What the Measure Would Do

Proposition 29 would establish a set of regulations for the staffing and operations of chronic dialysis clinics in the state. Specifically, the measure would require that clinics:

• Have at least one of the following on site during patient treatments:
  • specialized physician, such as a nephrologist
  • nurse practitioner
  • physician assistant with at least six months of experience with end-stage renal disease
• Report dialysis-related infections to the California Department of Public Health (CDPH).
• Provide patients with a list of physicians who have an ownership interest of 5% or more in the clinic.
• Provide the CDPH with a list of physicians who have an ownership interest of 5% or more in the clinic.
• Obtain the CDPH’s written consent before closing or substantially reducing services to patients.

Prop. 29 would also prohibit clinics from refusing patient care based on the patient’s form of payment, whether the patient is an individual payer or whether the patient’s health insurer is Medi-Cal or Medicare.

If this proposition passes, clinics across the state would see cost increases due to the administrative and staffing requirements this initiative mandates.

The Backstory

Dialysis, a treatment that removes waste and chemicals from the bloodstream, is administered to people whose kidneys no longer function properly. Patients need about three treatments per week, and missing a treatment can result in serious health complications. In California, about 80,000 patients receive dialysis treatments each month, most of which happen at one of the roughly 600 private clinics across the state.^[1] Most of these private clinics are owned and operated by two companies, DaVita and Fresenius Medical Care.^[2]

Prop. 29 is the third attempt in four years by labor organization Service Employees International Union-United Healthcare Workers West (SEIU-UHW West) to regulate dialysis clinics. Prop. 8 in 2018 and Prop. 23 in 2020 included similar requirements for dialysis clinics, and both failed when taken to voters. Prop. 29 differs from Prop. 23 by introducing medical personnel specifications and introducing stakeholder reporting.^[3]

Dialysis clinics are already required to report ownership interests of 5% or more to the state survey agency,^[4] and current federal rules already require that dialysis clinics have an assigned medical director — a physician responsible for staff training and implementing quality of care measures — although there are no rules for how long this doctor needs to be on site.^[5] Additionally, most patients in California already use Medi-Cal or Medicare to pay for dialysis treatments.^[6] Prop. 29 aims to improve reliability and accuracy of data, which can be difficult to obtain, and to maximize the time that a trained physician, nurse practitioner or physician assistant is present during a patient’s treatment.

Proponents assert that there is a need for dialysis industry reform. Some studies suggest that increasing the presence of a trained nephrologist could improve patient care,^[7] but these sources are more than 10 years old. There are no recent or relevant statistics, surveys or studies that suggest a need for dialysis reform, nor is there substantial support for this proposition from dialysis professionals. Opponents view the measure as a further attempt to politically and financially weaken DaVita and Fresenius Medical Care and to unionize dialysis workers, and assert that the shortage of nephrologists in the state would leave clinics unable to meet the requirements of Prop. 29.^[8]

This proposition was placed on the ballot through the collection of signatures, and a simple majority (50% plus one vote) is required for it to pass.

Equity Impacts

This measure would result in higher operating and penalty costs for dialysis clinics. Higher costs could result in clinics being forced to close, which would reduce access to dialysis care or cause higher costs to be passed along to patients. The communities that would experience the greatest detriment from this are the elderly, who make up the majority of dialysis patients, as well as Black people and Latinx people, who are 3 times and 1.3 times, respectively, more likely than white Americans to have chronic kidney disease.

However, if trained nephrologists are present during treatment, these patients could receive improved quality of care.

Pros

• Having on-site, fully trained physicians, nurse practitioners or physician assistants at dialysis clinics would ensure that a trained professional would be present in emergencies.
• Improved transparency and accessibility of information can help patients make informed decisions for their care.

Cons

• Should dialysis clinics be forced to close as a result of increased operating costs, vulnerable patients could lose access to life-saving treatments, sending them to emergency rooms to receive necessary procedures.
• There are not enough nephrologists in the state to meet the staffing requirements set forth by the proposition.