Those who work in refugee resettlement say the increase could be a coincidence, since the highest priority refugees – such as ones with urgent medical issues – are likely to be from the seven banned nations anyway.

“Many have bad livers, or need constant dialysis, the costs are in the millions per year. We have no policy denying entry to those in need of high price medical procedures” said Wendy Simmons, director of the refugee health organization.

Many Mexicans also stream in for costly dialysis and other programs.

Each had crossed the border years before, smuggled across the desert by a coyote, never imagining the journey would lead to a drab and dusty clinic on the ninth floor of Grady Memorial Hospital in Atlanta.

Some knew before the crossing that they had diabetes or lupus or high blood pressure, but it was only after they arrived that their kidneys began to fail. To survive, they needed dialysis at a cost of about $50,000 a year, which their sporadic work as housekeepers, painters and laborers could not begin to cover.

And so they turned to Grady, a taxpayer-supported safety-net hospital that would provide dialysis to anyone in need, even illegal immigrants with no insurance or ability to pay. Every Tuesday, Thursday and Saturday morning, the 15 or so patients would settle into their recliners, four to a room, and while away the monotonous three-hour treatments by chitchatting in Spanish.

That all changed on Oct. 4, when the strapped public hospital closed its outpatient dialysis clinic, leaving 51 patients — almost all illegal immigrants — in a life-or-death limbo.

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 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.7

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.8

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.