Roughly 140,000 Californians spend the equivalent of a part-time job — 12 to 20 hours a week — in a dialysis clinic, where a machine functioning as a kidney filters waste out of their blood.
It’s a tricky procedure — and right now it’s at the center of a heated political battle between labor unions and dialysis companies.
Californians will vote in November on Proposition 8, which would regulate dialysis clinic spending. It’s a move that could either improve patient conditions or degrade them, depending on who you ask.
So far, it’s the most expensive proposition on the ballot, with supporters putting in $20 million and opponents fighting back with $99 million as of October 11.
The measure would cap what clinics can spend on overhead and administrative costs, versus actual care.
One of the largest health care labor groups on the West Coast — Service Employees International Union - United Healthcare Workers West — put it on the ballot. Their members say clinic owners are overcharging for low-quality care, and that Prop. 8 will force dialysis companies to spend more on patients, including hiring additional staff.
The opposition campaign, backed by two of the state’s largest dialysis companies, argues that spending limitations could make it harder for clinics to stay afloat.
Los Angeles resident Tangi Foster, who’s working with the “Yes on 8” campaign, said she’s visited multiple dialysis clinics over the last decade and that employees seem overwhelmed and exhausted. She says this makes her feel unsafe.
“These people have to save our lives,” she said. “ I don’t think it’s fair to them, nor is it fair to us as patients, for them to carry this kind of workload.”
Opponents of the measure argue it is a power-play by labor groups trying to unionize dialysis workers.
They also worry that, if the measure passes, funding for certain positions would be in jeopardy. That’s because it would create two categories for dialysis company spending: “allowable” and “other” costs. Anything that goes over the limit in the other category would have to be paid back to insurance companies.
“These things are going to result in the closure of clinics, and they are going to result in less access for patients,” said Dr. Luis Alvarez, a practicing physician and board member for a dialysis clinic group called Satellite Healthcare. “To me, that is really a terrible, terrible thing.”
The allowable category would include “non-managerial” staff that provide direct care to dialysis patients. Opponents say jobs that are key to delivering patient care, such as medical director or nurse manager, could be excluded and face a funding cut.
Prop. 8 would also require clinic operators to report spending to the state, and forbid them from turning away patients based on their insurance payer.
The California Department of Public Health received 577 complaints about dialysis clinics and found 370 deficiencies during a two-and-a-half-year period between 2014 and 2017 — roughly 18 complaints and 12 deficiencies per month, according to an analysis by nonprofit journalism site CalMatters.
Those included complaints that patients’ vital signs weren’t checked by staff every 30 minutes, as required by law, and that translation services were not provided to non-English-speaking patients.
One grievance accused staff members of failing to check the connection between a patient and machine, even though blood was inappropriately oozing from the patient’s medical port, according to the CalMatters story.
DaVita, one of two major dialysis companies in California, has faced multiple lawsuits in recent years from the families of patients who died at their clinics.
If the measure passes, the decision on how clinics can spend their budgets will fall to the state and to the courts. The nonpartisan Legislative Analyst's Office said in its assessment that the measure’s vague language makes its fiscal impact difficult to determine.
“If the measure is ultimately interpreted to have a narrower, more restrictive definition of allowable costs, the amount of rebates chronic dialysis clinic owners and operators are required to pay would be greater,” the office wrote in the California voter guide.
The office said clinic groups might need to “scale back operations in the state.”
Ken Jacobs at the UC Berkeley Center for Labor Research and Education pointed out that just two dialysis companies control 70 percent of all clinics in California. And because very few laws require them to be transparent about their costs, prices will just continue to climb.
“I think we’re going to see a lot more attention on these issues in the future,” he said. “The ballot initiative specifically addresses [market consolidation] in a particularly profitable industry in terms of the dialysis centers. But the issues its raising are issues that go well beyond this particular case.”
Opponents feel the measure is too drastic and doesn’t belong on the ballot. Supporters have tried legislation before — bills to require staffing ratios in dialysis clinics and impose a revenue cap on clinic operators failed in prior legislative sessions.
Still, much of the Prop. 8 debate brings into question whether the voters should be the ones to decide how to fix these problems.