Immigration Debate Hits Home for Liver Transplant Patients

Anna Gorman, Los Angeles Times, April 13, 2008

Ana Puente was an infant with a liver disorder when her aunt brought her illegally to the U.S. to seek medical care. She underwent two liver transplants at UCLA Medical Center as a child in 1989 and a third in 1998, each paid for by the state.

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This year, her liver began failing again and she was hospitalized at County-USC Medical Center. In her Medi-Cal application, a USC doctor wrote, “Her current clinical course is irreversible, progressive and will lead to death without another liver transplant.” The application was denied.

The county gave her medication but does not have the resources to perform transplants.

Late last month Puente learned of another, little-known option for patients with certain healthcare needs. If she notified U.S. Citizenship and Immigration Services that she was in the country illegally, state health officials might grant her full Medi-Cal coverage. Puente did so, her benefits were restored and she is now awaiting a fourth transplant at UCLA.

Puente’s case highlights two controversial issues: Should illegal immigrants receive liver transplants in the U.S. and should taxpayers pick up the cost?

The average cost of a liver transplant and first-year follow-up is nearly $490,000, and anti-rejection medications can run more than $30,000 annually, according to the United Network for Organ Sharing, which oversees transplantation nationwide.

Donor livers are also in scarce supply. In California, nearly 3,700 people are on a waiting list for livers, according to the network. Last year, 767 liver transplants were performed in the state. More than 90% of the organs were given to U.S. citizens.

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Immigration status does not play a role in allocating organs.

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“All transplants are about rationing,” said Roy Beck, executive director of NumbersUSA, which favors stricter controls on immigration. “I just don’t think the public ought to be funding any kind of benefits for people who are breaking the law.”

Larry Gonzalez, a U.S. citizen who has hepatitis C, has known for a decade that he needs a new liver but was just placed on the transplant waiting list last week.

“Why do we have to get in line behind immigrants, foreigners, when we have enough people here to fill the hospitals?” asked Gonzalez, 54, who lives in Ventura. “It just seems obvious to me that we shouldn’t be taking a back seat.”

But Dr. Michael Shapiro, vice chairman of the ethics committee for the organ network, said illegal immigrants have just as much right to organ transplants as U.S. citizens. He said it is likely that more illegal immigrants donate organs than receive them.

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Holes in the safety net

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If illegal immigrants inform the state in writing that U.S. immigration services “is aware of their presence and does not plan to deport them,” they could be eligible for full-scope Medi-Cal, said Norman Williams, spokesman for the state health department. Medical condition is one factor that would make immigrants eligible for coverage.

The immigrants send a form to Citizenship and Immigration Services, but the agency said it does not respond to patients or make any promises about their immigration status.

Looking to the future

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The larger problem, [Dr. Sue V. McDiarmid, medical director of UCLA’s pediatric liver transplant program] said, is that the state healthcare system cuts off illegal immigrants who were covered as children. “We took care of those undocumented children because we thought, and the state thought, that it was the right thing to do,” she said. “Why would we as a society then turn our backs on them?”

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Repeat transplants, which are not uncommon, can be necessary if the patients’ bodies reject the livers at the time of the transplant or while they are on medication, or if the transplant livers develop hepatitis C, Stolz said.

Jose Lopez said he came to the U.S. with his mother illegally as a child. Soon after, he contracted hepatitis A and received his first liver transplant. Eight years later, he got cirrhosis and received another transplant.

Both were performed at UCLA and paid for by the state.

As his 21st birthday approached, his mother, Maria Elena Lopez, searched for clinics that might agree to treat her son. She applied for Medi-Cal for him but has not received a response.

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About a month later, his mother found the Roybal clinic, which provided Lopez with medication and monitored his care. Though his drugs never lapsed, his liver is still in rejection.

“I’m just mad,” he said from the Los Angeles apartment he shares with his parents. “You can’t just leave a person to die. That’s pretty much what they’re telling me: ‘You’re illegally here. We’re just gonna let you die.’ ”

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A question of ethics

Medical ethicists said doctors and hospitals have a duty to continue treatment for their transplant patients unless they can find them comparable care elsewhere.

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Caplan said UCLA doctors were under no obligation to perform liver transplants on the illegal immigrant children knowing that their insurance would run out at 21 and that their livers would probably need to be replaced.

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