A growing number of US states are providing coverage for outpatient hemodialysis for undocumented immigrants, according to new research published in the Annals of Internal Medicine.1

Outpatient Hemodialysis

As of 2022, 20 states and the District of Columbia provide statewide coverage for standard outpatient hemodialysis for undocumented immigrants, Katherine Rizzolo, MD, of the University of Colorado in Aurora, and colleagues reported.1 The states include:

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  1. Arizona
  2. California
  3. Colorado
  4. Connecticut
  5. Illinois
  6. Louisiana
  7. Maryland
  8. Massachusetts
  9. Michigan
  10. Minnesota
  11. Nevada
  12. New Mexico
  13. New York
  14. North Carolina
  15. Oregon
  16. Pennsylvania
  17. Utah
  18. Virginia
  19. Washington
  20. Wisconsin

Full Medicaid is provided to undocumented individuals in California and Massachusetts, and patients meeting age and income criteria in Illinois. Emergency Medicaid provides outpatient hemodialysis in 17 states. New Mexico uses a high-risk insurance pool. Washington, DC relies on a municipal-funded program.

Kidney Transplantation

Kidney transplantation for undocumented immigrants is covered in 5 of the 50 states: California, Massachusetts, Minnesota, Illinois, and New Mexico. Full Medicaid is used in California. Massachusetts and Illinois rely on Medicaid coupled with a health safety net or charity-provided insurance. Emergency Medicaid funds transplantation in Minnesota. A high-risk insurance pool covers transplantation services in New Mexico.

“The heterogeneity of these systems allows for a wide range of strategies that can guide efforts in other states,” according to Dr Rizzolo and colleagues.

For the study, the investigators reviewed Medicaid and emergency Medicaid policy manuals and interviewed clinicians, National Kidney Foundation state chapters, and regional end-stage renal disease networks.

Economic Impact

In an accompanying editorial, Sylvia E. Rosas, MD, MSCE, and M. Catalina Morales Alvarez, MD, of Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, noted that working undocumented immigrants contributed $9.8 billion in federal, state, and local taxes in 2019, yet most were uninsured.2 Currently, undocumented immigrants are ineligible for federal health coverage under Medicare or the federal health insurance marketplace under the Patient Protection and Affordable Care Act. The cost of emergency inpatient hemodialysis for uninsured individuals exceeds the cost of outpatient dialysis.

In addition, according to a 2018 report in JAMA Internal Medicine, emergency hemodialysis is significantly associated with a 14-fold higher mortality rate within 5 years compared with standard outpatient thrice-weekly maintenance hemodialysis.3

National Solution Urged

“We call for a humane national solution to abandon emergency dialysis as the only option for undocumented immigrants and instead pursue a move toward covering outpatient dialysis (including expanded coverage of dialysis access procedures and home dialysis) in all 50 states,” Drs Rosas and Alvarez wrote. “This approach has proven to be both economically and medically advantageous with no evidence of increased undocumented immigration or transplantation tourism.”

There are an estimated 11.4 million undocumented immigrants in the United States, according to 2018 data from the US Department of Homeland Security.4 Perhaps 5000 to 9000 undocumented immigrants currently have kidney failure, according to a 2020 study published in Clinical Nephrology.5


1. Rizzolo K, Dubey M, Powe NR, Cervantes L. Access to kidney care for undocumented immigrants across the United States. Ann Intern Med. Published online April 24, 2023. doi:10.7326/M23-0202.

2. Morales Alvarez MC, Rosas SE. A call for a national policy of scheduled dialysis and transplantation for all people with kidney failure living in the United States. Ann Intern Med. Published online April 24, 2023. doi:10.7326/M23-083

3. Cervantes L, Tuot D, Raghavan R, et al. Association of emergency-only vs standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease. JAMA Intern Med. 2018;178:188-195. doi:101001/jamainternmed.2017.7039.

4. Baker B. Estimates of the unauthorized immigrant population residing in the United States: January 2015–January 2018. US Dept of Homeland Security; January 2021.

5. Rodriguez R, Cervantes L, Raghavan R. Estimating the prevalence of undocumented immigrants with end-stage renal disease in the United States. Clin Nephrol. 2020;93:108-112. doi:10.5414/CNP92S119.