One-Way Street

What’s your initial reaction to the idea of undocumented immigrants receiving organ transplants in the United States?

If you balked at this, is that response based on the rationale that it wouldn’t be fair to allow an individual living illegally in the U.S. access to an already scarce resource — viable organs desperately needed by critically ill patients?

Or, are you more pragmatic, immediately considering some of the practicalities involved – are undocumented immigrants insured? And if not, who is going to cover the cost of the procedure and subsequent treatments necessary to prevent rejection of the new organ?

Let’s look at the costs and consider fairness.

Maybe you’ve heard that every 10 minutes, someone is added to the national transplant waiting list.  Or that 22 people die each day waiting for a transplant organ. So, it’s obvious the demand for organs far outpaces their availability. On average, only 54% of adults are registered for organ donation, but this figure differs so widely by state that we see 86% registration in Alaska but only 26% registration in New York.

You can visit your state’s donor registry and sign up at any time, but a majority of people are only confronted with the decision to opt-in when they obtain or renew their state driver’s license.

As of 2016, 12 states and the District of Columbia permit undocumented immigrants to obtain driver’s licenses. When AB60 was passed in California, allowing anyone that could prove their identity and California residency to apply for a driver’s license, they saw a huge spike in organ donor registration, a 30% increase over the same time period from the previous year. After similar legislation in Illinois, 45% of those signing up for driver’s licenses also joined the donor registry.

So people in the U.S. illegally can donate organs. In fact, between March 2012 and December 2013, 3.3% of organ donations came from US residents who were non-citizens. That’s donors, not people registered to donate. To put into perspective the number of people registered for organ donation versus those that become donors, although 2.2 million individuals were registered in 2010 in Massachusetts, less than 250 became organ donors.

Who can legally receive a transplant? The Organ Procurement and Transplantation Network policies don’t exclude undocumented immigrants from receiving transplant organs. In fact, the National Organ Transplant Act requires that only medical criteria is used to determine who receives an available organ. The variety of factors considered can include the geographical location of the patient and the donated organ, medical need, time on the waiting list, and physical matching of blood and tissue type. Citizenship is not permitted to play a role in who is placed on the wait list. Ability to pay is. Health insurance may be a requirement for even being listed.

Then isn’t this a problem for all uninsured? Even U.S. citizens? Well, yes. But U. S. citizens have much greater flexibility in their ability to obtain insurance – whether through the workplace, the marketplace, Medicaid, or Medicare. Granted, none of these options feel particularly flexible, and the lack of access to affordable health care is a huge problem across the country. But undocumented immigrants are not eligible for marketplace insurance and are barred from Medicaid and Medicare. And as far as the workplace, it’s a crime for an employer to knowingly hire anyone without the legal ability to work in the U.S. Since they can’t obtain health insurance, in most cases undocumented immigrants won’t even make it onto the transplant list.

It won’t surprise you that medical costs associated with organ transplants are prohibitive for the uninsured. This extends beyond the initial surgery to a lifetime of anti-rejection medications. But those that cannot receive transplants end up costing U.S. taxpayers more money than the transplants and subsequent treatments combined because hospitals don’t turn away people that show up at an emergency room – they are treated regardless of ability to pay or citizenship status. Perhaps a kidney transplant would cost $100,000 initially with $10,000 every year after in medications, but dialysis in lieu of transplant can run $80,000 a year. Some states will cover scheduled dialysis, and emergency dialysis is even more costly. So prohibiting undocumented immigrants from receiving transplants by requiring health insurance to be put on the organ transplant list doesn’t save money.

As the AMA says, “any system that uses the organs of individuals who would themselves not be considered eligible for a transplant because of inability to pay is clearly unjust“.

Are you okay with obtaining organs from deceased individuals who never had a chance to receive one while they were alive?

One-Way Street













The Pre-existing Condition Consideration

Prior to the Affordable Care Act (ACA), insurance companies could charge higher premiums or deny coverage altogether based on an individual’s medical history or health status. The ACA included protections for those with pre-existing health conditions.

Pre-existing conditions differ from insurer to insurer, but they generally designate an individual with a health condition requiring medical treatment or someone who has a greater likelihood of illness and injury due to occupation or lifestyle.

Today, millions of Americans suffer from pre-existing conditions, and based on a recent review from the U.S. Department of Health and Human Services (HHS), the most common of those are:

  • High Blood Pressure  :  46 million people
  • Behavioral Health Disorders  :  45 million people
  • High Cholesterol  :  44 million people
  • Asthma/Chronic Lung Disease  :  34 million people
  • Heart Conditions  :  16 million people
  • Diabetes  :  13 million people
  • Cancer  :  11 million people

Pregnancy is also considered a pre-existing condition.

This Kaiser Family Foundation review of pre-ACA medical underwriting also lists occupations ineligible for insurance.

Active military personnel Iron workers Professional athletes
Air traffic controller Law enforcement/detectives Sawmill operators
Aviation and air transportation Loggers Scuba divers
Blasters or explosive handlers Meat packers/processors Security guards
Bodyguards Mining Steel metal workers
Crop dusters Nuclear industry workers Steeplejacks
Firefighters/EMTs Offshore drillers/workers Strong man competitors
Hang gliding Oil and gas exploration and drilling Taxi cab drivers
Hazardous material handlers Pilots Window washers

It’s apparent that some of the individuals previously unable to obtain medical insurance due to pre-existing conditions were children, but how many?

Using a breakdown by the Center for American Progress that summarizes these numbers by age and state, we were able to determine how many children were affected on a state-by-state basis and which states had the highest percentages of children in the population with pre-existing conditions.

Pre-existing conditions

So, when you’re talking about residents of Utah (ranking #1) losing coverage for pre-existing conditions, around 18% of those impacted are kids. But even where the percentage is lowest in Vermont, the under-18 group still adds up to 11% of those that would be impacted.

A removal of these protections has nationwide impact for both adults and children. Of the 134 million individuals under age 65 that could lose coverage, 17.5 million (13%) are under 18.

Pre-existing Conditions - Children