Associated Press

California voters will again weigh in on the quality of care dialysis clinics provide to about 80,000 people in the state with kidney failure.

Proposition 23 would require a doctor or highly trained nurse at each of the state’s 600 dialysis clinics whenever patients are being treated to improve patient care. It was placed on the ballot by unions that represent health care workers.

Opponents, financed by dialysis clinic companies, say that under that mandate, between two and three doctors would be required at every facility because most are open at least 16 hours a day, creating a financial burden that could lead some clinics to close.

“There are a tremendous number of complications that can occur during and around dialysis, and a doctor onsite will be able to respond not only to emergencies such as cardiac arrest, bleeding, dangerous fluctuations in blood pressure — all other common side effects of dialysis — but they also will be able to oversee the overall quality of care,” said Steve Trossman, a spokesman for the Oakland-based Service Employees International Union-United Healthcare Workers West, which spent more than $6 million in a signature drive to get it on the ballot.

Proposition 23 is the second attempt by the union to increase regulations of dialysis clinics in California, where DaVita Inc. and Fresenius Medical Care — two of the country’s largest for-profit dialysis providers — operate about three-quarters of the state’s dialysis market. Early voting begins Monday for the Nov. 3 contest.

In 2018, the union-backed Proposition 8, which sought to cap dialysis clinics’ profits and force them to invest more of their profits in patient care. Voters rejected the measure but not before it became the most expensive initiative on the 2018 ballot, generating more than $130 million in campaign spending — more than $111 million from dialysis companies to kill the initiative and about $19 million from unions that supported it.

Dialysis providers say most California clinics already offer high-quality care and are regulated by federal and state authorities. They also point out all patients already have a nephrologist — a kidney specialist — who oversees their care and that nephrologists also direct each clinic in California. They say the initiatives are part of a tactic to pressure the dialysis companies to let workers unionize.

“The motive is to force the dialysis community to spend a bunch of money to defeat it because ultimately this is more about a union organizing battle. I have no doubt that in 2022 there will be another initiative on the ballot targeting dialysis providers and dialysis patients,” said Kathy Fairbanks, a spokeswoman for No on Prop. 23, a coalition led by DaVita and Fresenius that also includes the California Medical Association and American Nurses Association-California.

The nonpartisan Legislative Analyst’s Office estimates dialysis companies currently make roughly $3 billion a year from their California operations.

So far this year, the union has raised nearly $6.2 million backing it and the coalition against Proposition 23 has raised more than $93 million.

To stay alive, dialysis patients typically undergo four-hour treatments at least three times a week, during which the machines remove the blood in the patient’s body, filter toxins out, then put the blood back in, essentially temporarily performing the functions of the kidneys but outside the body.

Rick Barnett, who runs the largest nonprofit dialysis provider in California, Satellite Healthcare, which operates 60 clinics in the state, said highly trained nurses and technicians already staff the clinics, and having to pay for two or three doctors per clinic would force most of the nonprofit’s clinics to close.

“And then what happens to those patients?” Barnett asked.

DeWayne Cox, who is working with the opposition campaign and receives treatment at a DaVita clinic in Los Angeles, said if the goal were improving patient care, then proponents would focus on facilities that have issues.

“If there are facilities that have problems and poor outcomes, then let’s focus on those facilities, don’t just do a broad stroke and make everyone incur these costs that are unnecessary and dangerous,” because they could lead to shorter clinic hours or closures, meaning patients would miss life-sustaining treatments, said Cox, 57, who has been on dialysis for 10 years.

Carmen Cartagena, 59, receives dialysis three times a week at a DaVita clinic in Walnut Creek and is working with the union to promote Proposition 23. She said she was convinced a doctor should always be at her clinic after seeing another patient drop to the floor bleeding. She says the woman was taken to a hospital and later died.

“I don’t want to see somebody else die on that chair,” she said. “It’s a medical facility. I should feel safe.”