Uninsured, undocumented immigrants often go to the emergency room for treatment. Since 1986 the federal government has required that patients in the emergency room receive care, regardless of their immigration status or ability to pay.
But caring for chronic conditions such as kidney disease or cancer in the emergency room is expensive. So some states are quietly expanding access for undocumented immigrants to obtain medical treatment beyond the ER.
One of those states is Washington, where an undocumented immigrant named Gonzalo lives with his wife, Ricarda.
Gonzalo is really sick.
"I can't enjoy the day — go out — because I'm always unwell," he said in an interview in Spanish.
Gonzalo moved to the U.S. from Mexico about 30 years ago. He's 60 years old. We're not using his last name because of his immigration status.
Ten years ago, Gonzalo's kidneys failed. Since then, he's gotten sicker and sicker. Five years ago, he had to quit his job as a painter.
"I used to pay the rent. I paid for everything, and we didn't lack anything," he said. "But I got sick and everything changed."
Now, Gonzalo and his wife live with one of their daughters in her apartment south of Seattle.
Across the country, there are about 6,500 undocumented immigrants with kidney failure, according to the National Institutes of Health. What kind of care they get depends on where they live.
In most states, they can only get dialysis in hospital emergency rooms.
That means, every couple of weeks, they go to the hospital when so many toxins have built up in their body it's life-threatening. Usually, they have to stay overnight so they can be dialyzed twice. That costs nearly $300,000 per person every year.
So seven states, including Washington, have a different system.
"The state of Washington has something called AEM," said Leah Haseley, a nephrologist — a kidney doctor — in Seattle. She's talking about Alien Emergency Medical, part of Washington's Medicaid.
"AEM pays for two things," she explained. "They pay for dialysis for undocumented people, and they pay for chemotherapy for cancer treatment for undocumented people as well."
The first time that you show up at a hospital with kidney failure, that's an emergency. After that, it's a chronic condition, and we don't believe that it's appropriate to reward lawbreakers with benefits at the expense of U.S. taxpayers.
Regular dialysis costs about a quarter of what emergency dialysis does — but it's controversial.
"The first time that you show up at a hospital with kidney failure, that's an emergency," said Matthew O'Brien, with the Federation for American Immigration Reform, a group that advocates for stricter immigration laws. "After that, it's a chronic condition, and we don't believe that it's appropriate to reward lawbreakers with benefits at the expense of U.S. taxpayers."
But there are others who say even regularly scheduled dialysis isn't enough: undocumented immigrants who qualify should be given kidney transplants, because the cost of a transplant is less than the ongoing costs of regular or emergency dialysis. But, without health insurance, few undocumented immigrants can afford a transplant.
In 2015, Illinois became the first state with a system for paying for organ transplants for undocumented immigrants.
Dr. David Ansell was a prominent advocate for the change.
If you're undocumented in Illinois, you can get a driver's license, and disproportionately the Latino community is signing up to donate their organs. It's a simple matter of ethics and fairness.
"In about a year and a half the cost for a transplant pays itself back," he said, "but also people can go back to work and contribute to the state."
So far, more than 200 undocumented immigrants in Illinois have been given access to organ transplants, with their insurance premiums paid for by a non-profit. Now, Dr. Ansell and other public health advocates hope to see a similar program at the national level.
Many who oppose this say, with limited organs available, they should be reserved for citizens and legal immigrants.
But Dr. Ansell says, in Illinois, 75 percent of kidney transplants for undocumented immigrants come from donations from their own family — a much higher rate than the rest of the population.
"If you're undocumented in Illinois, you can get a driver's license, and disproportionately the Latino community is signing up to donate their organs," Dr. Ansell added. "It's a simple matter of ethics and fairness."
He said, since Illinois started paying for the transplants, the total number of organs available has increased, because so many more Latinos have signed up for organ donation.
Overall in the US, studies have found that undocumented immigrants donate 2 to 3% of all organs.
Back in the Seattle area, Gonzalo says all three of his daughters are willing to give him a kidney, but he has no way to pay for the transplant.
That's why his wife, Ricarda, says she's taken to buying lottery tickets.
She said in Spanish, "I've told my husband, 'If I win the lottery, I won't think twice. I'm going to get you a kidney.'"
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