After being denied the regular dialysis treatment she needs to survive, Reina Andrade became so sick last week that she passed out and had to be treated in a suburban Atlanta emergency room. With prospects for future treatment uncertain, she boarded a plane Wednesday for her native Honduras.

Andrade is one of nearly two dozen indigent patients, most of them undocumented immigrants, whose dialysis treatment has been in limbo several times since budget cuts forced Atlanta's safety-net hospital to close its outpatient dialysis clinic two years ago.

Patients with end-stage renal failure need regular dialysis two or three times a week to survive. After closing its clinic, Grady Memorial Hospital paid for treatment for about three dozen patients at private clinics through the end of last August. Under an agreement reached last year, three private clinics took on 13 patients as charity cases, and Grady agreed to pay Fresenius Medical Care to treat the remaining patients.

The hospital has seen further budget cuts this year, and spokesman Matt Gove said it simply can't afford to pay for the care anymore. After Grady's agreement with Fresenius expired Aug. 31, Fresenius turned away patients who arrived for care, telling them to go to Grady.

Medicare, the federal health insurance program for people 65 and older, covers routine dialysis for U.S. citizens regardless of their age. But undocumented immigrants are ineligible.

Hospitals can get reimbursed by Medicaid, the state-federal program that helps low-income people, when they provide emergency dialysis for undocumented immigrants in life-or-death situations. But the reimbursement doesn't come close to covering what hospitals spend.

Andrade, who had lived in the U.S. illegally for 11 years, has needed dialysis for the last five years. She was among a group of patients who were turned away from a Fresenius clinic last Thursday and was also turned away from Grady's emergency room Saturday because her condition was not considered critical enough, said Dorothy Leone-Glasser, a patient advocate. On Sunday evening, Andrade's condition deteriorated and she passed out. Her sister took her to Gwinnett Medical Center, where she received emergency dialysis treatment.

"I feel so terrible because I can't help my sister," said Marlen Andrade, sobbing during a phone interview from the Atlanta airport where she had just dropped off Reina for a flight to Honduras. "We didn't want to wait for her to be in that condition again."

Marlen Andrade said she doesn't know whether her sister will be able to get the regular treatment she needs in Honduras because their mother lives far from a major city. But a doctor who gave her emergency treatment earlier this week told the 33-year-old that if she kept waiting to get treatment until she was in critical condition, she could only expect to live for about a year. The sisters and their mother decided that risk wasn't worth taking.

Bineet Kaur came to the U.S. from India on a tourist visa in 2000 and applied for political asylum, saying she didn't feel safe in her country as a single woman living alone. Her asylum request was denied, making her an undocumented immigrant. She was diagnosed with kidney failure in 2003 and told she needed dialysis, but she didn't get treatment because she had no insurance. After several years of extreme pain, she fainted while driving in early 2009, crashing her car into a pole and eventually ended up getting regular treatment at Grady.

She also was turned away from Fresenius last week and from Grady on Saturday. She went back to Grady Tuesday night and was deemed sick enough for emergency treatment. But she was so weak that she had to be hospitalized overnight before dialysis could begin Wednesday morning, she said by phone from Grady as she was being dialyzed.

"I'm so stressed out," she said. "I'm getting dialysis today, but I don't know when I'll get it next. It's scary."

She said she's afraid that if she shows up in the emergency room again and isn't considered sick enough she'll have to go home and may become so sick she can't get to an emergency room in time.

Grady has offered Fresenius $270,000 to treat the patients, whom it says are now Fresenius' responsibility since Fresenius has been treating them for the last two years, but that offer hasn't been accepted, Gove said.

Fresenius said the patients are Grady's responsibility but has offered to pay for dialysis for them for 60 days at hospitals in the area, including Grady, and hopes that a "long-term, community-based solution" can be found in the meantime, said spokeswoman Jane Kramer.

Grady no longer has a license or the facilities to provide regular outpatient treatment, Gove said.

"It's a false offer," he said of the Fresenius proposal. "Offering to pay for something that we cannot provide is no real offer at all."

If Fresenius really wants to help, he said, it should continue to treat the patients at its clinics as it has for the past two years until a solution can be found.

"We're doing our share," Kramer said, when asked why Fresenius wouldn't continue treatment at its clinics. "It's a community-based problem, and we're trying to help lead the way for a community-based solution."

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