David Walter Banks and Kevin Sack
for The New York Times

January 5, 2010

After a sleepless night, Cruz Constancia got up wondering whether this would be the day that she finally stopped receiving dialysis without charge.

When Ms. Constancia, El Salvador, arrived at her dialysis clinic, she was escorted promptly to her recliner. “I thanked God,” she said after concluding the three-hour session, “because he is really the only one that can allow us to continue our treatments.”

More immediately, it was Grady Memorial Hospital that allowed it on Tuesday.

In early October, when Grady, Atlanta’s public hospital, closed its outpatient dialysis unit for budgetary reasons, it agreed to pay for three months of dialysis at private clinics for about 50 dislocated patients.

The patients, mostly illegal immigrants with no access to insurance, signed documents stating they understood that Grady’s payments would end on Jan. 3. Until then, the hospital would help them relocate to their home countries or other states.

But only a few immigrants left, and many of those who remain acknowledge that they have done little to explore what they regard as untenable options at home.

Grady officials extended the deadline to Feb. 3.

“We think it’s the right thing to do,” said Matt Gove, a senior vice president at Grady, “to help give patients more time to make long-term arrangements.”

The one-month reprieve prolongs a standoff that has become emblematic of the medical crisis facing illegal immigrants. An estimated 7 million of the country’s 11 million illegal immigrants have no health coverage, and are not eligible for government insurance programs like Medicare and Medicaid.

Ms. Constancia, 44, heard the news about the extension Tuesday from a nurse with Fresenius Medical Services, which operates her dialysis clinic in an Atlanta office park. “To think that today was my last day, and then hear that I’ve got another one makes me happy,” she said. “Obviously, I was scared because my life depends on this.”

When serious illness strikes, many immigrants have few options beyond presenting themselves at charity hospitals like Grady. Supported by direct appropriations from Fulton and DeKalb Counties, as well as insurance payments subsidized by state and federal taxpayers, the hospital accepts patients regardless of their insurance or immigration status.

But caring for uninsured immigrants has imposed a heavy financial burden, particularly for public hospitals with broad missions to care for the indigent. At Grady, where thrice-weekly dialysis treatments cost about $50,000 a year, the outpatient clinic ran a deficit of $3.5 million in 2008. That was one-tenth of the hospital’s loss that year, although the clinic served only about 90 patients.

The hospital said they would consider assisting patients beyond Feb. 3 case by case.

In interviews Monday and Tuesday, some patients said they had not made detailed investigations of options for dialysis in their own countries. They said that they were convinced it would not be economically viable and that the quality of care would be poor. Several mentioned that two Grady dialysis patients who returned to Mexico had died (as has one who stayed in Atlanta).

Most of the seven patients interviewed said their plan was to stay put until Grady stopped paying, and then to present themselves at emergency rooms if necessary. Federal law requires that emergency rooms treat anyone in serious jeopardy. Going without dialysis can be fatal in as little as two weeks.

“I’m going to stay here until there’s really not a hope of getting it any more,” said Jesús Neave, 32, who crossed illegally from his native Mexico in 1992 and was diagnosed with kidney disease four years later.

Like the others, Mr. Neave, a maintenance worker, said he would not be able to make enough in Mexico to afford regular dialysis. “Mexico is my country,” he said, “but over there if you don’t have money, the doctors won’t treat you.”

Ms. Constancia said the same of El Salvador: “People die very fast. The way it works down there is that if you do not have money, they don’t put medicine in your machine.”

Several of the patients said the nearest dialysis provider would be a four-or-five-hour drive from their towns. Many said their families and support systems were all in the United States.

While recognizing that Grady is providing care they would not receive at home, some said it had been unfair to withdraw it. “If somebody holds your hand to support you and then stops, you’re going to fall,” said Bineet Kaur, an Indian who said she had had overstayed a visa by three years.

“They don’t have the obligation, but they have a moral duty to help us,” said Rosa Lira, 78, a legal immigrant from Mexico. “They cannot let us die.”

Many of the immigrants said they simply had no plan for when Grady stopped paying the bills.

“The only thing that came to my mind is if they don’t treat me I would go to the emergency room,” said Adolfo Sánchez, 31, an illegal immigrant from Mexico.