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November 3, 2020 — California General Election
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State of California
Proposition 23 — Kidney Dialysis Clinics Initiative Statute - Majority Approval Required

To learn more about measures, follow the links for each tab in this section. For most screenreaders, you can hit Return or Enter to enter a tab and read the content within.

Election Results

Failed

6,141,692 votes yes (36.6%)

10,653,918 votes no (63.4%)

100% of precincts reporting (20,497/20,497).

AUTHORIZES STATE REGULATION OF KIDNEY DIALYSIS CLINICS. ESTABLISHES MINIMUM STAFFING AND OTHER REQUIREMENTS. INITIATIVE STATUTE. 

Requires physician or other specified medical professional on site during dialysis treatment. Prohibits clinics from reducing services without state approval. Prohibits clinics from refusing to treat patients based on payment source.

Fiscal impact: Increased state and local government costs likely in the low tens of millions of dollars annually.

Put on the Ballot by Petition Signatures

What is this proposal?

Easy Voter Guide — Summary for new and busy voters

Information provided by The League of Women Voters of California Education Fund

The way it is now

If a person’s kidneys stop working, they may need a special treatment called dialysis. In California, dialysis is usually provided by licensed dialysis clinics. A patient’s personal doctor must visit them at least once per month during treatment at a dialysis clinic. Dialysis treatment is paid for by Medicare, Medi-Cal and private insurance. Private insurance pays more money for treatment than Medicare and Medi-Cal.

What if it passes?

Prop 23 would require dialysis clinics to have a doctor present during all treatment hours. Clinics would have to report any dialysis-related infections to the state every three months. Clinics would need permission from the state before closing or reducing services. Clinics could not discriminate against clients based on their insurance or how they are paying for their treatment.

Budget effect

Budget effects would depend on how dialysis clinics respond to Prop 23. Dialysis companies might close some clinics or try to charge more money for treatment. Health care costs for state and local governments would likely increase in the low tens of millions of dollars each year. The state would spend in the low millions of dollars each year to enforce Prop 23. These state costs could be paid for by increasing licensing fees.

People FOR say

  • Dialysis is a dangerous procedure; clinics should always have a doctor available to help.
  • Prop 23 prevents discrimination and protects patients in rural communities.

People AGAINST say

  • Prop 23 would take thousands of doctors away from hospitals and emergency rooms, making California’s doctor shortage worse.
  • Some dialysis clinics in the state might close due to increased costs.

Pros & Cons — Unbiased explanation with arguments for and against

Information provided by League of Women Voters of California Education Fund

The Question

Should outpatient dialysis clinics be required to have a physician on site at all hours when patients are being treated, offer the same level of care to all patients regardless of insurance, and report infection-related information?

The Situation

People suffering from End-Stage Renal Disease, the final stage of kidney disease, must receive dialysis to survive. Dialysis filters out waste and toxins from blood. It is typically done in a chronic dialysis clinic three times a week with each treatment lasting up to four hours. To address patients’ needs, clinics often operate six days a week for extended hours. These clinics are licensed by the California Department of Public Health using federal certification standards, which have limited requirements about staffing hours or ratios.

Approximately 600 licensed clinics operate in California. The majority of the clinics are owned and run by one of two private for-profit companies. Estimated annual revenue of the private companies is $3 billion. Most dialysis is paid for by Medicare and Medi-Cal. These government programs pay a fixed rate established by regulation and close to the average cost of treatment. Private insurance also covers dialysis with payment rates fixed by negotiation with the providers. On average those rates are multiple times higher than those paid by the government programs.

The Proposal

Prop 23 says that clinics must:

  • Have at least one licensed physician on site during all hours when patients are receiving treatment. An exemption may be granted if no qualified physician is available but a nurse practitioner or physician assistant is on site.
  • Offer the same level of care to all patients regardless of whether treatment is paid for by private insurance or a government program.
  • Report more information about infections among their patients to the state health department, with penalties for non-reporting.
  • Notify and obtain consent from the state health department before closing or reducing services.

Fiscal effect

Prop 23 could increase costs for clinics because a licensed physician would have to be present during all treatment hours. This could average several hundred thousand dollars per year per clinic. The new data-reporting requirement would not significantly increase costs.

Prop 23 could increase healthcare costs to state and local governments if clinics negotiate higher reimbursement rates or if some clinics close and patients have to receive treatment at more expensive facilities. These costs are estimated to be in the low tens of millions of dollars annually.

Supporters say

  • Patients should have access to a physician on site whenever dialysis treatment is being provided.
  • Proper reporting and transparency of infection rates encourages clinics to improve quality.
  • Strong protections should be provided to vulnerable patients when clinics close.

Opponents say

  • Prop 23 would force community dialysis clinics to cut services or close, putting lives at risk.
  • Prop 23 would make our physician shortage worse and lead to more overcrowding in emergency rooms.
  • Dialysis clinics are already strictly regulated and provide high-quality care.

Measure Details — Official information about this measure

YES vote means

A YES vote on this measure means: Chronic dialysis clinics would be required to have a doctor on-site during all patient treatment hours.

NO vote means

A NO vote on this measure means: Chronic dialysis clinics would not be required to have a doctor on-site during all patient treatment hours.

Summary

Source: California Attorney General's Office - Official Voter Information Guide p. 60

OFFICIAL TITLE AND SUMMARY
PREPARED BY THE ATTORNEY GENERAL 

PROPOSITION 23.
AUTHORIZES STATE REGULATION OF KIDNEY DIALYSIS CLINICS. ESTABLISHES MINIMUM STAFFING AND OTHER REQUIREMENTS. INITIATIVE STATUTE. 

  • Requires at least one licensed physician on site during treatment at outpatient kidney dialysis clinics; authorizes California Department of Public Health to exempt clinics from this requirement if there is a shortage of qualified licensed physicians and the clinic has at least one nurse practitioner or physician assistant on site.
  • Requires clinics to report dialysisrelated infection data to state and federal governments. 
  • Prohibits clinics from closing or reducing services without state approval.
  • Prohibits clinics from refusing to treat patients based on the source of payment for care.

SUMMARY OF LEGISLATIVE ANALYST’S ESTIMATE OF NET STATE AND LOCAL GOVERNMENT FISCAL IMPACT:

  • Increased state and local government costs likely in the low tens of millions of dollars annually. 

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=60

 

Background

Source: California Legislative Analyst's Office - Official Voter Information Guide pp. 60-62

BACKGROUND

DIALYSIS TREATMENT

Kidney Failure. Healthy kidneys filter a person’s blood to remove waste and extra fluid. Kidney disease refers to when a person’s kidneys do not function properly. Over time, a person may develop kidney failure, also known as “end-stage renal disease.” This means the kidneys no longer work well enough for the person to live without a kidney transplant or ongoing treatment called “dialysis.”

Dialysis Mimics Normal Kidney Functions. Dialysis artificially mimics what healthy kidneys do. Most people on dialysis undergo hemodialysis. This form of dialysis removes blood from the body, filters it through a machine to remove waste and extra fluid, and then returns it to the body. A single treatment lasts about four hours and happens about three times per week.

Most Dialysis Patients Receive Treatment in Clinics. Most people with kidney failure receive dialysis at chronic dialysis clinics (CDCs), although some may receive dialysis at hospitals or in their own homes. About 600 licensed CDCs in California provide dialysis to roughly 80,000 patients each month. Given how often patients need dialysis and how long treatments last, clinics often offer services six days per week and often are open outside of typical business operating hours. 

Patients’ Own Doctors Oversee Treatment. When a patient has kidney failure, the patient’s doctor develops a plan of care, which could include a referral for dialysis. The patient’s doctor designs the dialysis treatment plan, including specific aspects such as frequency, duration, and associated medicines. CDCs carry out the treatment. The patient’s doctor continues to oversee the patient’s care. Under federal rules, the doctor must visit the patient during dialysis treatment at the CDC at least once per month.

Various Entities Own and Operate CDCs, With Two Entities Owning/Operating the Vast Majority of Them. Two private for-profit companies—DaVita, Inc. and Fresenius Medical Care—are the “governing entity” of nearly three-quarters of licensed CDCs in California. (The measure refers to the governing entity as the entity that owns or operates the CDC.) The remaining CDCs are owned and operated by a variety of nonprofit and for-profit governing entities. Most of these other governing entities have multiple CDCs in California, while a small number own or operate a single CDC. Currently, the majority of CDCs’ earnings exceed costs, while a smaller share of CDCs operate at a loss. A governing entity that owns or operates multiple CDCs can use its higher-earning CDCs to help support its CDCs that operate at a loss.

PAYING FOR DIALYSIS

Payment for Dialysis Comes From a Few Main Sources. We estimate that CDCs have total revenues of more than $3 billion annually from their operations in California. These revenues consist of payments for dialysis from a few main sources, or “payers”:

  • Medicare. This federally funded program provides health coverage to most people ages 65 and older and certain younger people who have disabilities. Federal law generally makes people with kidney failure eligible for Medicare coverage regardless of age or disability status. Medicare pays for dialysis treatment for the majority of people on dialysis in California.
  • Medi-Cal. The federal-state Medicaid program, known as Medi-Cal in California, provides health coverage to low-income people. The state and federal governments share the costs of Medi-Cal. Some people qualify for both Medicare and Medi-Cal. For these people, Medicare covers most of the payment for dialysis as the primary payer and Medi-Cal covers the rest. For people enrolled only in Medi-Cal, the Medi-Cal program is solely responsible to pay for dialysis.
  • Group and Individual Health Insurance. Many people in the state have group health insurance coverage through an employer or another organization (such as a union). Other people purchase health insurance individually. When an insured person develops kidney failure, that person can usually transition to Medicare coverage. Federal law requires that a group insurer remain the primary payer for dialysis treatment for a “coordination period” that lasts 30 months.

The California state government, the state’s two public university systems, and many local governments in California provide group health insurance coverage for their current workers, eligible retired workers, and their families. 

Group and Individual Health Insurers Typically Pay Higher Rates for Dialysis Than Government Programs. The rates that Medicare and Medi-Cal pay for a dialysis treatment are fairly close to the average cost for CDCs to provide a dialysis treatment. These rates are largely determined by regulation. In contrast, group and individual health insurers negotiate with CDCs and their governing entities to set rates. The rate agreed upon depends in large part on how many people the insurer covers and how many people the governing entity’s CDCs treat. On average, group and individual health insurers pay multiple times what government programs pay for a dialysis treatment.

HOW CDCS ARE REGULATED

California Department of Public Health (CDPH) Licenses and Certifies Dialysis Clinics. CDPH is responsible for licensing CDCs to operate in California. CDPH also certifies CDCs on behalf of the federal government, which allows CDCs to receive payment from Medicare and Medi-Cal. Currently, California relies primarily on federal regulations as the basis for its licensing program.

Federal Regulations Require a Medical Director at Each CDC. Federal regulations require each CDC to have a medical director who is a board-certified physician. The medical director is responsible for quality assurance, staff education and training, and development and implementation of clinic policies and procedures. Federal regulations do not require medical directors to spend a specific amount of time at the CDC; however, federal guidance indicates that the medical director’s responsibilities reflect about one-quarter of a full-time position. 

CDCs Must Report Infection-Related Information to a National Network. To receive payments from Medicare, CDCs must report specified dialysis-related infection information to the National Healthcare Safety Network at the federal Centers for Disease Control. For example, CDCs must report when a patient develops a bloodstream infection and the suspected cause of the infection.

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=60

Impartial analysis / Proposal

Source: California Legislative Analyst's Office - Official Voter Information Guide pp. 62-63

PROPOSAL

The measure includes several provisions affecting CDCs, as discussed below. It gives duties to CDPH to implement and administer the measure, including adopting regulations within one year after the law takes effect. If CDPH cannot meet that deadline, it can issue emergency regulations as it completes the regular process. 

Requires Each CDC to Have a Doctor On-site During All Treatment Hours. The measure requires each CDC to maintain, at its expense, at least one doctor on-site during all the hours patients receive treatments at that CDC. The doctor is responsible for patient safety and the provision and quality of medical care. A CDC may request an exception from CDPH if there is a valid shortage of doctors in the CDC’s area. If CDPH approves the exception, the CDC can meet the requirement with a nurse practitioner or physician’s assistant, rather than a doctor. The exception lasts for one year.

Requires CDCs to Report Infection-Related Information to CDPH. The measure requires each CDC—or its governing entity—to report dialysis-related infection information to CDPH every three months. CDPH must specify which information CDCs should report, and how and when to report the information. CDPH must post each CDC’s infection information on the CDPH website, including the name of a CDC’s governing entity. 

Charges Penalties if CDCs Fail to Report Infection-Related Information. If a CDC or its governing entity does not report infection information or if the information is inaccurate, CDPH may issue a penalty against the CDC. The penalty could be up to $100,000 depending on how severe the violation is. The CDC may request a hearing if it disputes the penalty. Any penalties collected would be used by CDPH to implement and enforce laws concerning CDCs.

Requires CDCs to Notify and Obtain Consent From CDPH Before Closing or Substantially Reducing Services. If a CDC plans to close or significantly reduce its services, the measure requires the CDC or its governing entity to notify CDPH in writing and obtain CDPH’s written consent. The measure allows CDPH to determine whether or not to consent. It allows CDPH to base its decision on such information as the CDC’s financial resources and the CDC’s plan for ensuring patients have uninterrupted dialysis care. A CDC may dispute CDPH’s decision by requesting a hearing. 

Prohibits CDCs From Refusing Care to a Patient Based on Who Is Paying for the Patient’s Treatment. Under the measure, CDCs and their governing entities must offer the same quality of care to all patients. They cannot refuse to offer or provide care to patients based on who pays for patients’ treatments. The payer could be the patient, a private entity, the patient’s health insurer, Medi-Cal, Medicaid, or Medicare.

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=62 

Financial effect

Source: California Legislative Analyst's Office - Official Voter Information Guide p. 62

FISCAL EFFECTS

INCREASED COSTS FOR DIALYSIS CLINICS AFFECT STATE AND LOCAL COSTS

How the Measure Increases Costs for CDCs. Overall, the measure’s provisions would increase costs for CDCs. In particular, the measure’s requirement that each CDC have a doctor on-site during all treatment hours would increase each CDC’s costs by several hundred thousand dollars annually on average. Other requirements of the measure would not significantly increase CDC costs. 

Clinics Could Respond to Higher Costs in Different Ways. The cost to have a doctor on-site would affect individual CDCs differently depending on their finances. Most CDCs operate under a governing entity that owns/operates multiple CDCs so the governing entity could spread costs across multiple locations. Governing entities might respond in one or more of the following ways:

  • Negotiate Increased Rates With Payers. First, governing entities might try to negotiate higher rates from the entities that pay for the dialysis treatment to cover some of the costs imposed by the measure. Specifically, governing entities may be able to negotiate higher rates with private commercial insurance companies and to a lesser extent with Medi-Cal managed care plans. 
  • Continue Current Operations, but With Lower Profits. For some governing entities, the higher costs due to the measure could reduce their profits, but they could continue to operate at current levels without closing clinics.
  • Close Some Clinics. Given the higher costs due to the measure, some governing entities, particularly those with fewer clinics, may decide to close some clinics. 

Measure Could Increase Health Care Costs for State and Local Governments by Low Tens of Millions of Dollars Annually. Under the measure, state Medi-Cal costs, and state and local employee and retiree health insurance costs could increase due to: 

  • Governing entities negotiating higher payment rates. 
  • Patients requiring treatment in more costly settings like hospitals (due to fewer CDCs).

Overall, the most likely scenario is that CDCs and their governing entities generally would: (1) be able to negotiate with some payers to receive higher payment rates to cover some of the new costs imposed by the measure, and (2) continue to operate (with reduced income), with relatively limited individual CDC closures. This scenario would lead to increased costs for state and local governments likely in the low tens of millions of dollars annually. This represents a minor increase in the state’s total spending on Medi-Cal and state and local governments’ total spending on employee and retiree health coverage. This cost represents less than 1 percent of state General Fund spending. In the less likely event that a more significant number of CDCs closed, state and local governments could have additional costs in the short run. These additional costs could be significant, but are highly uncertain.

INCREASED ADMINISTRATIVE COSTS FOR CDPH COVERED BY CDC FEES

The measure imposes new regulatory responsibilities on CDPH. The annual cost of these new responsibilities likely would not exceed the low millions of dollars annually. The measure requires CDPH to adjust the annual licensing fee paid by CDCs to cover these costs.

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=62

Published Arguments — Arguments for and against the ballot measure

Arguments FOR

Arguments are the opinions of the authors, and have not been checked for accuracy by any official agency. 

Combats poor hygiene in dialysis clinics by requiring infection reporting. Improves staffing, including requiring a doctor in clinics during treatment. Stops discrimination based on patients' insurance. Applies improvements to ALL clinics, whether in wealthy neighborhoods or poor, rural, Black or Brown communities. Patients, healthcare professionals, veterans, faith leaders agree: YesOnProp23.com

FOR ADDITIONAL INFORMATION FOR:
Yes on Prop 23: Better Care for Dialysis Patients
(888) 251-5367
info@YesOnProp23.com
YesOnProp23.com

— Source: California Secretary of State - Official Voter Information Guide p. 12

Arguments FOR

Arguments are the opinions of the authors, and have not been checked for accuracy by any official agency. 

ARGUMENT IN FAVOR OF PROPOSITION 23 

Life-Saving Changes for Dialysis Patients

Three times each and every week, 80,000 Californians with End Stage Renal Disease go to one of more than 600 commercial dialysis centers in the state where they spend three to four hours connected to a machine that removes their blood, cleans it, and returns it to their bodies. Dialysis literally is what keeps them alive, and they must continue the treatment for the rest of their lives or until they receive a kidney transplant.

Because the lives of these fellow Californians are so dependent on dialysis that is done both safely and effectively, we give our absolute support to the Protect the Lives of Dialysis Patients Act, an initiative appearing on the Nov. 3 ballot. This initiative will make common-sense improvements to dialysis treatment that will protect some of the most medically vulnerable people in our society.

The initiative does four major things:

First, it requires a physician or nurse practitioner to be in the clinic any time patients are being treated, which is not currently required. Dialysis is a dangerous procedure, and if something goes wrong, a doctor or highly trained nurse should be nearby.

Second, dialysis patients are prone to infections from their treatments that can lead to more serious illnesses or even death. This initiative requires clinics to report accurate data on infections to the state and federal governments so problems can be identified and solved to protect patients.

Third, like all other life-saving health care facilities, the initiative says the dialysis corporations cannot close clinics or reduce their services unless approved by the state. This also is designed to protect patients, particularly in rural communities, to make sure they have access to dialysis treatment, and to stop the dialysis corporations from using closures to pad their bottom line.

Fourth, it prohibits clinics from discriminating against patients because of the type of insurance they have, and it protects patients in every clinic. No matter if they are located in a wealthy neighborhood or a poor, rural, Black or Brown community, all clinics will be required to have a doctor or nurse practitioner on site, all clinics will be required to report their infection rates to the state and federal governments, and all dialysis corporations will be prohibited from discriminating against patients because of the type of insurance they have.

Don't listen when the dialysis industry claims the initiative will create huge new costs or say patients will be harmed or claim that it will create a shortage of doctors—those fake arguments are just designed to use patients and the coronavirus pandemic as scare tactics in their dishonest public relations campaign. The fact is, these corporations can easily make these changes and still make hundreds of millions of dollars a year without disrupting our healthcare system.

Proposition 23 will make the changes we need to truly protect dialysis patients. We urge you to vote YES!

MEGALLAN HANDFORD, Dialysis Registered Nurse 

PASTOR WILLIAM D. SMART, JR., Southern Christian Leadership Conference of Southern California

CARMEN CARTAGENA, Dialysis Patient

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=64

— Source: California Secretary of State/ Official Voter Information Guide

Arguments AGAINST

Arguments are the opinions of the authors, and have not been checked for accuracy by any official agency. 

American Nurses Association\ California, California Medical Association, patient advocates strongly urge NO on 23! Prop. 23 would force many community dialysis clinics to shut down—threatening the lives of 80,000 California patience who need dialysis to survive. Prop. 23 increases health care costs by hundreds of millions annually; makes our doctor shortage and ER overcrowding worse. NoProposition23.com

FOR ADDITIONAL INFORMATION AGAINST:
No on 23—Stop the Dangerous & Costly Dialysis Proposition
(888) 424-0650
info@NoProposition23.com
www.NoProposition23.com

— Source: California Secretary of State - Official Voter Information Guide p. 12

Arguments AGAINST

Arguments are the opinions of the authors, and have not been checked for accuracy by any official agency. 

ARGUMENT AGAINST PROPOSITION 23

NURSES, DOCTORS AND PATIENTS URGE NO ON 23—THE DANGEROUS AND COSTLY DIALYSIS PROPOSITION

Nearly 80,000 Californians with failed kidneys receive dialysis treatment three days a week to stay alive. Dialysis treatment does the job of the kidneys by removing toxins from the body. Missing a single treatment increases patient risk of death by 30%.

Prop. 23 seriously jeopardizes access to care for tens of thousands of Californians who need dialysis to stay alive. That's why the American Nurses Association\California, California Medical Association and patient advocates OPPOSE Prop. 23. 

PROP. 23 WOULD FORCE COMMUNITY DIALYSIS CLINICS TO CUT SERVICES AND CLOSE—PUTTING LIVES AT RISK 

Proposition 23 would force dialysis clinics to have a physician administrator on-site at all times, even though they would not care for patients. Each dialysis patient is already under the care of their personal kidney physician and dialysis treatments are administered by specially trained and experienced dialysis nurses and technicians.

This useless bureaucratic mandate would increase clinic costs by hundreds of millions annually, putting half of all clinics at risk of closure. 

“Prop. 23 dangerously reduces access to care, putting vulnerable dialysis patients at serious risk.”—Marketa Houskova, Doctor of Nursing Practice, RN, American Nurses Association\California

PROP. 23 WOULD MAKE OUR PHYSICIAN SHORTAGE WORSE AND LEAD TO MORE EMERGENCY ROOM OVERCROWDING 

“Proposition 23 would take thousands of doctors away from hospitals and clinics—where they’re needed—and place them into bureaucratic jobs at dialysis clinics where they aren’t. This is not the time to make our physician shortage worse.” —Dr. Peter N. Bretan, MD, President, California Medical Association 

Emergency room doctors strongly oppose Prop. 23. It would force dialysis clinics to close—sending tens of thousands of vulnerable patients to emergency rooms, creating longer ER waits and reducing capacity to deal with serious emergencies. 

PROP. 23 WOULD INCREASE HEALTH CARE COSTS BY HUNDREDS OF MILLIONS 

According to a study by the Berkeley Research Group, Prop. 23 would increase health care costs by $320 million annually. This massive increase would be especially damaging when so many Californians struggle financially. 

DIALYSIS CLINICS ARE STRICTLY REGULATED AND PROVIDE HIGH QUALITY CARE 

The federal and state governments extensively regulate dialysis clinics. According to the federal Centers for Medicare & Medicaid Services, California dialysis clinics outperform other states in clinical quality and patient satisfaction.

“Every dialysis patient is under the care of a physician kidney specialist, and dialysis treatments are administered by specially-trained nurses and technicians. It makes no sense to require physician administrators on-site full-time.” —Dr. Jeffrey A. Perlmutter, MD, President, Renal Physicians Association, representing 3,500 kidney doctors

ANOTHER SPECIAL INTEREST ABUSE OF OUR INITIATIVE SYSTEM 

The same group promoting Prop. 23 spent $20,000,000 last election pushing a similar measure voters rejected. They’re at it again, pushing another dangerous dialysis proposition. 

DOCTORS, NURSES AND PATIENT ADVOCATES: NO ON 23! 

• American Nurses Association\California • California Medical Association • Chronic Disease Coalition • NAACP California • Latino Diabetes Association • Women Veterans Alliance • Minority Health Institute 

www.NoProposition23.com

MARKETA HOUSKOVA, DNP, RN, Executive Director 
American Nurses Association\California 

LETICIA PEREZ, Kidney Dialysis Patient 

PETER N. BRETAN, MD, President 
California Medical Association

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=65

— Source: California Secretary of State/ Official Voter Information Guide

Replies to Arguments FOR

Arguments are the opinions of the authors, and have not been checked for accuracy by any official agency. 

REBUTTAL TO ARGUMENT IN FAVOR OF PROPOSITION 23

Proposition 23 is a DANGEROUS, COSTLY MEASURE funded by one special interest group with no expertise in dialysis. More than 100 leading organizations strongly urge: NO on 23.

• AMERICAN NURSES ASSOCIATION\CALIFORNIA WARNS PROP. 23 IS DANGEROUS: "Nearly 80,000 Californians with kidney failure rely on dialysis to survive. Prop. 23 adds unnecessary, costly requirements that could shut down hundreds of dialysis clinics—dangerously reducing access to care and putting tens of thousands of vulnerable patients at serious risk."

• CALIFORNIA MEDICAL ASSOCIATION URGES NO ON PROP. 23: "Proposition 23 would take thousands of doctors away from hospitals and clinics—where they’re needed—and place them into bureaucratic jobs at dialysis clinics where they aren’t. Prop. 23 worsens our physician shortage and would make us all wait longer to see our doctors."

• DIALYSIS PATIENT CITIZENS, A PATIENT ADVOCACY ORGANIZATION REPRESENTING 28,000 PATIENTS:

"Prop. 23 threatens access to care, putting dialysis patients at greater risk of death for missed treatments."

• NAACP CALIFORNIA: "Kidney disease disproportionately affects people of color. Prop. 23 hurts minority patients and those in disadvantaged communities the most."

• CALIFORNIA TAXPAYER PROTECTION COMMITTEE: “Prop. 23 would increase health care costs by $320,000,000 annually. This massive increase would hurt Californians already struggling financially.” 

PROP. 23 MAKES NO SENSE 

Each dialysis patient is already under the care of their own kidney doctor. And dialysis treatments are administered by specially-trained dialysis nurses and technicians. Furthermore, the federal and state governments extensively regulate dialysis clinics and California clinics outperform other states in clinical quality. 

JOIN DOCTORS, NURSES, SOCIAL JUSTICE & PATIENT ADVOCATES: NO ON 23!

www.NoProposition23.com

MARKETA HOUSKOVA, DNP, RN, Executive Director 
American Nurses Association\California 

DEWAYNE COX, Kidney Dialysis Patient 

PETER N. BRETAN, MD, President 
California Medical Association

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=64

— Source: California Secretary of State/ Official Voter Information Guide

Replies to Arguments AGAINST

Arguments are the opinions of the authors, and have not been checked for accuracy by any official agency. 

REBUTTAL TO ARGUMENT AGAINST PROPOSITION 23

DIALYSIS CORPORATIONS WANT TO PROTECT THEIR PROFITS 

In 2018, the California dialysis industry spent a record $110 million to defeat an initiative to improve conditions in dialysis clinics and protect patients from inflated billing. 

Why did they spend so much? To protect their massive $468 million in profits in California in 2018.

To patients, dialysis is lifesaving. But to industry executives, it’s a huge money-maker, so they’re at it again, stoking fear by threatening to close clinics if Prop. 23 passes and they’re held accountable to higher standards. Once again they are using gravely ill dialysis patients to shield their perks and million-dollar salaries. 

They claim, falsely, that the initiative will cost them huge sums of money, based on a highly dubious “study” that THEY paid for.

They claim doctors are against it, but many of those doctors are on their payroll.

They say it will cause doctor shortages and overcrowded emergency rooms, but kidney doctors do not staff ERs.

They say dialysis clinics are already highly regulated, but they face far fewer inspections than other health facilities, and even so deficiencies are often uncovered.

Prop. 23 makes commonsense improvements to protect patients’ lives, like having a doctor onsite to deal with emergencies, requiring the centers to report infection data, ending discrimination against some patients based on the type of insurance they have, and requiring the state to approve any clinic closures so patients aren’t left without treatment. 

Once and for all, Californians can protect fragile dialysis patients by voting YesOnProp23.com.

EMANUEL GONZALES, Dialysis Technician 

PASTOR WILLIAM D. SMART, JR. 
Southern Christian Leadership Conference of Southern California

ROBERT VILLANUEVA,  Dialysis Patient

https://vig.cdn.sos.ca.gov/2020/general/pdf/complete-vig.pdf#page=65

— Source: California Secretary of State/ Official Voter Information Guide

Who gave money?

Contributions

Yes on Proposition 23

Total money raised: $8,964,254
Bar graph showing total amount relative to total amount for this entire campaign.

No on Proposition 23

Total money raised: $105,243,991
Bar graph showing total amount relative to total amount for this entire campaign.

Below are the top 10 contributors that gave money to committees supporting or opposing the ballot measures.

Yes on Proposition 23

1
SEIU United Healthcare Workers West
$6,227,447
2
California Democratic Party
$41,898
3
SEIU United Health Care Workers West Political Issues Committee
$25,000

No on Proposition 23

1
DaVita
$66,823,445
2
Fresenius Medical Care
$29,785,427
3
US Renal Care
$7,635,118
4
Dialysis Clinic, Inc. (DCI)
$600,000
5
Satellite Healthcare
$400,000

More information about contributions

Yes on Proposition 23

By State:

California 100.00%
100.00%

By Size:

Large contributions (70.22%)
Small contributions (29.78%)
70.22%29.78%

By Type:

From organizations (100.00%)
From individuals (0.00%)
100.00%

No on Proposition 23

By State:

District of Columbia 63.49%
Kansas 28.30%
Texas 7.25%
Tennessee 0.57%
Other 0.38%
63.49%28.30%

By Size:

Large contributions (100.00%)
Small contributions (0.00%)
100.00%

By Type:

From organizations (100.00%)
From individuals (0.00%)
100.00%

More information

Videos (6)

— September 9, 2020 KCET
Prop 23 would require dialysis clinics in California to have at least one physician on site at all times, report patient infection data and get consent from the state health department before closing a clinic. Supporters say big dialysis businesses are making profits running unsanitary clinics with outdated equipment. Opponents say it would worsen doctor shortages and increase healthcare costs.
— October 4, 2020 League of Women Voters of San Diego
Ballot measures can sometimes feel like trick questions. We at the League of Women Voters are dedicated to providing non-partisan "prop talks" to help break down each measure. We will present the pros and cons of how these policies will impact your day to day life.
If Proposition 23 passes, it would increase rules for kidney dialysis centers, such as requiring at least one physician to remain on-site during a dialysis center’s operating hours.
Si se aprueba la Proposición 23, aumentaría las reglas para los centros de diálisis renal, como la exigencia de que al menos un médico permanezca en el lugar durante las horas de funcionamiento de un centro de diálisis.
— October 12, 2020 League of Women Voters of Cupertino-Sunnyvale
This video covers all 12 Propositions, Measure 23 starts at time: 38:37
— October 18, 2020 League of Women Voters of Southwest Santa Clara Valley

Events (5)

Contact Info

Yes on Proposition 23
Yes on Prop 23: Better Care for Dialysis Patients
Email info@YesOnProp23.com
Phone: (888) 251-5367
No on Proposition 23
No on 23—Stop the Dangerous & Costly Dialysis Proposition
Email info@NoProposition23.com
Phone: (888) 424-0650
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Who supports or opposes this measure?

No on Proposition 23

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