Funding Undocumented CKD-5 to initiate Home PD

I am a nephrology consultant at a safety net clinic, Marin Community Clinic, in San Rafael, CA. I am aware of a general push to get patients into the home for ESRD services, to both improve QOL and to address costs for ESRD. I have identified an uninsured CKD-5 patient who should have a hidden PD catheter placed, to initiate home training. He has been evaluated by a PD nurse affiliated with Satellite Healthcare, Greenbrae, and deemed acceptable for home training. A private practice nephrologist will assume his care at the clinic and training can begin…WHEN he has the equipment. If he is not trained, he is at risk to enter ESRD via the ER, ICU, a central venous catheter, emergency hemodialysis, a week in the hospital, at an estimated cost of $250,000. THEN, with a CV catheter in place, having had dialysis, he will be given MediCal, and proceed to have placement of a catheter for PD and embark upon training while getting HD. CRAZY! What are the resources I can use to prevent this farce, and motivate others, like myself, to identify what is best for the patient, and society, and then accomplish society’s end; compassionate, cost effective renal care?

Some people who are undocumented have been able to get Medi-Cal under a program called PRUCOL I believe this is the form to use to establish this status.

A friend gave me the name of a Medi-Cal attorney who has been tremendously helpful to his patients in LA County through the Neighborhood Legal Services’ Health Consumer Center. Her name is Toni Vargas and the phone number is 800-896-3202. If her organization doesn’t cover your patient’s area, she may be able to recommend someone in that area.

Thank you for reminding me. PRUCOL is the route! I had forgotten, 5 years into retirement. You got me going: Here’s what I sent out to local activists.

This letter to the director of enrollment at Marin Community Clinic (MCC), while specific to the costs added to the healthcare system by undocumented patients, stresses the additional cost born by the taxpayers due to rules restricting efficient distribution of treatment to segments of the patient population, and, ultimately, the need to meet this problem through political action. If a Medicare 4 All program were substituted for the hodgepodge of rules and regulations, the enrollment counselors would be out of business, as would the bureaucracy that administers PRUCOL. This is part of the administrative burden that consumes efficiency, funding and energy, and would be eliminated in the enactment of Medicare 4 All.

This is what I confront in the ongoing battle, and this is what I will take to Diane Feinstein, Alex Padilla, Gavin Newsom, Mike McGuire and Mark Levine, in the attempt to bring justice and economic efficiency to healthcare.

Best to all in the ongoing battle for justice in healthcare.


Hi Armando,

Thank you again for your prompt and complete response to my inquiry about PRUCOL and whether it had been proposed to my patient with impending end stage renal disease (ESRD) and the regrettable choice between the modes of dialysis that are unavoidable if he wants to live. Following your help, I did identify the notes showing repeated references to PRUCOL, but failed to find a clearly delineated reason why the patient had not undertaken the process that ends with full scope MediCal. In our discussion, you mentioned 3 reasons why an individual might not qualify for PRUCOL. They are:

1.) income may exceed eligibility guidelines

2.) immigration status requires documentation that the patient is known to the IRS

3.) public charge concern in a potential future application for citizenship

I then asked about the process of documentation in the eMR, and the directions that you were following, who gave those directions, and why the resultant entry might not contain a more specific explanation of which of the three possibilities applied to the patient. You mentioned your director, Jackie Jones, and Isabella Mihai, the compliance officer as being in the decision tree, if any change in the current policy is to be made. I am in full agreement that the entire process must be patient centered, and that the patient is our primary concern. I am satisfied that a well trained patient educator/enrollment counselor, can discuss the alternatives, and that you are working with the Canal Alliance to be sure that legal advice is available so that the patient may make a decision in their own perceived best interests.

As I explained, my experience over 60 years in training, private practice, at county and private hospitals, at safety net clinics and most recently, at MCC (a FQMC) has been a lifelong career in pursuit of justice in healthcare and this continues to this time, even in retirement. Ultimately, the granting of health care to those who can’t afford it, must come by way of the political process, and the past four years did not bring us closer to that goal. However, the COVID pandemic has demonstrated to so many more than previously understood it, that disparities in health care fall disproportionately on people of color and immigrants. If we didn’t already know it, no one can deny that those disparities and the consequent higher incidence of disease and death, stayed confined within geographic areas of de facto economic segregation. COVID knows no borders, city, county, state or nation. It has no prejudice. This is a time to finally achieve justice in health care.

Ultimately, that justice will be gained or lost via a political process, and the approach to be taken must be fact based and defensible. Rules, following from laws, can be changed, if minds can be changed. It is my intention to show the economic justification that tips the scales in favor of the existing empathy and altruism expressed in our ideals…. “all men being created equal.” At a Convention of the Medical Committee for Human Rights held in Chicago in March 1966, Martin Luther King Jr declared: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” I was at Cedars/Sinai Medical Center in Los Angeles, at the time, and hemodialysis was in its infancy, and unaffordable. Medicare had come into existence in 1965, and by 1971, ESRD alone, amongst all medical conditions, was included as a justification for the extension of Medicare benefits to anyone, so afflicted, regardless of age. To its eternal credit, MediCal, born in 1971, covered services necessary to sustain life, hemodialysis, from its inception, and no one has ever died, in California, of ESRD, be they indigent, or undocumented immigrant, if they wanted to live. In my 60 year career, I know of no one receiving dialysis treatments in the USA who was returned by immigration to their country of citizenship.

Changing the rules means changing the laws. Knowing why patients chose not to apply for PRUCOL will help legislators to understand how the law should be changed. The savings of $100,000 per patient by avoiding the unnecessary emergency room visit, hospital admission, unnecessary surgery will provide a fiscal justification for a humanitarian act. I know that my employment at MCC has saved $400,000 in 4 years, and that is only a start of what can be done. But, the questions will be asked, and they are legitimate. Why did the patient choose not to apply for PRUCOL, and of course, how many people declined to apply for PRUCOL, and how much money can be saved by allowing justice and altruism and empathy, to prevail?

Sincerely yours,

IMG_362 Rainbow 993TT Norwalk.jpeg

Davita Norwalk Dialysis Clinic - 1996 Porsche 911 Turbo ~ 2005

Laurence Lewin, M.D.

Nephrology & Transplantation Management

Nephrologist, Marin Community Clinic

Patient Advocate

PNHP - Marin Justice in Healthcare

183 Mark Twain Avenue

San Rafael, CA 94903-2820

(415) 991-5942 - home

Mobile: (714) 478-2308 (best)

Fax: (415) 366-9108

Thank you for your advocacy. It does seem like you make a winning human interest as well as an economic argument.