What you need to know about the dialysis measure

Starting kidney dialysis too soon can be risky.
A patient receives kidney dialysis. California’s Proposition 23 would implement new rules for dialysis clinics. (Mark Boster / Los Angeles Times)

Proposition 23 would require dialysis clinics across California to employ at least one doctor who is on-site whenever patients are receiving treatment.

Here is a rundown of the ballot measure:

The measure

The dialysis industry and the healthcare union have been locked in a years-long fight, which resulted in SEIU-UHW pushing Proposition 8 in 2018. That failed measure would have required businesses with revenues exceeding 115% of specified costs related to patient care to provide rebates to insurers and pay a penalty to the state.

This year’s measure would require dialysis clinics to employ a doctor who is on-site when patients are receiving treatment, increase reporting requirements for dialysis infections, require clinics to obtain approval from the state’s public health department before closing or substantially reducing services, and bar clinics from refusing access to a patient based on their insurance.

Dialysis is a life-saving treatment for people suffering from kidney failure where machines remove a patient’s blood and filter it to remove waste and excess fluids before returning the blood to their body. There are roughly 600 dialysis clinics in California, with nearly three-quarters of the clinics owned or operated by two companies — DaVita Inc. and Fresenius Medical Care.

Pro arguments

Backers of Proposition 23, the Service Employees International Union-United Healthcare Workers West, say the dialysis industry favors profits over patient care by not having a doctor available in the event of complications or an emergency.

The union says its efforts to push for more oversight and higher quality care have been met with fierce — and heavily funded — campaigns aimed at protecting profits of the $3-billion industry in California.

Supporters say that dialysis centers provide critical life-saving treatment and that clinics should therefore be required, like hospitals, to receive approval from the state before reducing services or closing.

Anti arguments

Opponents say the measure is unnecessary and that the added cost would lead to dialysis clinics closing, which would put patients at even greater risk. This year, opponents have so far raised $105.2 million to fight Proposition 23, according to a Times analysis of campaign contributions. Of that amount, DaVita has contributed $66.8 million.

Opponents argue that there are already sufficient medical staff at clinics and that reporting requirements in the measure are superfluous since clinics are currently required to report dialysis-infection-related information to the U.S. Centers for Disease Control and Prevention.

Opponents argue SEIU-UHW has been weaponizing the ballot measure process to force the dialysis industry to spend heavily to defend itself when the union’s real interest is getting workers in clinics to unionize.

Reading list

California voters will again consider new dialysis center regulations with Prop. 23

Times columnist George Skelton assesses Prop. 23

More than $100 million spent on 2018 battle over dialysis industry profits in California

Hospitals and union make deal to avoid ballot measure fight

A look at California’s

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California’s $100M dialysis battle comes with ancillary benefits for labor union

A patient undergoes dialysis at a clinic in Sacramento, Calif.

A patient undergoes dialysis at a clinic in Sacramento, Calif. | Rich Pedroncelli/AP Photo

OAKLAND — In initiative-happy California, one set of ads stands out — those involving dialysis clinics, an industry that’s historically been a lower-profile player in politics.

The ads are unusual not only because of their unlikely topic but their volume, which is high because industry opponents of a labor ballot measure are spending more than any group opposing the other 11 proposals California voters must decide on.


The massive spending gap between the $100 million opponents, including DaVita Inc., have raised and the $8.9 million by supporters led by SEIU United Healthcare Workers West means that the dialysis industry has flooded airwaves as it defends itself against organized labor. The same chain of events played out two years ago, resulting in a resounding defeat for the union’s ballot initiative.

California’s ballot wars have escalated in recent years as industries see little problem spending more than $100 million — and nearly twice that amount in the gig industry’s case — to persuade the electorate. Businesses and organizations that don’t get their way in the state Capitol often use the ballot to change state laws or as leverage to pressure lawmakers and other powerful interests. Proposition 23 is the third most expensive ballot initiative in 2020, according to data compiled by POLITICO.

While SEIU-UHW says it is committed to passing Prop 23, political strategists suggest that labor backers may simply be playing the long game by placing an initiative on the ballot every two years challenging the industry. Win or lose, the union is putting pressure on dialysis companies to spend gobs of money each general election.

“The threat of a ballot measure is something UHW has used strategically,” said Brian Brokaw, a Democratic strategist in Sacramento who is not involved in the Prop. 23 campaign. “In order for a threat to actually be credible, sometimes you have to put it on the ballot. But appearing on a ballot and actually running a campaign to support something are two different things.”

Proposition 23 faces long odds not just because of the industry’s $100 million war chest, but also because it involves a regulatory matter on a crowded ballot — a perfect recipe for voter rejection.

Two years ago, Californians voted 60-40 to reject Prop. 8, another SEIU-UHW-backed initiative that would have capped dialysis profits. But to get that win, the dialysis industry, led by the dominant franchises DaVita Inc. and Fresenius Medical Care, invested about $111 million to defeat it, or nearly six times what the proponents spent.

One day after that Nov. 6, 2018 election, the union vowed to refile the initiative in California and other states. SEIU-UHW did file another initiative, but Prop 23 looks dramatically different, focusing on requirements that clinics must meet such as staffing one doctor on site.

John Logan, director of labor employment studies at San Francisco State University, said unions have long used non-traditional tactics like ballot-box campaigns to get

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