Kevin Stark [00:01:04] So Prop 29 is aimed at improving care at the dialysis clinics in California. There’s roughly 650 of them. And this would impose new regulations and rules. The biggest significant change here is that it would require that there be some kind of care provider onsite with patients as they’re receiving treatment. That’s a change from how it works. Now there are technicians onsite at all times and there’s doctors that supervise, but they only come in occasionally and there isn’t one always in the building.
Olivia Allen-Price [00:01:34] If you’re not familiar. Dialysis is for people with kidney failure. Our kidneys clean toxins from our blood. So when they’re not working, people need dialysis treatment to stay alive. Patients usually go three times a week and the procedure last three or 4 hours. So being on dialysis is really disruptive to someone’s life, even more so if they’re having to travel to a clinic far away. Kidney failure is caused by a number of health conditions, but most often diabetes or high blood pressure, because people of color are more likely to experience those conditions. They’re more likely to be on dialysis. Proposition 29 is going to feel super familiar to people who have voted in previous elections here in California, because this is the third time that voters are being asked to weigh in on how dialysis clinics should run. Kevin, why do we keep seeing dialysis on the ballot?
Kevin Stark [00:02:27] You’re absolutely right. Californians voted on this twice recently, Proposition eight in 2018 and Proposition 23 in 2020. Behind the scenes, here is a labor dispute. SEIU UHW, West is one of the largest health care unions in the state, and they have been trying for nearly a decade now to organize workers at dialysis clinics. The major companies that own these clinics, DaVita, Fresenius, have pushed back on this effort. And in fact, they’ve dumped tens of millions of dollars into fighting all of the propositions. If you talk to the companies, they will tell you that this is the unions really kind of putting the screw on them. They’re trying to bleed them of money. This is all about that fight for unionization. And if they were to come to an agreement on that, that maybe you wouldn’t be seeing the propositions. So basically, in a nutshell, they’re arguing that the unions are taking advantage of California’s proposition system. The unions have a completely different view of this. Obviously, they say this is about improving the care for patients. You know, they say that they after the last propositions failed, they went back. They listen to the criticism. They actually talked with researchers to figure out ways to improve the policy. And this is the result, Proposition 29. I asked SEIU’s David Miller to respond exactly to the criticism that this is not about the clinics, but it’s about a larger fight over unionization.
David Miller [00:03:54] Where movement of workers and also of patients. And we seek to improve care across the spectrum. We are seeking to do stuff in the broad interests so that this is not about some narrow play to sort of get dialysis. We see this is actually part of our mandate that we want to improve staffing in these clinics.
Olivia Allen-Price [00:04:12] So is Prop 29 the same thing we voted on in 2020?
Kevin Stark [00:04:17] The No on Prop 29 campaign would argue that this is a carbon copy of that policy, and they say that voters have already rejected it. Not entirely true. There is a core idea here that is really the same and that’s, you know, having a physician or a care provider onsite at all times when patients are receiving care, there’s not a lot of difference there. There’s a lot of smaller nuances and changes in the edges of this policy. The union expanded the definition of care providers here. It used to be that it was exclusively doctors. Now it’s nurse practitioners as well as physician assistants, also capitalizing on the pandemic and this expansion of telehealth. There’s also a stipulation in here that if there was no one available to be onsite, they could have someone that, you know, a doctor or a nurse that’s available over telehealth.
Olivia Allen-Price [00:05:07] A key question here is does having a physician or nurse practitioner onsite at a dialysis clinic make patients safer? KQED health reporter April Dembosky had something interesting to say about this in our Prop Fest episode from 2020, which is the last time we voted on a similar measure.
April Dembosky [00:05:26] So health care is complicated, and it’s hard to know if this would really help patients or if it might have unintended consequences. So patients already have their own doctors. They come see them in the clinics once a month or once a week to check on their dialysis prescription and medications to monitor their labs. And researchers have studied whether the frequency of doctor’s visits makes a difference in patient’s health. Back in 2004, Medicare, the government health program that pays for most dialysis treatment created a new incentive to encourage doctors to visit their dialysis patients more often. So instead of one or two times a month, it pushed them to visit four or more times per month. Well, after more than ten years of doing this, it turns out seeing your doctor more often has no impact on health outcomes. In fact, patients who were seen less often by their doctor actually had better survival rates. So the government was paying doctors more money for more services with no conclusive benefits to show for it.
Olivia Allen-Price [00:06:34] Kevin What would happen in the event of an emergency? You know, imagine having a physician or a nurse practitioner, there would be a good thing.
Kevin Stark [00:06:41] That is exactly the argument that the unions make, you know, in an emergency. Let’s say a patient faints, their heart stops. If that happens while in the clinic, someone has to perform CPR, call 911 to have paramedics take them to the hospital. Advocates say having a doctor, a nurse practitioner or physician on site would absolutely help here.
Olivia Allen-Price [00:06:59] But it’s worth noting that this proposition moves in the opposite direction of a lot of other health policy changes that have happened recently. You know, generally California and the rest of the nation have been changing laws so that physicians aren’t having to do everything. There’s sort of been this wider recognition that a lot of health care duties don’t require the expertize of a doctor or a nurse practitioner.
Kevin Stark [00:07:22] Yeah, I think that’s a really good point. And I think if you talk to the companies that manage all these clinics, they would say, you know, you don’t need a doctor in the clinic to perform CPR and to call 911. This is something that a technician can do. And then I think the addition of the telehealth argument into this proposition might be a way for the union to try and get around this idea itself. Like, you know, I think they’re saying basically, okay, maybe you don’t need someone on site, but you need someone that’s there that’s supervising. And then I think I would also note that the clinics do have doctors that work for them. They just don’t happen to always be on site.
Olivia Allen-Price [00:07:54] Now, there are a few other regulations in this prop that aren’t getting as much attention. Tell me about those.
Kevin Stark [00:08:00] So the unions added that clinics would need to report any infection that happens during treatment to the state. You know, the companies say they already are required to do this. Individuals without insurance would not be able to be denied care. Again, you know, the companies say that it’s not something that happens. Clinics would have to report additional information to state regulators and they would also actually have to get the consent of state health officials before they would close a clinic.
Olivia Allen-Price [00:08:32] One thing the No on 29 campaign has been saying in campaign ads is that these new regulations could cause clinics to close. Is that a real threat?
Kevin Stark [00:08:41] Well, I think that’s the argument that the companies that run these clinics are making. State analysts projected it would cost them hundreds of millions of dollars to comply with these regulations if they were to pass. Here’s Bryan Wong, who’s a medical director for DaVita in Oakland. He says clinics there might actually need to close.
Bryan Wong [00:08:57] Those that are in the rural area, probably even worse because those in a rural area. They probably have a huge amount of medical only patients, and those are the patients that are at most risk of getting harm. Why? Because the density of dialysis clinics in rural areas is much, much less than in urban areas.
