found that Californians pay more than twice as much for illegal immigrants than the next closest state, Texas, where the price tag is $11 billion.

The costs cover added expenditures for education, welfare, law enforcement, and medical care.

When federal costs are included, the price tag nationally soars to $135 billion a year.

FAIR’s data also includes the offset of taxes paid by illegal immigrants, though the numbers are much lower. In the state and local column, they are $3.5 billion. Nationally they are $15 billion.

Overall, the costs associated with illegal immigrants is much higher for state and local governments than the federal government. States pay $89 billion, Uncle Sam, $46 billion.

The states paying the most to care for illegals:

1. California – $23,038,125,353
2. Texas – $10,994,614,550
3. New York – $7,489,141,357
4. Florida – $6,290,429,108
5. New Jersey – $4,466,838,574
6. Illinois – $3,220,767,517
7. Georgia – $2,487,719,503
8. North Carolina – $2,437,965,113
9. Maryland – $2,378,996,947
10. Arizona – $2,314,131,964

Focusing on Healthcare Costs of Illegal Immigrants Draws Attention Away from the Real Problem

Too many illegal immigrants are overwhelming the health care system and driving up health insurance costs. That’s the latest sound bite in the war of words over immigration reform. In a recent poll, a majority of the respondents thought that illegal immigrants were responsible for 50 percent or more of the uninsured treated in Southern California hospitals. But is that really the case?

While it is true that providing treatment to undocumented immigrants creates a drain on hospital resources, the question is: How much of the problem can reasonably be attributed to the undocumented? And if we solved the problem of illegal immigration tomorrow — which we won’t — would health care costs return to “reasonable” levels?

Illegal immigrants are responsible for roughly 20 percent of the $2 billion in unreimbursed care that Southern California hospitals deliver each year. Even if you consider that factor, you have to conclude that it’s the larger problem of just simply having so many uninsured patients that is a key driver of rising hospital costs.

In order to receive federal Medicare and Medicaid payments, a hospital must agree to treat and stabilize everybody who shows up to a hospital ER regardless of their ability to pay or their immigration status. That means undocumented immigrants who show up at the emergency room will receive treatment regardless of their immigration status or whether they’re insured. But so will legal immigrants, naturalized citizens and native-born Americans.

It is a matter of law that these people receive treatment. Indeed, we may have an ethical responsibility to do so as well. The problem is that most hospitals in California end up being paid for only about 5 percent of the medical care given to uninsured patients. And that leads to the question: So, who’s going to pick up the tab?

In the absence of strong political leadership on the question of insuring the uninsured, the answer, inevitably, is that hospitals and those patients with insurance, as well as those uninsured who do pay, will end up paying for those who seek care without insurance — regardless of whether they are here legally or not.

An ironic healthcare twist for undocumented immigrants

The University of Michigan Medical School study noted that the undocumented immigrants are in the country illegally. Or maybe they had protected status before but lost it due to policy changes by the current presidential administration.

Or they’re waiting for word from Congress or the courts on whether they’ll get to stay.

Whatever their situation under the law, the 11.3 million undocumented immigrants currently in the United States still need, and sometimes get, health care.

Even if they don’t have health insurance, federal law requires hospitals to care for them in emergencies. They can turn to safety-net clinics for basic needs.

Now, a new analysis highlights an ironic development in the intertwined issues of immigration and health care – two areas where the current and previous administrations differ greatly.

Undocumented people in certain states may get more medical help while they are here, it finds, thanks to the current administration’s effort to give states more flexibility with their health care spending. And in a reversal of the previous administration’s stance, states may find it easier to get that permission.

In a new article in the New England Journal of Medicine, two members of the University of Michigan Institute for Healthcare Policy and Innovation unpack recent events, political philosophies and medical evidence about caring for the undocumented.

They conclude that more states may want to apply for permission to use state and federal dollars to pay safety-net hospitals that care for everyone – whether or not they are here legally.

Waivers already in action

Such permission, which requires the government to approve an application called a waiver, has already gone into effect in Florida and Texas.

As two of the states with the highest numbers of undocumented immigrants living in their borders, they’ve seen the amount of money they can award to safety-net hospitals rise by 50 percent to 70 percent.

“Ironically, the same administration that is targeting undocumented immigrants with one set of policies may be helping them get care by preserving hospitals’ abilities to serve them with other policies,” says A. Taylor Kelley, M.D., M.P.H., who led the analysis.

Kelley says their example may bode well for other states that, like Florida and Texas, didn’t choose to expand Medicaid under the ACA.

“The United States has one of the highest rates of uninsured people in the world among developed countries, and the Affordable Care Act was designed to increase health insurance options for men, women, and children across the country. But undocumented immigrants were excluded,” so they can’t enroll in Medicare or Medicaid, or buy a plan on the ACA marketplace, explains Kelley, who is a clinical lecturer in general internal medicine at the U-M Medical School and a National Clinician Scholar at IHPI.

“Undocumented immigrants rely on safety-net institutions that deliver care for people, with insurance or without insurance,” he explains. “Safety net hospitals are also major employers and economic drivers in their communities. And so to keep their doors open, states can seek federal permission to increase the funding they get. And generally, the current administration has been very receptive.”

States didn’t get a warm welcome from the Obama administration for such waivers, because that administration’s priority was encouraging states to expand Medicaid coverage to all low-income adults – or at least those who had legal status. In fact, the previous administration said it would take away existing funding for safety-net hospitals in states that didn’t expand Medicaid.

Florida actually decided to redirect some of its own funds to help its hospitals, rather than expand Medicaid, when its waiver was ended by the Obama administration.

A door closes, a door opens 

But with the change in administrations, Kelley and co-author Renuka Tipirneni, M.D., M.Sc., write, the states that didn’t expand Medicaid and have high numbers of undocumented residents may find it easier.

States along the Mexican border, for instance, may want to seek a waiver – or apply to take part in a program that incentivizes new care delivery models for poor patients.

As for the states that did expand Medicaid, only time will tell if the government will also approve waivers to further ease the financial burden on safety net hospitals and clinics there.

A recent IHPI report about Michigan’s Medicaid expansion finds that while hospitals saw their uncompensated care drop by an average of 50 percent in the first year after expansion, the level has stayed flat since that time.

So hospitals are still absorbing the cost of caring for many people who can’t pay their medical bills, whether it’s because they have no insurance or they can’t afford the part of their bill that their insurance expects them to pay. Around half of the undocumented immigrants in the U.S. lack insurance of any kind, according to estimates.

“The major question when talking about state flexibility is, where are the limits? And how much are we going to honor states’ rights?” says Kelley. “Both Medicaid expansion and support for the safety net are programs where states are now being given the autonomy to act as they feel best for the people within their borders. Will these approaches be honored by the administration as a state right?”

Spending up front, or later 

At the same time, Kelley notes, the inpatient hospitals that have historically received the waiver funds are more and more likely to be part of new network-based models of care, such as accountable care organizations, which makes it easier for them to offer integrated care for those who come through the doors of their emergency rooms.

That may mean it’s easier to care for undocumented immigrants in a preventive or early-stage way, rather than waiting for an emergency.

In addition, Congress recently extended funding for federally qualified health centers that provide care to underserved patients outside of the hospital.

Such care can actually save money, according to research cited in the new piece. For instance, one study showed that states can save money by covering dialysis care for undocumented immigrants whose kidneys are failing, rather than waiting to provide the legally required emergency dialysis when they are in crisis. Illinois has even gone so far as to cover kidney transplants for undocumented people, because of the potential long-term cost savings.

Other research shows that expansion of individual insurance coverage provides better outcomes and use of resources than insurance for some and no insurance for others who must turn to safety net care, says Kelley. But the political philosophies and policy stances of current leadership don’t make expanded coverage likely right now.

“We’ve come out of eight years of one way of thinking, now we’re in a new way of thinking,” says Kelley. “And it’s a new shift for states if they’re going to cover the people they need to cover and help institutions out, then they have to shift their focus and their thinking.”

“Some might ask, what does care for the undocumented have to do with me as an American citizen. And the reality is that, because we provide care to anyone who stands in need of a health emergency, we all pay for everyone’s healthcare sooner or later,” he says. “When we provide access to care for undocumented immigrants, it’s not necessarily going to be a cost burden every time. In some ways, it may be beneficial to us in both indirect ways and even in direct ways.”

The impact of undocumented workers on health care costs

The Pew Charitable Trusts recently outlined the quietly building demand that undocumented workers will place on the health care system as they age.

Dan Cook of Benefitspro.Com reviewed a 2014 report which found that undocumented immigrants who needed kidney dialysis cost Texas taxpayers $10 million—much of which could have been avoided, had the immigrants been able to treat their disorders upstream. Talk about a one-two punch to the U.S. healthcare system’s gut. First, there are the widely publicized 40 million new clients that will enter Medicare’s ranks by 2050 as Baby Boomers age into the system. Then, there’s the much less publicized, but still ominous, aging undocumented worker wave about to hit the system.

This group, representing millions of illegal immigrants, is for the most part uninsured. To date, its members have made few demands on a system they don’t trust and can’t afford. But as they age and their health breaks down, they will find the system, and in all likelihood, enter through its most expensive doors: the ER or hospital admissions. Unable to pay for the care they receive, their cost will be shifted to the same health systems and insurers already panicking about how to care for those with coverage.

The Pew Charitable Trusts outlined this quietly building demand in its Stateline publication. An article entitled Aging, Undocumented and Uninsured Immigrants Challenge Cities and States reviewed research on the healthcare needs these estimated 11 million undocumented residents will have as they grow older in America. Because most don’t even qualify for Medicaid, they will be forced to go to hospitals and emergency rooms for treatment as conditions that have gone untreated worsen with age. And, the article concluded, the current health care model in the U.S. makes no provision for covering the cost of their care beyond shifting it to those with coverage.

“… Senior citizens without documentation don’t have access to care for chronic issues such as kidney disease and high blood pressure. What’s more, experts predict that many will forgo primary preventive care even when it is available, likely making their chronic health problems worse — and more expensive to treat,” the article said.

Author Teresa Wiltz noted that there are pockets across the U.S. where local communities have addressed this coming crisis with local dollars. Washington, D.C., Los Angeles and San Francisco have developed funding streams for programs that make regular health check-ups and treatment available and affordable to immigrants regardless of their status.

But throughout most of the U.S., the health of undocumented workers remains invisible. That is until somebody puts a number on it.

The Pew article cites statistics from Texas, an especially difficult state for undocumented workers to receive regular or preventive health care. There, a 2014 report found, undocumented immigrants who needed kidney dialysis and couldn’t pay for it cost state taxpayers $10 million—much of which could have been avoided had the immigrants been able to treat their disorders upstream.

What’s the solution? Conservatives tend to default to the “go back to from where you came” strategy. “The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem,” Steven Camarota, director of research for the Center for Immigration Studies, a conservative think tank that favors limiting immigration, told Stateline.

For others of a more liberal bent, the answers aren’t so off-the-shelf. Community health centers could be expanded and encourage more illegal immigrants to get regular care. Federal policies could be loosened to open up Medicaid or other options. Becoming a citizen should be made easier, especially for seniors, say others.

Meantime, hospitals and insurers play the cost-shifting game and hope for help from the nation’s capital—where the political wrangling over individual health care access seems unaffected by the looming crisis brought on by aging Americans.

The Affect on Texas

Rohit Kuruvilla and Rajeev Raghaven, doctors at Baylor College of Medicine researched the impact on Texas and found the providing health care to the 1.6 million undocumented immigrants in Texas is an existing challenge. Despite the continued growth of this vulnerable population, legislation between 1986 and 2013 has made it more difficult for states to provide adequate and cost-effective care. As this population ages and develops chronic illnesses, Texas physicians, health care administrators, and legislators will be facing a major challenge. The new legislation, such as the Affordable Care Act and immigration reform, does not address or attempt to solve the issue of providing health care to this population. One example of the inadequate care and poor resource allocation is the experience of undocumented immigrants with end-stage renal disease (ESRD). In Texas, these immigrants depend on safety net hospital systems for dialysis treatments. Often, treatments are provided only when their conditions become an emergency, typically at a higher cost, with worse outcomes. This article reviews the legislation regarding health care for undocumented immigrants, particularly those with chronic illnesses such as ESRD, and details specific challenges facing Texas physicians in the future.

Introduction- The undocumented immigrant population in Texas has been increasing since 2008 with a current estimate approaching 1.6 million persons.1 Although this may be attributed primarily to proximity to the US-Mexico border, the favorable growth of the Texas economy and the creation of low-wage jobs predicts a continued increase along this path over the next decade.  Addressing the health care needs of undocumented immigrants and their families constitutes an existing problem that is solved currently by a patchwork of clinics, safety net hospital systems, and uncompensated charity care. We expect this problem to increase as this population ages and develops costly chronic illnesses such as obesity, diabetes, heart disease, kidney disease, and cancer. Unfortunately, forthcoming national health care and immigration reform legislation do not adequately address the issue of health care for this population.

Undocumented immigrants with end-stage renal disease (ESRD) represent a patient population at the center of this problem. These patients require dialysis treatments several times a week for survival. The lack of a uniform national policy to cover the cost of dialysis for noncitizens forces local health care systems into the ethical dilemma and financial challenge of providing adequate, cost-effective care for these patients. Not surprisingly, the type and frequency of dialysis treatments that an undocumented immigrant receives vary between El Paso and Houston, and even within a particular city, such as Houston.

This article reviews the past, present, and future legislation regarding health care for undocumented immigrants while describing the challenge of managing these patients with a chronic illness, such as ESRD.

Delivering Health Care to Undocumented Immigrants- The Pew Research Center estimates that 11.2 million undocumented immigrants reside in the United States. Approximately 14% of these persons live in Texas, and this number is expected to increase.1 Primary care is delivered to this population at 1 of the 69 federally qualified health centers (FQHCs) in Texas or via safety net hospital systems. Both locations care for uninsured and indigent patients, regardless of citizenship. The FQHCs receive money from the federal government and are equipped to provide both primary and preventative care. Safety net hospital systems (also called “county” or “public” hospitals) tend to be located in larger cities (e.g., Houston or San Antonio) and are funded by their specific county. Although they offer a multitude of services, including specialist care and elective surgeries, a longer wait time is usually involved. One unfortunate consequence of the current system is that patients often present to the emergency room with a more advanced disease due to lack of early diagnosis or treatment. The resulting health care costs more and is often either uncompensated or inadequately compensated.

Besides the relative lack of access to specialists, undocumented immigrants face cultural and social barriers in obtaining care. One major cultural barrier is language; more than 75% of undocumented immigrants come from Spanish-speaking countries, and most are not fluent in English. Two social barriers often encountered are difficulty keeping medical appointments because of an irregular work schedule and fear of deportation or exposure to the law.

Legislation- Between 1986 and 2013, many legislative documents have addressed the issues of health care and immigration. The various tables summarize the four most comprehensive acts, which are detailed below.

1986: Emergency Medical Treatment and Labor Act (EMTALA)- Signed in 1986, EMTALA stipulates that any person, regardless of his or her legal status, insurance status, or ability to pay, who presents to an emergency room must be medically stabilized before discharge or transfer. This law was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer. According to the law, an emergency medical condition is defined as “a 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 placing the person’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”

1996: Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) – The “Permanent Residents Under Color of Law” (PRUCOL) status applies to persons whom the United States acknowledges are here illegally but for whom the country is not actively pursuing deportation. Under this status, these undocumented immigrants were granted access to many public benefits. However, in 1996, PRWORA eliminated classifying undocumented immigrants as PRUCOL status, effectively terminating their access to certain benefits (eg, welfare programs and Medicaid). Some states appealed this and continue to grant PRUCOL status to undocumented immigrants.  In California and Massachusetts, the PRUCOL status given to the undocumented immigrants allows them to receive certain health care benefits, such as scheduled dialysis. However, in Texas, undocumented immigrants are not given PRUCOL status and, hence, do not receive any public or health care benefits.

2013: Border Security, Economic Opportunity, and Immigration Modernization Act of 2013 (S 744)- Passed by the Senate in June 2013 by a vote of 68-32, this bill was awaiting approval by the House of Representatives as of May 2014. Its three primary goals are the following: to enhance border security, to renovate the immigration system by integrating the current undocumented immigrant population, and to streamline the citizenship process for highly skilled and educated persons.1 Ultimately, this bill will reduce the number of undocumented immigrants as a result of strengthened border security (adding 40,000 new agents to border patrol) and enforced hiring codes, while encouraging persons with broader educational achievement and economic potential to come into the United States through an extended visa program.

Undocumented immigrants who have lived in the United States since 2011 will be addressed as registered provisional immigrants (RPIs). After paying an initial $500 fee and any back taxes a person may owe, these immigrants may receive the RPI status if they have no criminal history. The RPI status must be extended after a 6-year probationary period. After 10 years, an RPI can apply for permanent residence, and at 13 years for citizenship. While the 13-year path to citizenship is an extended process, it affords current undocumented residents legal rights and provides them with a stable environment, relieving fears of deportation.

This act does not address health care for persons of RPI status. Hence, if this bill is signed into law, the challenge of providing care to undocumented immigrants will continue and may even increase as these persons will “come out of the shadows” and be more likely to seek primary, preventative health care and, eventually, specialist care.

2014: Patient Protection and Affordable Care Act- The Patient Protection and Affordable Care Act (ACA), also named Obamacare, has been under intense scrutiny and debate since its inception. Regarding health care for undocumented immigrants, RPIs, and persons on a visa, much debate has produced no conclusive answers. Obamacare was passed in 2010; it envisions complete national coverage by 2019 via a series of mandates, subsidies, and insurance exchanges. The act requires all legal residents to purchase insurance and penalizes those who do not. While Section 246 of the bill claims that “there shall be no federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States,” argument has ensued on where this places RPIs and how this will affect undocumented immigrants.

Until they receive full citizenship, neither undocumented immigrants nor RPIs will gain access to health care under the ACA as it is written today. They will be exempt from the mandatory fee imposed on uninsured citizens, and they will be unable to purchase health care insurance.

Texas and the Medicaid Expansion- The ACA can be expected to have several direct and indirect effects in Texas. Although Texas has declined Medicaid expansion, ramifications from the bill will still be present as federal insurance subsidies and the insurance trading market will be available to Texas residents. The ACA also calls for decreased reimbursements to disproportionate share hospitals (DSHs) under the assumption that most persons will be insured. In theory, this would reduce money available to care for undocumented immigrants and possibly place DSH (safety net hospitals) at jeopardy for hospital shutdown or withdrawal of certain services. Texas, with its large undocumented immigrant population and nonrecognition of PRUCOL status, is likely to feel these changes more than other states.

Undocumented Immigrants and Emergent Dialysis- All patients with ESRD require dialysis treatments to cleanse the blood of toxins and remove excess salt and water. Dialysis is either done every day by the patient at home (peritoneal dialysis) or in a center 3 times a week (hemodialysis). All dialysis patients, particularly those who are younger and healthier, are encouraged to be listed for a kidney transplant. In 1973, Congress enacted a historic legislation guaranteeing federal or state funding for all US citizens diagnosed with ESRD to defray the high cost of this treatment. The cost of hemodialysis today is estimated at $87,000 per person annually.

Undocumented immigrants with ESRD represent a population at the crux of immigration reform, health care reform, and the rising cost of chronic illnesses. EMTALA specified that an undocumented immigrant with ESRD who is medically unstable and presents to a hospital emergency room in need of emergent dialysis must be stabilized. Interpretation of EMTALA has led many hospitals, including safety net hospitals, to practice “emergent dialysis.” In emergent dialysis, the patient is first evaluated in the emergency room and then only receives treatment if a life-threatening indication is present. Typical indications include shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia). This is in contrast to scheduled dialysis, which happens regularly.

Emergent dialysis is 3.7 times more expensive per patient due to the associated costs of emergency room care (laboratory draws, studies, and physician fees) and more frequent patient hospitalizations as a result of poor health.9 Despite this high cost, this practice has been the standard of care because of the perceived notion that offering scheduled dialysis to undocumented immigrants could trigger an influx of immigrants with ESRD to the state. In the past decade, individual counties or cities have devised unique solutions to this problem.  For example, all patients in San Antonio receive scheduled dialysis, paid for by the county hospital system via contract to local for-profit dialysis centers; in Dallas, patients only receive emergent dialysis. In Houston, all patients begin with emergent dialysis, but one county-funded and county-operated dialysis center accepts emergent dialysis patients when space becomes available. The figures show this variability in care across these three cities in Texas. This same variability in dialysis options exists across the United States for this population.

More than 400,000 US citizens receive dialysis. Through extrapolation of published incident rates, experts estimate that 6000 undocumented immigrants in the United States require dialysis.10 From personal communication, we estimate that more than 1000 undocumented residents in Texas require dialysis. Given the high cost of dialysis and the even higher cost of emergent dialysis, Texas taxpayers are likely paying more than $10 million to manage these patients.

Emergent dialysis is not just more costly but also forces physicians into making difficult ethical decisions, such as deciding “which patient should receive treatment.” It is also associated with worse patient outcomes; the patient suffers physically from infrequent dialysis and financially from lost wages secondary to an inability to work around an irregular dialysis schedule.

Conclusion-Texas has a large, growing population of undocumented immigrants. Providing comprehensive health care to this population is a challenge, and these patients rely on safety net hospital systems. Legislation from 1986 to 2013 has made it increasingly difficult for these persons with chronic illnesses to receive cost-effective, adequate care. Undocumented immigrants with ESRD receive dialysis in Texas primarily when it becomes an emergent condition. While future RPI status may grant undocumented immigrants legality, the ACA specifies that this does not grant access to health care. With a growing undocumented immigrant population in Texas, our state legislators must be aware of and address this problem before it evolves into a health care crisis.

So, we have to learn from the European experience that if we as a country decide that we are responsible for all the undocumented illegal immigrants we need to find a way to pay for the increasing expense of allowing the immigrants to enter our country illegally.