One patient’s death changed the course of Dr. Lilia Cervantes’ career. The patient, Cervantes says, was a woman from Mexico with kidney failure who repeatedly visited the emergency room for more than three years. In that time, her heart had stopped more than once, and her ribs were fractured from CPR. The woman finally decided to stop treatment because the stress was too much for her and her two young children. Cervantes says she died soon after.

Kidney failure, or end-stage renal disease, is treatable with routine dialysis every two to three days. Without regular dialysis, which removes toxins from the blood, the condition is life threatening: Patients’ lungs can fill up with fluid, and they’re at risk of cardiac arrest if their potassium level gets too high.

But Cervantes’ patient was undocumented. She didn’t have access to government insurance, so she had to show up at the hospital in a state of emergency to receive dialysis.

Cervantes, an internal medicine specialist and a professor medicine at University of Colorado in Denver, says the woman’s death inspired her to focus more on research. “I decided to transition so I could begin to put the evidence together to change access to care throughout the country,” she says.

Cervantes says emergency-only dialysis is harmful to patients: The risk of death for someone receiving dialysis on an emergency basis is 14 times higher than someone getting standard care, she found in research published in February. Cervantes’ newest study, published Monday in the Annals of Internal Medicine, shows these cyclical emergencies harm health care providers, too. “It’s very, very distressing,” she says. “We not only see the suffering in patients, but also in their families.”

There are an estimated 6,500 undocumented immigrants in the U.S. with end-stage kidney disease. Many of them can’t afford treatment or private insurance, and are barred from Medicare or Medicaid. This means the only way they can get dialysis is in the emergency room.

Cervantes and her colleagues interviewed 50 healthcare providers in Denver and Houston and identified common concerns among them. The researchers found that providing undocumented patients with suboptimal care because of their immigration status contributes to professional burnout and moral distress.

“Clinicians are physically and emotionally exhausted from this type of care,” she says.

Cervantes says the relationships clinicians build with their regular patients conflicts with the treatment they have to provide, which might include denying care to a visibly ill patient, because their condition was not critical enough to warrant emergency treatment.

“You may get to know a patient and their family really well,” she says. Providers may go to a patient’s restaurant, or to family gatherings such as barbacoas or quinceañeras.

“Then the following week, you might be doing CPR on this same patient because they maybe didn’t come in soon enough, or maybe ate something that was too high in potassium,” she says.

Other providers, Cervantes says, report detaching from their patients because of the suffering they witness. “I’ve known people that have transitioned to different parts of the hospital because this is difficult,” she says.

Melissa Anderson, a nephrologist and assistant professor at the Indiana University School of Medicine in Indianapolis who was not involved in Cervantes’ study, says Cervantes research matches her own experience. She says that when she worked at a safety net hospital in Indianapolis, patients would come to the ER when they felt sick. But some hospitals would not provide dialysis until their potassium was dangerously high.

To avoid being turned away when their potassium level was too low, she says, patients in the waiting room would drink orange juice, which contains potassium, putting themselves at risk of cardiac arrest.

“That’s Russian roulette,” Anderson says. “That was hard for all of us to watch.”

Anderson eventually stopped working at that hospital, and like Cervantes, has also worked on research and advocacy efforts to change how undocumented immigrants with kidney failure are treated. “I practically had to take a class in immigration to understand what’s going on,” she says. “Physicians just don’t understand it, and we shouldn’t have to.”

Providers in Cervantes’ study also worried that these avoidable emergencies strain hospital resources — clogging emergency departments when undocumented patients could simply receive dialysis outside the hospital — and about the cost: Emergency-only hemodialysis costs nearly four times as much as standard dialysis, according to a 2007 study from researchers at Baylor College of Medicine.

Those costs are often covered by taxpayers through emergency Medicaid, which pays for emergency treatment for low-income individuals without insurance. In a study published in Clinical Nephrology last year, Anderson and her colleagues found that at one hospital in Indianapolis, the state paid significantly more for emergency-only dialysis than it did for more routine care.

Areeba Jawed, a nephrologist in Detroit who has performed her own survey research into this issue, said many providers don’t understand how much undocumented immigrants actually contribute to society, while receiving few of the societal benefits. “A lot of people don’t know that undocumented immigrants do pay taxes,” she says. “There’s a lot of misinformation.”

“I think there are better options,” says Jawed, who has treated undocumented patients there and in Indianapolis.

To work around this problem, some hospitals simply provide charity care to cover regular dialysis for undocumented patients. But Cervantes argues that a better solution is a policy fix. States are allowed by the federal government to define what qualifies as an emergency.

“Several states, like Arizona, New York and Washington, have modified their emergency Medicaid programs to include standard dialysis for undocumented immigrants,” she says.

Illinois covers routine dialysis and even passed a law allowing undocumented immigrants to receive kidney transplants, she points out.

“Ideally, we could come up with federal language and make this the national treatment strategy for undocumented immigrants,” Cervantes says.

Ultimately, Cervantes says providers don’t want to treat undocumented patients differently. “At the end of the day, clinicians become providers because they want to provide care for all patients,” she says.

This story was produced in partnership with Side Effects Public Media, a news collaborative covering public health.

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The planned revival of a policy dating to Ronald Reagan’s presidency that was slightly retooled and quietly submitted for federal budget review Friday may finally present a way for President Trump to fulfill his campaign promise to “defund” Planned Parenthood.

Or at least to evict it from the federal family planning program, where it provides care to more than 40 percent of that program’s 4 million patients.

Congress last year failed to wipe out funding for Planned Parenthood, because the bill faced overwhelming Democratic objections and would not have received the 60 votes needed to pass in the Senate. But Trump’s move Friday could potentially accomplish what Congress could not.

According to administration officials, the proposed rules they have submitted to the Office of Management and Budget would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.

All those changes would particularly affect Planned Parenthood.

Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion-rights groups, which supported candidate Trump.

“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the Susan B. Anthony List, a group that opposes abortion, said in a written statement.

In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.

“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.

Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:

What is Title X?

The federal family planning program, known as “Title X,” is named for its section in the federal Public Health Service Act. It became law in 1970, three years before the Supreme Court legalized abortion in Roe v. Wade. The original bill was sponsored by then-Rep. George H.W. Bush, R-Texas, and signed into law by President Richard Nixon.

The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.

In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.

Title X patients are overwhelmingly young, female and low-income. An estimated 11 percent of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.

What is Planned Parenthood’s relationship to Title X and Medicaid?

Planned Parenthood’s affiliates account for about 13 percent of all Title X sites but serve an estimated 40 percent of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.

Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X. Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding likely is not at risk.

While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.

Texas, Iowa and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials say.

Why is Planned Parenthood’s involvement with Title X controversial?

Even though Planned Parenthood cannot use federal funding for abortions, opponents of abortion rights claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.

Planned Parenthood has also been a longtime public target for forces that oppose abortion rights because it is such a visible provider and vocal proponent of legal abortion services. In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control.

That was followed by efforts to eliminate abortion counseling. Starting in 2011, in an effort to get the organization defunded, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts. Planned Parenthood denied the allegations, which were proved false in court.

What happened the last time an administration tried to move Planned Parenthood out of Title X?

In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the Trump administration’s new proposal is not yet public, because the details are still under review by the federal Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.

The original gag rule would have forbidden Title X providers to offer abortion counseling or refer patients for abortions. It would have required physical separation of Title X facilities from those that provide abortions and would have forbidden recipients to use nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)

Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v. Sullivan. Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel people about the availability of abortion created another round of legal fights.

Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president has tried to revive them until now.

How is the Trump administration’s proposal different from earlier rules?

According to the summary of the new proposal, released Friday, it will require physical separation of family planning facilities from those that provide abortions, will repeal current counseling requirements, and will ban abortion referrals.

One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.

But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.

“Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule,” said Kashif Syed, a senior policy analyst for Planned Parenthood.

What happens next?

All proposed rules are reviewed by the OMB. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.

Meanwhile, Planned Parenthood officials say they will not know whether they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the proposed changes that have been made public so far.

Kaiser Health News is a nonprofit news service and an editorially independent program of the Kaiser Family Foundation. It is not affiliated with Kaiser Permanente. KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

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The White House is expected to announce as early as Friday that it is reviving a rule first proposed during the Reagan administration that bars groups who provide abortions, discuss the procedure or refer patients for abortions from receiving federal family planning funds, a Trump administration has confirmed.

The proposed regulation would apply to Title X, the federal program that provides $260 million annually for contraception, screenings for sexually transmitted diseases, and other reproductive health services to millions of low-income people, according to the White House official, who asked not to be named.

The rule change would put Planned Parenthood back in the cross-hairs after repeated attempts by congressional Republicans to de-fund the family planning group, which also provides abortions, but says the federal money it receives does not go toward paying for the procedures.

Under current law, federal funding for abortions is prohibited in most cases. However, anti-abortion rights advocates have long made cutting funds to any group providing abortions or referring patients for abortions a high priority.

The new rule, expected to be announced by the Department of Health and Human Services, would also bar federal funds for any group that discusses abortion with patients or shares space with an abortion provider.

Abortion-rights supporters have described the proposal as a “gag rule” and say it would undermine reproductive health care for low-income patients.

However, anti-abortion rights groups praised the proposed change. Students for Life of America, which says it has members on more than 1,200 U.S. university and high school campuses, said in a statement:

“These changes are long overdue as abortion is not healthcare or birth control and many women want natural healthcare choices rather than hormone-induced changes,” the group’s president, Kristan Hawkins, said. “The Trump Administration has every right to require that Title X programs focus on healthcare, not abortion, and to keep such programs aimed at helping women make a plan for a family outside of the facilities designed to making sure women don’t have a family at all.”

The rule, first proposed during the Reagan era, was hit by legal challenges by Planned Parenthood and other groups and was never fully implemented. It was later rescinded altogether by President Bill Clinton. Abortion-rights groups are likely to take to the courts again in efforts to stop the proposal.

“This ‘gag rule’ is not only unconscionable, but it undermines medical ethics by forcing health care professionals to withhold accurate and timely medical information from patients,” Dr. Jenn Conti, a fellow with Physicians for Reproductive Health, said in a statement Thursday.

“As a provider of comprehensive reproductive health care, it is my number one priority to keep my patients safe and honor the trust they give me. If I can’t mention the word ‘abortion,’ then I am not providing my pregnant patients who want to know all of their options with complete, accurate, unbiased medical information,” she said.

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