California Proposition 8, Limits on Dialysis Clinics' Revenue and Required Refunds Initiative (2018)

California Proposition 8
Election date November 6, 2018
Topic Healthcare and Business regulation
Status d Defeated
Type State statute	Origin Citizens
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California Proposition 8, the Limits on Dialysis Clinics' Revenue and Required Refunds Initiative, was on the ballot in California as an initiated state statute on November 6, 2018.^[1] The measure was defeated.

A "yes" vote supported requiring dialysis clinics to issue refunds to patients or patients' payers for revenue above 115 percent of the costs of direct patient care and healthcare improvements.

A "no" vote opposed requiring dialysis clinics to issue refunds to patients or patients' payers for revenue above 115 percent of the costs of direct patient care and healthcare improvements.

Election results

California Proposition 8
Result		Votes	Percentage
Yes		4,845,264	40.07%
No		7,247,917	59.93%

Results are officially certified.

Source

Overview

What would Proposition 8 have required of dialysis clinics?

Proposition 8 would have required dialysis clinics to issue refunds to patients or patients' payers, such as insurers, for revenue above 115 percent of the costs of (a) direct patient care, such as wages and benefits of non-managerial clinic staff who furnish direct care to patients, pharmaceuticals, medical supplies, and (b) healthcare improvements, such as staff training and patient education and counseling. Revenue earned above the 115 percent cap would have needed to be refunded to patients or the patients' payers each year. Clinics that do not issue required refunds within 210 days after the end of the fiscal year would have been fined an amount equal to 5 percent of their total required refunds, but not to exceed $100,000. The measure would have also prohibited dialysis clinics from discriminating or refusing services based on a patient's payer, including the patient himself or herself, a private insurer, Medi-Cal, Medicaid, or Medicare. The initiative would have required chronic dialysis clinics to report to the state government information required to enforce the measure, including the costs associated with operating a chronic dialysis clinic, treatment revenue, and the amount of each payer’s refund. The state department of public health would have enforced the initiative.^[1]

What did the campaigns believe would be the effects of limiting revenue and requiring refunds?

The ballot initiative itself would not have required dialysis clinics to invest in equipment, staffing, and patient care. According to Sean Wherley, a spokesperson for the SEIU-UHW West, the requirement to refund profits above the limit would incentivize clinics to spend revenue on healthcare improvements because the revenue spent on direct patient care services and healthcare improvements would not be limited.^[2] SEIU-UHW president Dave Regan added, "Right now they have every financial incentive to keep staffing and other direct patient services at a bare minimum because then they reap every dollar in profit margin."^[3] The concepts of direct patient care services and healthcare improvements would have been defined as follows:^[1]

• direct patient care services costs: salaries, wages, and benefits of non-managerial clinic workers who furnish direct care to dialysis patients; staff training and development; pharmaceuticals and medical supplies; costs associated with renting and maintaining facilities, utilities, lab testing; and depreciation of facilities and equipment.
• healthcare improvement costs: additional health information technologies; training non-managerial workers engaged in direct patient care; and patient education and counseling.

Patients and Caregivers to Protect Dialysis Patients, the committee opposed to Proposition 8, said that direct patient care services and healthcare improvement costs would not include spending on medical directors, clinic coordinators, professional services, regulatory compliance, or facility security. Therefore, according to the committee, the requirement to refund profits above the limit would result in clinic closures and reduced patient access.^[4] "This is going to devastate the clinics in California and, by extension, all the patients," said campaign spokesperson Kathy Fairbanks.^[3]

Who was behind the campaigns?

The committees in support or opposition of Proposition 8 had raised a combined $130.43 million, making the ballot measure the most expensive of 2018.

Californians for Kidney Dialysis Patient Protection led the campaign in support of the initiative. The SEIU-UHW West organized the campaign committee. Supporters called the initiative the Fair Pricing for Dialysis Act. Californians for Kidney Dialysis Patient Protection had raised $18.94 million, with the SEIU-UHW West donating 94 percent of the total funds.^[5]

The California Dialysis Council, a statewide association of dialysis clinics, organized the campaign committee Patients and Caregivers to Protect Dialysis Patients. The committee had raised $111.48 million, with 60 percent from the dialysis business DaVita, 30 percent from the dialysis business Fresenius Medical Care North America, and 7 percent from the dialysis business U.S. Renal Care.^[5]

What was the background of the labor vs. dialysis firms conflict?

Proposition 8 established a new front in the conflict between the SEIU-UHW West, a labor organization, and the state's two largest dialysis businesses DaVita and Fresenius Medical Care. The SEIU-UHW West said workers at dialysis clinics have been attempting to unionize since 2016, but that their employers were retaliating against pro-union employees.^[6] Kent Thiry, CEO of DaVita, argued that "Proposition 8 puts California patients at risk in an effort to force unionization of employees."^[3][7] Kathy Fairbanks, an opposition spokesperson, similarly stated, "[Sponsors] want to bring the dialysis community to the table and unionize it. This is just leverage."^[2] Wherley, a spokesperson for the SEIU-UHW West, contended that dialysis workers "want these [initiative] reforms regardless of what happens with their union efforts."^[8] Dave Regan stated, "The reason Prop. 8 is on the ballot is because they have a terrible business model and they’re gouging patients and insurers."^[3]

Jim Miller, a columnist for The Sacramento Bee, and Melanie Mason, a state politics journalist for the Los Angeles Times, both stated that the ballot initiative could also provide the SEIU-UHW West with leverage over legislation to enact new regulations on dialysis clinics in the California State Legislature.^[8][9] Wherley said the union was taking a two-pronged approach, wanting to make "sure we have as many options available as possible."^[8] In 2017, legislation was introduced, but not passed, to require staff-patient ratios in dialysis clinics and, like the ballot initiative, limit the revenue of businesses.^{[10][11][12][8][13]}

What local ballot initiatives was the SEIU-UHW West backing in 2018?

In 2018, the SEIU-UHW West, a labor union based in California, backed Proposition 8 and two local ballot initiatives designed to limit healthcare costs.

The two local initiatives were on the ballot in Livermore and Palo Alto. The SEIU-UHW West proposed additional local initiatives in Emeryville, Pleasanton, Redwood City, and Watsonville, but those initiatives did not make the ballot. Both Livermore Measure U and Palo Alto Measure F were designed to limit healthcare charges to 115 percent of the costs of what the initiatives termed the reasonable cost of direct patient care. Proponents aimed to require healthcare providers within the local jurisdictions to provide rebates or cost reductions when billing exceeds the predetermined amount.^[14] Stanford University Medical Center (SUMC), the headquarters of Stanford Health, is located in Palo Alto. Branches of Stanford Health are located in four of the five cities where the local initiatives were filed.^[15][16]

Text of measure

Ballot title

The official ballot title was as follows:^[17]

“

Authorizes State Regulation of Kidney Dialysis Clinics. Limits Charges for Patient Care. Initiative Statute.[18]

”

Ballot summary

The official ballot summary was as follows:^[19]

“

Limits the charges to 115 percent of the costs for direct patient care and quality improvement costs, including training, patient education, and technology support. Requires rebates and penalties if charges exceed the limit. Requires annual reporting to the state regarding clinic costs, patient charges, and revenue. Prohibits clinics from refusing to treat patients based on the source of payment for care.[18]

”

Fiscal impact

Note: The fiscal impact statement for a California ballot initiative authorized for circulation is prepared by the state's legislative analyst and director of finance.

The fiscal impact statement was as follows:^[17]

“

State administrative costs of around $1 million annually to be covered by increases in license fees on chronic dialysis clinics. State and local government savings largely associated with reduced government employee and retiree health benefits spending on dialysis treatment, potentially up to tens of millions of dollars annually.[18]

”

Full text

The full text of the measure was as follows:^[1]

SECTION 1. Name. This act shall be known as the “Fair Pricing for Dialysis Act.” SEC. 2. Findings and Purposes This act, adopted by the people of the State of California, makes the following findings and has the following purposes: (a) The people make the following findings: (1) Kidney dialysis is a process where blood is cleaned of waste and excess water, usually through a machine outside the patient’s body, and then returned to the patient. If someone who needs dialysis cannot obtain or afford high quality care, toxins build up in the body, leading to death. (2) In California, at least 66,000 Californians undergo dialysis treatment. (3) Just two multinational, for-profit corporations operate or manage nearly threequarters of dialysis clinics in California and treat almost 70 percent of dialysis patients in California. These two multinational corporations annually earn billions of dollars from their dialysis operations, including almost $400 million each year in California alone. (4) Because federal law mandates that private health insurance companies offer and pay for dialysis, private insurance companies have little ability to bargain with the two multinational dialysis corporations on behalf of their customers. (5) Thus, for-profit dialysis corporations charge patients with private health insurance four times as much as they charge Medicare for the very same dialysis treatment, resulting in vast profits. (6) In a market dominated by just two multinational corporations, California must ensure that dialysis is fairly priced and affordable. (7) Other states have taken steps to protect these very vulnerable patients from these two multinational corporations. (8) Efforts to enact protections for kidney dialysis patients in California have been stymied in Sacramento by the dialysis corporations, which spent over $600,000 in just the first six months of 2017 to influence the California Legislature. (b) Purposes: (1) It is the purpose of this act to ensure that outpatient kidney dialysis clinics provide quality and affordable patient care to people suffering from end stage renal disease. (2) This act is intended to be budget neutral for the state to implement and administer. SEC. 3. Section 1226.7 is added to the Health and Safety Code, to read: 1226.7. (a) Reasonable limits on charges for patient care by chronic dialysis clinics; rebates of amounts charged in excess of fair treatment payment amount. (1) For purposes of this section, the “fair treatment payment amount” shall be an amount equal to 115 percent of the sum of all direct patient care services costs and all health care quality improvement costs incurred by a governing entity and its chronic dialysis clinics. (2) For each fiscal year starting on or after January 1, 2019, a governing entity or its chronic dialysis clinics shall annually issue rebates to payers as follows: (A) The governing entity shall calculate the “unfair excess charged amount,” which shall be the amount, if any, by which treatment revenue from treatments provided by all of the governing entity’s chronic dialysis clinics exceeds the fair treatment payment amount. (B) The governing entity or its chronic dialysis clinics shall, on a pro rata basis based on the amounts paid and reasonably estimated to be paid, as those amounts are included in treatment revenue, issue rebates to payers (other than Medicare or other federal, state, county, city, or local government payers) in amounts that total the unfair excess charged amount. (C) The governing entity or chronic dialysis clinic shall issue any rebates required by this section no less than 90 days and no more than 210 days after the end of its fiscal year to which the rebate relates. (D) If, in any fiscal year, the rebate the governing entity or chronic dialysis clinic must issue to a single payer is less than twenty dollars ($20), the governing entity or chronic dialysis clinic shall not issue that rebate and shall provide to other payers in accordance with subparagraph (B) the total amount of rebates not issued pursuant to this subparagraph. (E) For each fiscal year starting on or after January 1, 2020, any rebate issued to a payer shall be issued together with interest thereon at the rate of interest specified in subdivision (b) of Section 3289 of the Civil Code, which shall accrue from the date of payment by the payer. (3) For each fiscal year starting on or after January 1, 2019, a governing entity shall maintain and provide to the department, on a form and schedule prescribed by the department, a report of all rebates issued under paragraph (2), including a description of each instance during the period covered by the submission when the rebate required under paragraph (2) was not timely issued in full, and the reasons and circumstances therefor. The chief executive officer or principal officer of the governing entity shall certify under penalty of perjury that he or she is satisfied, after review, that all information submitted to the department under this paragraph is accurate and complete. (4) In the event a governing entity or its chronic dialysis clinic is required to issue a rebate under this section, no later than 210 days after the end of its fiscal year the governing entity shall pay a penalty to the department in an amount equal to 5 percent of the unfair excess charged amount, provided that the penalty shall not exceed one hundred thousand dollars ($100,000). Penalties collected pursuant to this paragraph shall be used by the department to implement and enforce laws governing chronic dialysis clinics. (5) If a chronic dialysis clinic or governing entity disputes a determination by the department to assess a penalty pursuant to this subdivision or subdivision (b), or the amount of an administrative penalty, the chronic dialysis clinic or governing entity may, within 10 working days, request a hearing pursuant to Section 131071. A chronic dialysis clinic or governing entity shall pay all administrative penalties when all appeals have been exhausted and the department’s position has been upheld. (6) If a governing entity or chronic dialysis clinic proves in any court action that application of this section to the chronic dialysis clinic or governing entity will, in any particular fiscal year, violate due process or effect a taking of private property requiring just compensation under the Constitution of this state or the Constitution of the United States, the provision at issue shall apply to the governing entity or chronic dialysis clinic, except that as to the fiscal year in question the number “115” whenever it appears in the provision at issue shall be replaced by the lowest possible whole number such that application of the provision to the governing entity or chronic dialysis clinic will not violate due process or effect a taking of private property requiring just compensation. In any civil action, the burden shall be on the governing entity or chronic dialysis clinic to propose a replacement number and to prove that replacing “115” with any whole number lower than the proposed replacement number would, for the fiscal year in question, violate due process or effect a taking of private property requiring just compensation. (b) Compliance reporting by chronic dialysis clinics. (1) For each fiscal year starting on or after January 1, 2019, a governing entity shall maintain and submit to the department a report concerning all of the following information for all of the chronic dialysis clinics the governing entity owns or operates in California: (A) The number of treatments performed. (B) Direct patient care services costs. (C) Health care quality improvement costs. (D) Treatment revenue, including the difference between amounts billed but not yet paid and estimated realizable revenue. (E) The fair treatment payment amount. (F) The unfair excess charged amount. (G) The amount, if any, of each payer’s rebate, provided that any individual patient shall be identified using only a unique identifier that does not reveal the patient’s name or identity. (H) A list of payers to whom no rebate was issued pursuant to subparagraph (D) of paragraph (2) of subdivision (a) and the amount not issued, provided that any individual patient shall be identified using only a unique identifier that does not reveal the patient’s name or identity. (2) The information required to be maintained and the report required to be submitted by this subdivision shall each be independently audited by a certified public accountant in accordance with the standards of the Auditing Standards Board of the American Institute of Certified Public Accountants and shall include the opinion of that certified public accountant as to whether the information contained in the report fully and accurately describes, in accordance with generally accepted accounting principles in the United States, the information required to be reported under paragraph (1). (3) The governing entity shall annually submit the report required by this subdivision to the department on a schedule, in a format, and on a form prescribed by the department, provided that the governing entity shall submit the information no later than 210 days after the end of its fiscal year. The chief executive officer or other principal officer of the governing entity shall certify under penalty of perjury that he or she is satisfied, after review, that the report submitted to the department under paragraph (1) is accurate and complete. (4) In the event the department determines that a chronic dialysis clinic or governing entity failed to maintain the information or timely submit a report required under paragraph (1) of this subdivision or paragraph (3) of subdivision (a), that the amounts or percentages reported by the chronic dialysis clinic or governing entity under paragraph (1) of this subdivision were inaccurate or incomplete, or that any failure by a chronic dialysis clinic or governing entity to timely issue in full a rebate required by subdivision (a) was not substantially justified, the department shall assess a penalty against the chronic dialysis clinic or governing entity not to exceed one hundred thousand dollars ($100,000). The department shall determine the amount of the penalty based on the severity of the violation, the materiality of the inaccuracy or omitted information, and the strength of the explanation, if any, for the violation. Penalties collected pursuant to this paragraph shall be used by the department to implement and enforce laws governing chronic dialysis clinics. (c) Definitions. For purposes of this section: (1) “Direct patient care services costs” means those costs directly associated with operating a chronic dialysis clinic in California and providing care to patients in California. Direct patient care services costs shall include, regardless of the location where each patient undergoes dialysis, only (i) salaries, wages, and benefits of nonmanagerial chronic dialysis clinic staff, including all clinic personnel who furnish direct care to dialysis patients, regardless of whether the salaries, wages, or benefits are paid directly by the chronic dialysis clinic or indirectly through an arrangement with an affiliated or unaffiliated third party, including but not limited to a governing entity, an independent staffing agency, a physician group, or a joint venture between a chronic dialysis clinic and a physician group; (ii) staff training and development; (iii) pharmaceuticals and medical supplies; (iv) facility costs, including rent, maintenance, and utilities; (v) laboratory testing; and (vi) depreciation and amortization of buildings, leasehold improvements, patient supplies, equipment, and information systems. For purposes of this section, “nonmanagerial chronic dialysis clinic staff” includes all clinic personnel who furnish direct care to dialysis patients, including nurses, technicians and trainees, social workers, registered dietitians, and nonmanagerial administrative staff, but excludes managerial staff such as facility administrators. Categories of direct patient care services costs may be further prescribed by the department through regulation. (2) “Governing entity” means a person, firm, association, partnership, corporation, or other entity that owns or operates a chronic dialysis clinic for which a license has been issued, without respect to whether the person or entity itself directly holds that license. (3) “Health care quality improvement costs” means costs, other than direct patient care services costs, that are related to the provision of care to chronic dialysis patients and that are actually expended for goods or services in California that are required to maintain, access, or exchange electronic health information, to support health information technologies, to train nonmanagerial chronic dialysis clinic staff engaged in direct patient care, and to provide patient-centered education and counseling. Additional costs may be identified by the department through regulation, provided that such costs are actually spent on services offered at the chronic dialysis clinic to chronic dialysis patients and are spent on activities that are designed to improve health quality and to increase the likelihood of desired health outcomes in ways that are capable of being objectively measured and of producing verifiable results and achievements. (4) “Payer” means the person or persons who paid or are financially responsible for payments for a treatment provided to a particular patient and may include the patient or other individuals, primary insurers, secondary insurers, and other entities, including Medicare and any other federal, state, county, city, or other local government payer. (5) “Treatment” means each instance when the chronic dialysis clinic provides services to a patient. (6) “Treatment revenue” for a particular fiscal year means all amounts actually received and estimated realizable revenue for treatments provided in that fiscal year. Estimated realizable revenue shall be calculated in accordance with generally accepted accounting principles and shall be a reasonable estimate based on (i) contractual terms for patients covered under commercial healthcare plans with which the governing entity or clinics have formal agreements; (ii) revenue from Medicare, Medicaid, and Medi-Cal based on rates set by statute or regulation and estimates of amounts ultimately collectible from government payers, commercial healthcare plan secondary coverage, patients, and other payers; and (iii) historical collection experience. SEC. 4. Section 1226.8 is added to the Health and Safety Code, to read: 1226.8. (a) A chronic dialysis clinic shall not discriminate with respect to offering or providing care, and shall not refuse to offer or provide care, to patients on the basis of the payer for treatment provided to a patient, including but not limited to on the basis that the payer is a patient, private payer or insurer, Medi-Cal, Medicaid, or Medicare. (b) A chronic dialysis clinic shall not terminate, abridge, modify, or fail to perform under any agreement to provide services to patients covered by Medi-Cal, Medicaid, or Medicare on the basis of requirements imposed by this chapter. SEC. 5. Section 1266.3 is added to the Health and Safety Code, to read: 1266.3. It is the intent of the people that California taxpayers not be financially responsible for implementation and enforcement of the Fair Pricing for Dialysis Act. In order to effectuate that intent, when calculating, assessing, and collecting fees imposed on chronic dialysis clinics pursuant to Section 1266, the department shall take into account all costs associated with implementing and enforcing Sections 1226.7 and 1226.8. SEC. 6. Nothing in this act is intended to affect health facilities licensed pursuant to subdivision (a), (b), or (f) of Section 1250 of the Health and Safety Code. SEC. 7. The State Department of Public Health shall issue regulations necessary to implement this act no later than 180 days following its effective date. SEC. 8. Pursuant to subdivision (c) of Section 10 of Article II of the California Constitution, this act may be amended either by a subsequent measure submitted to a vote of the people at a statewide election, or by a statute validly passed by the Legislature and signed by the Governor, but only to further the purposes of the act. SEC. 9. The provisions of this act are severable. If any provision of this act or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

Readability score

See also: Ballot measure readability scores, 2018

Using the Flesch-Kincaid Grade Level (FKGL and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The attorney general wrote the ballot language for this measure. The FKGL for the ballot title is grade level 13, and the FRE is 9. The word count for the ballot title is 14, and the estimated reading time is 3 seconds. The FKGL for the ballot summary is grade level 11, and the FRE is 41. The word count for the ballot summary is 60, and the estimated reading time is 16 seconds. In 2018, for the 167 statewide measures on the ballot, the average ballot title or question was written at a level appropriate for those with between 19 and 20 years of U.S. formal education (graduate school-level of education), according to the FKGL formula. Read Ballotpedia's entire 2018 ballot language readability report here.

Support

Californians for Kidney Dialysis Patient Protection, also known as Yes on Prop 8, led the campaign in support of the initiative. SEIU-UHW West, a labor organization, sponsored the support campaign.^[20] Supporters called the initiative the Fair Pricing for Dialysis Act.^[1]

Supporters

Officials

Parties

Organizations

The following organizations endorsed Proposition 8:^[22]

California Public Employees' Retirement System (CalPERS)[23] California Alliance for Retired Americans California Hispanic Commission on Alcohol & Drug Abuse California League of United Latin American Citizens Californians for Disability Rights Congress of California Seniors Latino Coalition for a Healthy California Mi Familia Vota Minority Veterans Coalition of California National Action Network National Association of Social Workers – California National Montford Point Marine Association Inc. – Western Region Public Health Advocates Southern Christian Leadership Conference of Southern California Asian American Donor Program Black AIDS Institute Black Community Health Taskforce Black Women for Wellness Building Healthy Communities Long Beach California Hepatitis Alliance Dialysis Advocates, LLC Health Care for All – Sacramento Latino Diabetes Association National Asian Pacific American Families Against Substance Abuse Project Inform A Path With Heart Asian Pacific Policy & Planning Council (A3PCON) BA Huggins Ministry & Outreach Barrios Unidos Fresno Bay Rising Beth Rambam Black Business Association of Los Angeles Black Community, Clergy, and Labor Alliance Black Women Organized for Political Action Catalina’s List CAUSE (Central Coast Alliance United for a Sustainable Economy) CBDIO Centro Binacional para el Desarollo Indígena Oaxaqueño Center for Community Action and Environmental Justice Centro La Familia Christ Liberation Ministries City of Refuge CLUE: Clergy and Laity United for Economic Justice Community Advocacy Coalition of Ventura County Congregation B’nai Tzedek Cultiva La Salud Diversity Collective Ventura County Dolores Huerta Foundation EBASE East Bay Alliance for a Sustainable Economy El Concilio of Fresno Filipino Advocates for Justice First AME Church of Los Angeles Fresno Center for New Americans Fresno Immigration Coalition Fresno Interdenominational Refugee Ministry (FIRM) Fresno NAACP Branch Gardena Valley Chamber of Commerce Gray Panthers Greater Sacramento NAACP Branch Holman United Methodist Church Holy Nativity Holy Wisdom IE United Inland Empowerment LA Voice LAANE (LA Alliance for a New Economy) Latino Equality Alliance La Trinidad United Methodist Church Leo Baeck Temple Livermore Indivisible Long Beach Coalition for Good Jobs and Healthy Community LULAC Ventura County/District 17 McCarty Memorial Christian Church National Action Network Los Angeles New Bethel Apostolic Church of God in Christ Officers for Justice Older Women’s League (OWL) Sacramento-Capitol Orange County Congregation Community Organization Organize Sacramento Pacifica Progressive Alliance Pacifica Social Justice Peace & Justice Center of Sonoma County Peace & Justice Network of San Joaquin County Peace Project Coalition Sacramento ACT San Francisco Black Community Matters San Francisco Living Wage Coalition San Francisco Veterans for Peace Chapter 69 Sisters of St. Joseph of Carondelet St. Camillus Center for Spiritual Care St. George’s Episcopal Church Stockton NAACP Branch The Latina Center The LGBTQ Center Long Beach The Lillian Mobley Center The Revolution of Love Ministry United Methodist Church Unitarian Universalist Church of Studio City Ventura County Veterans for Peace Veterans Forever Watts Century Latino Organization Watts Labor Community Action CommitteeWorking Partnerships Working Partnerships

Unions

The following unions and labor organizations endorsed Proposition 8:^[22]

California Labor Federation[24] Service Employees International Union California[22] California Teamsters Public Affairs Council[22] California Professional Firefighters[22] California State Firefighters’ Association[22] AFSCME Council 57 Alameda Firefighters Local 689 Asian Pacific American Labor Alliance – San Francisco Chapter Asian Pacific American Labor Alliance – South Bay Asian Pacific American Labor Alliance Alameda Asian Pacific American Labor Alliance Los Angeles Asian Pacific American Labor Alliance San Diego Hayward Firefighters Local 1909 IAFF Local 1230 Contra Costa Firefighters IAFF Local 55 Alameda County Firefighters IAFF Local 55 Oakland Firefighters IATSE Local 80 IBEW Local 428 Laborers Local 270 Marin Professional Firefighters Monterey / Santa Cruz Counties Building & Construction Trades Council Monterey Bay Central Labor Council, AFL-CIO NAGE EMS 510 North Bay Labor Council, AFL-CIO OPEIU Local 30 Orange County Employees Association Plumbers & Pipefitters Local 442 San Francisco Labor Council Santa Clara and San Benito Counties Building & Construction Trades Council SF Firefighters Local 798 South Bay AFL-CIO Labor Council UA Local 393 Unite Here Local 2 Warehouse Workers Resource Center

Arguments

Californians for Kidney Dialysis Patient Protection issued an informational sheet. The following is an excerpt:^[25]

“

Dialysis patient care is in crisis and it’s driving up costs for all Californians. Patient care is suffering Patients and caregivers report bloodstains and cockroaches in dialysis clinics. The lack of sanitation and hygiene can contribute to high infection rates. Overcharging drives up costs California dialysis companies charge patients with private insurance an average $150,000 for a year of dialysis treatment. That’s a 350% markup from the cost of providing care! Insurance companies are forced to pass the costs to all policyholders, driving up healthcare premiums for ALL Californians. Blue Shield of California reports that it takes 3,800 enrollees to offset the cost of one dialysis patient. Dialysis corporation profits are out of control Big dialysis corporations make billions of dollars annually, yet the largest company in California, DaVita, spends only 73% of its revenue toward providing patient care. The average profit margin for dialysis clinics in California is 17% — nearly five times as high as an average hospital in California. Some patients face additional hurdles In low income communities and communities of color clinics are often in run-down strip malls with outdated equipment.[18]

”

Official arguments

Tangi Foster, a dialysis patient, Gary Passmore, president of the Congress of California Seniors, and Nancy Brasmer, president of the California Alliance for Retired Americans, wrote the official argument found in the state voter information guide in support of Proposition 8:^[19]

“ VOTE YES ON PROPOSITION 8—THE FAIR PRICING FOR DIALYSIS ACT Dialysis is a life-saving treatment for patients with kidney failure in which their blood is taken out, cleaned, and then put back in their body. Dialysis patients should have a clean, sterile environment during their treatments, but big, corporate dialysis providers, which make billions by charging these critically ill patients as much as $150,000 a year, won’t invest enough in basic sanitation. Bloodstains, cockroaches, and dirty bathrooms have all been reported at dialysis clinics, and patients’ lives have been put at risk from exposure to dangerous infections and diseases. These high prices drive up healthcare costs for all Californians. PROP. 8 will require the corporations to refund excessive profits that aren’t spent on improving dialysis patient care. STOP OVERCHARGING PATIENTS California’s largest dialysis company marks up its charges for some patients as much as 350% above the actual costs of providing care, or as much as $150,000 per year. PROP. 8 will provide strong incentives for dialysis companies to lower costs and improve their quality of care, making patients the priority everywhere, which is especially important in low income and minority communities. LOWER HEALTHCARE COSTS FOR EVERYONE Because dialysis patients are often charged such huge sums of money for their life-saving treatment, insurance companies are forced to pass those costs on to policyholders, driving up healthcare costs for all Californians. One insurance provider, Blue Shield of California, reported that it takes 3,800 other policyholders to offset the cost of one dialysis patient. PROP. 8 will help lower the cost of healthcare for all Californians. SUPPORTED BY A BROAD COALITION Dialysis Advocates, LLC • Californians for Disability Rights • CalPERS • Congress of California Seniors • Service Employees International Union California • Minority Veterans Coalition of California • and many more . . . MAKE PATIENTS THE HIGHEST PRIORITY We should vote “YES” on Prop. 8 and tell dialysis companies to prioritize lifesaving treatment for patients over corporate profits. VOTE YES ON PROPOSITION 8[18] ”

Opposition

Patients and Caregivers to Protect Dialysis Patients, also known as No on Proposition 8, led the campaign in opposition to the initiative. The California Dialysis Council, a statewide association of dialysis clinics, sponsored the opposition campaign.^[26]

Opponents

Parties

• California Republican Party^[27]

Organizations

The following organizations opposed Proposition 8:^[28]

California Medical Association[29] National Kidney Foundation[30] Renal Support Network[28] Dialysis Patient Citizens[28] Chronic Disease Coalition[28] California Hepatitis C Task Force[28] Alameda-Contra Costa Medical Association American College of Emergency Physicians-California Chapter American GI Forum of California American Legion, Department of California American Nurses Association\California AMVETS Department of California Anaheim Chamber of Commerce and Santa Barbara Counties Antelope Valley Hispanic Chamber of Commerce Association of California Healthcare Disctricts Association of California Nurse Leaders California Academy of Eye Physicians and Surgeons California Asian Pacific Chamber of Commerce California Association of County Veterans Services Officers California Association of Nurse Anesthetists California Chamber of Commerce California Dialysis Council California Farm Bureau Federation California Hispanic Chamber of Commerce California Senior Advocates League California State Commanders Veterans Council California State Conference NAACP California Taxpayer Protection Committee California Urological Association Cerritos Chamber of Commerce Chambers of Commerce Alliance of Ventura Coalition for Policy Reform Community Health Action Network Community Health Improvement Partners (CHIP) Public Policy Committee Contra Costa Taxpayers Association Desert AIDS Project Elk Grove Chamber of Commerce Federacion De Clubes De Michoacan Filipino American Chamber of Commerce of San Diego County Fresno Chamber of Commerce Fresno Madera Medical Society Fullerton Association of Concerned Taxpayers Gateway Chambers Alliance Global Healthy Living Foundation Greater Coachella Valley Chamber of Commerce Greater Riverside Chambers of Commerce Imperial County Medical Society Indian Physicians Association of Central California Inland Empire Economic Partnership (IEEP) Inyo-Mono County Medical Society Jewish War Veterans, Department of California Kern County Hispanic Chamber of Commerce Kern County Medical Society Kern County Taxpayers Association Latin Business Association Latino Diabetes Association Long Beach Area Chamber of Commerce Los Angeles Area Chamber of Commerce Los Angeles County Business Federation (BizFed) Los Angeles County Medical Association Los Angeles Wellness Station Lupus LA Meet Each Need with Dignity (MEND) Mendocino-Lake County Medical Society Mental Health America of Los Angeles Merced-Mariposa County Medical Society Military Officers Association of America, California Military Order of the Purple Heart Department of California Minority Health Institute Monterey County Medical Society Napa County Medical Society National Association for Hispanic Elderly National Association of Manufacturers National Guard Association of California National Hispanic Medical Association National Medical Association National Renal Administrators Association National Veterans Foundation Network of Ethnic Physician Organizations (NEPO) Northern California Chapter of the American College of Surgeons Norwalk Chamber of Commerce Orange County Business Council (OCBC) Orange County Medical Society Oxnard Chamber of Commerce Placer County Taxpayers Association Placer-Nevada County Medical Society Pomona Chamber of Commerce Renal Physicians Association Reserve Officers Association-Department of the Golden West Riverside County Medical Association Sacramento Asian Pacific Chamber of Commerce Sacramento Latino Community Roundtable Sacramento Taxpayers Association Sacramento Valley Section-National Council of Negro Women, Inc. San Bernardino County Medical Society San Diego County Medical Society San Diego-Imperial Chapter of the American College of Surgeons San Francisco Marin Medical Society San Joaquin Medical Society San Mateo County Medical Association Santa Clara County Medical Association Santa Monica Chamber of Commerce Scottish American Military Society Sierra Sacramento Valley Medical Society SoCal Tax Revolt Coalition Inc. Solano County Medical Society Sonoma County Medical Associaton Southern California Chapter of the American College of Surgeons Stanislaus Medical Society Tuolumne County Medical Society United Chambers of Commerce of the San Fernando Valley and Region Valley Industry and Commerce Association (VICA) Veterans of Foreign Wars, Department of California Women Veterans Alliance Yuba Sutter Colusa Medical Society

Healthcare clinics and firms

The following healthcare clinics and firms opposed Proposition 8:^[28]

DaVita Kidney Care Fresenius Medical Care Satellite Healthcare Dialysis Clinic, Inc. U.S. Renal Care Anaheim Cardiology Medical Group Caduceus for Women Centro De Medicina Alternativa San Ignacio Clinica De La Mujer Clinica Medica Central Clinica Medica Centro Hispano Clinica Medica Del Sagrado Corazon Clinica Medica Familiar de Montclair Clinica Medica San Miguel Clinica Santa Theresa Compton Quest Dialysis Center Dental Clinic Sheila Therese Amisola DDS, Inc. Dynamic Medical Imaging Fontana Clinica Medica Familiar Grupo Medico Del Carmen Hacienda Dialysis Center Hope Healthcare La Libertad Medical Clinic La Puente Family Medical Clinic Laurel Canyon Dialysis Life Point Medical Group and Urgent Care Llamas Clinica Medica Familiar Long Beach Quest Dialysis Center Los Niños Children’s Medical Clinic Lucero Dental Group Muñoz Healthcare Inc. Patient Choice Medical Group Pueblo Medical Associates Rita Medical Clinic Rosemead Dialysis Center Santa Clarita Dialysis Trinity Medical Clinic Urban Medical Clinic Valley Medical Clinic West Covina Family Medical Center

Arguments

Patients and Caregivers to Protect Dialysis Patients issued an informational sheet. The following is an excerpt:^[31]

“

United Healthcare Workers West (UHW) union, with a long history of pushing controversial ballot initiatives to leverage its political agenda, is behind a deeply-flawed dialysis proposition aimed for the November 2018 statewide ballot. The proposition limits what private health insurance companies pay for dialysis treatment in California. In doing so, this measure would dangerously reduce access to care for Californians with kidney failure who need dialysis treatments three days a week, three to four hours at a time, to survive. ... Sets artificially low limits on what insurance companies pay for dialysis treatments. These arbitrary limits fail to cover all costs necessary to provide high quality patient care. Specifically, the measure requires community dialysis clinics to issue annual rebates to private health insurance companies if any fee for treatment exceeds 115% of what the initiative defines as “patient care services costs.” Nothing in the initiative requires one dollar of these potential rebates to be passed along to consumers. ... Reduces access for California’s most vulnerable patients. Dialysis patients need treatment three days a week, for three to four hours at a time to survive. With demand for dialysis growing at about five percent a year in California, patients already have difficulty finding appointment times convenient and close to home. This proposition would result in clinic closures, and cutbacks in services forcing patients to travel further distances or seek treatment in a hospital, increasing the likelihood that they might miss a treatment. Research shows that missing even one dialysis appointment increases the risk of death for dialysis patients by 30%.[18]

”

Official arguments

Phillip Bautista, president of the American Nurses Association\California, Theodore M. Mazer, president of the California Medical Association, Aimee Moulin, president of the American College of Emergency Physicians, California Chapter, wrote the official argument found in the state voter information guide in opposition to Proposition 8:^[19]

“ PROP. 8 PUTS VULNERABLE DIALYSIS PATIENT LIVES AT RISK The American Nurses Association\California, California Medical Association, American College of Emergency Physicians, California Chapter and patient advocates all OPPOSE Prop. 8 because it jeopardizes access to care for 66,000 patients in California who need frequent dialysis treatments to stay alive. “Patients on dialysis have kidney failure and are very sick. They require dialysis three days a week, four hours at a time to do the job of their kidneys to remove toxins from the body. These patients cannot survive without regular treatments. Prop. 8 dangerously reduces access to care and places vulnerable patients at serious risk.”—Phillip Bautista, BSN, RN, PHN, President, American Nurses Association\California PROP. 8 WILL FORCE COMMUNITY DIALYSIS CLINICS TO CUT SERVICES AND CLOSE Proposition 8 severely limits what insurance companies are required to pay for dialysis care. These arbitrary limits will not cover the actual cost of providing care. In fact, an independent analysis conducted by California’s former Legislative Analyst concluded Prop. 8 will result in 83% of dialysis clinics operating at a loss. That will force hundreds of clinics to reduce operations or close, endangering patients. Without access to community clinics, patients will have to travel long distances, miss treatments or end up in the emergency room. DOCTORS, NURSES, AND PATIENT ADVOCATES ALL OPPOSE PROP. 8 “Missing even one appointment can be fatal for dialysis patients. By limiting access to dialysis care, this proposition jeopardizes patient lives.”—Dr. Theodore M. Mazer, President, California Medical Association, representing 43,000 doctors “As emergency physicians, we regularly treat dialysis patients who end up in the ER due to missed appointments or complications from kidney failure. This proposition will increase the risk of life-threatening complications for these very vulnerable patients.”— Dr. Aimee Moulin, President, American College of Emergency Physicians, California Chapter PROP. 8 DISPROPORTIONATELY HURTS DISADVANTAGED COMMUNITIES Prop. 8 is opposed by California NAACP and National Hispanic Medical Association because it will disproportionately impact patients in disadvantaged communities with higher risk of kidney failure. PROP. 8 INCREASES COSTS FOR ALL CALIFORNIANS BY HUNDREDS OF MILLIONS ANNUALLY When clinics close, dialysis patients end up in the ER where care is more expensive. According to the former Legislative Analyst, this measure will increase taxpayer costs by nearly $300 million annually. CALIFORNIA DIALYSIS QUALITY RANKS AMONG THE HIGHEST IN THE NATION California dialysis clinics are highly regulated by federal and state regulators that provide quality reports on every facility. According to the federal Centers for Medicare & Medicaid Services, California clinics outperform other states in clinical quality and patient satisfaction. This measure makes no sense when California dialysis care is highly regulated and saving lives. PROP. 8 COMES BETWEEN DOCTORS AND PATIENTS Vote NO on Prop. 8 and leave complicated medical decisions about dialysis in the hands of doctors and patients. PROP. 8 IS DANGEROUS. VOTE NO. Please join doctors, nurses and patient advocates and reject this dangerous proposition that puts vulnerable dialysis patients at risk.[18] ”

Campaign finance

See also: Campaign finance requirements for California ballot measures

Total campaign contributions:
Support:	$18,943,227.65
Opposition:	$111,482,980.16

There was one ballot measure committee registered in support of Proposition 8—Californians for Kidney Dialysis Patient Protection, Sponsored by Service Employees International Union - United Healthcare Workers West. The committee had raised $18.94 million, with 94 percent of funds received from the labor organization SEIU-UHW West. The committee had spent $19.29 million.^[5]

There was one ballot measure committee registered in opposition to Proposition 8—Patients and Caregivers to Protect Dialysis Patients, Sponsored by the California Dialysis Council. The committee had raised $111.48 million, with 60 percent from the dialysis business DaVita and 30 percent from the dialysis business Fresenius Medical Care North America. The committee had spent $110.38 million.^[5]

Note: The 501(c)(5) nonprofit organization SEIU-UHW West was also registered as supporting Proposition 8. As of 208, California required 501(c)(5) organizations, which includes labor unions, that contributed more than $50,000 to a ballot measure committee during a 12-month period to report contribution and expenditures under the same guidelines as committees. Contributions to the 501(c)(5) organization SEIU-UHW West were unitemized contributions of less than $100; therefore, state law did not require individual contributors' names to be reported.^[32] The SEIU-UHW West did not spend funds on Proposition 8 independent of the recipient committee Californians for Kidney Dialysis Patient Protection.^[5] Therefore, the 501(c)(5) nonprofit organization is not included in the support finance table.

Support

Committees in support of Proposition 8 Supporting committees Cash contributions In-kind services Cash expenditures Californians for Kidney Dialysis Patient Protection, Sponsored by Service Employees International Union - United Healthcare Workers West $18,864,841.00 $78,386.65 $19,212,710.49 Total $18,864,841.00 $78,386.65 $19,212,710.49

Totals in support Total raised: $18,943,227.65 Total spent: $19,291,097.14

Donors

The following were the donors who contributed to the support committee:^[5]

Donor	Cash	In-kind	Total
Service Employees International Union-United Healthcare Workers West	$17,787,341.00	$84,698.36	$17,872,039.36
SEIU California State Council Issues Committee	$1,000,000.00	$0.00	$1,000,000.00
California Democratic Party	$0.00	$52,971.14	$52,971.14
International Brotherhood of Electrical Workers Local Union No. 617	$2,500.00	$0.00	$2,500.00
Service Employees International Union Political Education and Action Fund	$0.00	$1,533.75	$1,533.75

Opposition

Committees in opposition to Proposition 8 Opposing committees Cash contributions In-kind services Cash expenditures Patients and Caregivers to Protect Dialysis Patients, Sponsored by the California Dialysis Council $110,492,462.01 $990,518.15 $110,378,950.36 Total $110,492,462.01 $990,518.15 $110,378,950.36

Totals in opposition Total raised: $111,482,980.16 Total spent: $111,369,468.51

Donors

The following were the donors who contributed to the opposition committee:^[5]

Donor	Cash	In-kind	Total
DaVita	$66,818,935.79	$208,935.74	$67,027,871.53
Fresenius Medical Care North America	$33,229,225.79	$752,887.51	$33,982,113.30
U.S. Renal Care	$8,176,421.43	$0.00	$8,176,421.43
Dialysis Clinic, Inc.	$1,215,417.00	$0.00	$1,215,417.00
Satellite Healthcare, Inc.	$500,000.00	$0.00	$500,000.00

Reporting dates

In California, ballot measure committees filed a total of five campaign finance reports in 2018. The filing dates for reports were as follows:^[33]

Campaign finance reporting dates for November 2018 ballot
Date	Report	Period
1/31/2018	Annual Report for 2017	1/01/2017 - 12/31/2017
4/30/2018	Report #1	1/01/2018 - 3/31/2018
7/31/2018	Report #2	4/01/2018 - 6/30/2018
9/27/2018	Report #3	7/01/2018 - 9/22/2018
10/25/2018	Report #4	9/23/2018 - 10/20/2018
1/31/2019	Annual Report for 2018	10/21/2018 - 12/31/2018

Methodology

To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.

Media editorials

Support

• East Bay Express: "Yes on the regulation of the kidney dialysis industry."^[34]
• San Diego Free Press endorsed Proposition 8, but did not provide a statement.^[35]
• San Francisco Bay Guardian: "Prop. 8 would set caps on what providers could charge for life-saving dialysis treatments. It’s only one procedure, and not really a step toward single-payer, but it’s hard to oppose."^[36]

Opposition

• Bakersfield Californian: "Let’s make this simple. This is an example of a special interest – in this case, a labor union – using the state’s initiative system to get what it could not get by organizing the workers of the state’s two largest dialysis businesses, DaVita and Fresenius Medical Care. The convoluted formula proponents would impose on company spending and revenues may apply organizing pressure on the companies. But smaller companies contend it could force them out of business and endanger their fragile clients, who depend on dialysis to live."^[37]
• Los Angeles Times: "But even if the revenue cap doesn’t drive clinics out of business, it would give them a perverse incentive to deliver care less efficiently — to raise patient-related spending in order to raise the revenue cap. And despite what supporters claim, there’s no guarantee that forcing clinics to spend more would do anything to make care better or more available."^[38]
• Marin Independent Journal: "This is a union-driven measure seeking to impose new requirements on private dialysis clinics. This is an issue that is complex and deserves to be studied and considered by the Legislature, not decided by a political shortcut to voters who won’t have time to dig into the issue and take a look at its long-term ramifications. This is a bad use of a state proposition."^[39]
• Merced Sun-Star/The Modesto Bee: "Proposition 8 is one union’s attempt to force two specific companies in a single industry segment – kidney dialysis – to hire more workers. It is unnecessarily elaborate, uses scare tactics and is unlikely to deliver what it promises. In fact, it’s more likely Proposition 8 will make matters worse in areas where specialized care can be difficult to obtain."^[40][41]
• San Francisco Chronicle: "Proposition 8, which would limit the profits of kidney dialysis clinics, is an example of a special interest trying to obtain from the ballot box what it could not achieve through other processes. ... This flawed measure should be rejected."^[42]
• Santa Cruz Sentinel: "But this measure, in attempting to regulate profit, deals with policy issues that should first have been taken up by legislators. Taking this directly to voters would be a last resort if no satisfactory remedies resulted from legislative give and take — a process that allows the complicated wording of new laws to be thoroughly reviewed and then altered if problems arise, as they often do."^[43]
• The Desert Sun: "Proposition 8 ostensibly is about dialysis patient care, but it boils down to an ugly $125 million brawl between a powerful labor union and California’s biggest dialysis clinic operators. This labor dispute disguised as health care policy has no place on the ballot and voters should reject it on Nov. 6."^[44]
• The Fresno Bee: "While SEIU has highlighted some valid financial issues, they should be addressed by state regulators – or by the Legislature, if necessary – not in a ballot measure that cannot be easily fixed if it causes problems. The same goes for patient care concerns, which should be dealt with by public health officials."^[45]
• The Mercury News: "California has a long history of propositions gone awry. Proposition 8 provides a classic example of a ballot measure that has no business being decided by California voters. The complex initiative designed to regulate the dialysis industry is better suited for the Legislature, where the wording of new laws can be thoroughly vetted and easily altered if problems arise."^[46]
• The Press Democrat: "We don’t have a position on whether clinic employees should unionize. However, we’re absolutely certain that voters shouldn’t be asked to judge a regulatory scheme for a specialty medical procedure that literally is a matter of life and death for tens of thousands of California residents suffering from serious kidney disease. That’s a job for the Legislature and the state Department of Public Health Services."^[47]
• Los Angeles Daily News/The San Bernardino Sun: "On the surface, Proposition 8 looks like a well-intended measure seeking to improve dialysis patient care. But upon even the most cursory of reviews, the measure is revealed to be nothing more than a cynical attempt by a labor union to accomplish what it couldn’t through the Legislature."^[48][49]
• The Sacramento Bee: "If we were confident that Proposition 8 would lead to better care for patients and lower bills, we would be inclined to support it. But because this measure is so complex – as is healthcare financing in general – it’s also possible that the measure could backfire and lead to less care."^[50]
• The Orange County Register: "By placing an artificially constructed cap on revenues, there will certainly be a bad impact on needed dialysis clinics across the state. Closures of existing clinics, and any slowdown in the opening of new clinics, would force patients into choosing between fewer and fewer options."^[51]
• The San Diego Union-Tribune: "Help dialysis patients? It could lead to the closure of an unknown number of dialysis clinics, especially in rural areas, which would up-end the lives of many of the nearly 70,000 Californians who depend on dialysis. That’s because the measure is written in a way that doesn’t allow clinics to count significant categories of spending in their profit-and-loss statements, a flaw that seems likely to lead to a court fight over revenue caps. ... A union should not put the lives of sick people at risk to win a labor battle. Vote no on Proposition 8."^[52]
• The San Luis Obispo Tribune: "Reform may be needed in this area, but the ballot box isn’t the place to do it."^[53]

Polls

See also: Ballotpedia's approach to covering polls

California Proposition 8 (2018)
Poll	Support	Oppose	Undecided	Margin of error	Sample size
SurveyUSA 10/12/2018 - 10/14/2018	47.0%	34.0%	19.0%	+/-4.8	762
Note: The polls above may not reflect all polls that have been conducted in this race. Those displayed are a random sampling chosen by Ballotpedia staff. If you would like to nominate another poll for inclusion in the table, send an email to editor@ballotpedia.org.

Background

What is dialysis?

Dialysis is a medical treatment that removes waste products and excess fluids and chemicals from a person's bloodstream. Dialysis is recommended when a person's kidneys lose most of their function. Kidneys filter a person's blood, removing wastes, excess water, and surplus chemicals and nutrients. The substances removed from the bloodstream are deposited in the bladder and discharged as urine.^[54][55][56]

There are two main types of dialysis treatment—hemodialysis and peritoneal dialysis.

• Hemodialysis: Before hemodialysis treatments can begin, surgeons create an access point, typically in an arm, to allow technicians to remove blood for treatments. Tubing is attached to allow blood to be pumped between the access point and a hemodialyzer machine, also referred to as an artificial kidney machine. The machine filters the blood and adds a solution to help remove waste. How often a person needs hemodialysis treatment can vary. According to the National Kidney Foundation, hemodialysis treatments usually occur three times per week and take around four hours each time.^[57][58]
• Peritoneal dialysis: Surgeons insert a catheter into the lining of a person's abdomen. The treatment involves pumping a solution into the abdomen. The solution absorbs wastes and uses the lining of the abdomen as a filter. A few hours after the solution has been pumped into the abdomen, the catheter is reopened to allow the solution to drain. Peritoneal dialysis typically occurs three to five times every day, with each treatment taking about 30 to 40 minutes, according to the National Kidney Foundation.^[59][60]

How many dialysis clinics were in California?

As of December 31, 2017, there were 577 state-licensed chronic dialysis clinics in California. Almost 30 percent of the clinics were located in Los Angeles County. There were sixteen counties—home to 1 percent of the state’s population—with no state-licensed chronic dialysis clinics.^[61] Using the U.S. Census Bureau's estimates of population on July 1, 2017, Ballotpedia found that the counties with more than two chronic dialysis clinics per 100,000 residents were Imperial, Merced, Mendocino, Solano, Stanislaus, and Lake.^[62]

The number of state-licensed chronic dialysis clinics increased between 2009 and 2017. In 2009, 430 chronic dialysis clinics were licensed in California. The state added an average of 17 state-licensed chronic dialysis clinics per year during the eight-year period.^[63]

Had Californians voted on other healthcare-related ballot measures?

Prior to 2018, California had several conflicts over healthcare-related ballot measures in which more than $50 million was spent. In 2016, more than $128 million was spent surrounding Proposition 61, which would have regulated drug prices. Proposition 61 was defeated. In 2014, voters considered Proposition 45, which would have regulated health insurance rates, and Proposition 46, which would have increased the state's medical lawsuits cap and required drug testing for doctors. Both were defeated. Initiatives addressing drug prices were also on the ballot as Proposition 78 and Proposition 79 in 2005. Both of the ballot measures were rejected. In each of the conflicts surrounding these healthcare ballot measures, opponents had outraised supporters.

Path to the ballot

See also: California signature requirements and Laws governing the initiative process in California

Process in California

In California, the number of signatures required for an initiated state statute is equal to 5 percent of the votes cast in the preceding gubernatorial election. Petitions are allowed to circulate for 180 days from the date the attorney general prepares the petition language. Signatures need to be certified at least 131 days before the general election. As the verification process can take multiple months, the secretary of state provides suggested deadlines for ballot initiatives.

The requirements to get initiated state statutes certified for the 2018 ballot:

• Signatures: 365,880 valid signatures were required.
• Deadline: The deadline for signature verification was June 28, 2018. However, the secretary of state suggested deadlines for turning in signatures of March 7, 2018, for initiatives needing a full check of signatures and April 24, 2018, for initiatives needing a random sample of signatures verified.

Signatures are first filed with local election officials, who determine the total number of signatures submitted. If the total number is equal to at least 100 percent of the required signatures, then local election officials perform a random check of signatures submitted in their counties. If the random sample estimates that more than 110 percent of the required number of signatures are valid, the initiative is eligible for the ballot. If the random sample estimates that between 95 and 110 percent of the required number of signatures are valid, a full check of signatures is done to determine the total number of valid signatures. If less than 95 percent are estimated to be valid, the initiative does not make the ballot.

Initiative #17-0014

On August 9, 2017, Edward Howard and Benjamen Tracey submitted a letter requesting a title and summary for the initiative. The attorney general issued ballot language on October 13, 2017, allowing proponents to begin collecting signatures. On November 22, 2017, supporters of the initiative had collected 25 percent of the required signatures. Proponents of the initiative had until April 11, 2018, to file 365,880 valid signatures to get their initiative placed on a future ballot.^[64]

On April 5, 2018, the support committee reported filing 569,259 signatures for the ballot initiative.^[65] About 60 percent of the signatures needed to be found valid for the initiative to make the ballot. Counties had until May 31, 2018, to complete a random sample of the filed signatures. On May 30, 2018, the secretary of state announced that enough signatures had been validated for the initiative to appear on the ballot. The random sample of signatures found that an estimated 405,037 signatures (71.15 percent of those submitted) were valid.^[66][67] Sponsors had the option to withdraw the ballot initiative before June 28, 2018.

Cost of signature collection:
Sponsors of the measure hired Kimball Petition Management to collect signatures for the petition to qualify this measure for the ballot. A total of $1,648,357.38 was spent to collect the 365,880 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $4.51.

How to cast a vote

See also: Voting in California

Poll times

All polls in California are open from 7:00 a.m. to 8:00 p.m. Pacific Time. An individual who is in line at the time polls close must be allowed to vote.^[68]

Registration requirements

Check your voter registration status here.

To vote in California, an individual must be a U.S. citizen and California resident. A voter must be at least 18 years of age on Election Day. Pre-registration is available at 16 years of age. Pre-registration automatically registers voters when they turn 18.^[69]

On October 10, 2015, California Governor Jerry Brown (D) signed into law Assembly Bill No. 1461, also known as the New Motor Voter Act. The legislation, which took effect in 2016, authorized automatic voter registration in California for any individuals who visit the Department of Motor Vehicles to acquire or renew a driver's license.^[70][71]

Automatic registration

California automatically registers eligible individuals to vote when they complete a driver's license, identification (ID) card, or change of address transaction through the Department of Motor Vehicles.

Online registration

See also: Online voter registration

California has implemented an online voter registration system. Residents can register to vote by visiting this website.

Same-day registration

California allows same-day voter registration.

Californians must be registered to vote at least 15 days before Election Day. If the registration deadline has passed for an upcoming election, voters may visit a location designated by their county elections official during the 14 days prior to, and including Election Day to conditionally register to vote and vote a provisional ballot. The state refers to this process as Same Day Voter Registration.^[72]

Residency requirements

To register to vote in California, you must be a resident of the state. State law does not specify a length of time for which you must have been a resident to be eligible.

Verification of citizenship

See also: Laws permitting noncitizens to vote in the United States

California's constitution requires that voters be U.S. citizens. When registering to vote, proof of citizenship is not required. Individuals who become U.S. citizens less than 15 days before an election must bring proof of citizenship to their county elections office to register to vote in that election.^[72]

Verifying your registration

The site Voter Status, run by the California Secretary of State's office, allows residents to check their voter registration status online.

Voter ID requirements

California does not require voters to present photo identification. However, some voters may be asked to show a form of identification when voting if they are voting for the first time after registering to vote by mail and did not provide a driver license number, California identification number, or the last four digits of their social security number.^[73][74]

The following list of accepted ID was current as of March 2023. Click here for the California Secretary of State page to ensure you have the most current information.

“

Current and valid photo identification provided by a third party in the ordinary course of business that includes the name and photograph of the individual presenting it. Examples of photo identification include, but are not limited to, the following documents: driver's license or identification card of any state; passport; employee identification card; identification card provided by a commercial establishment; credit or debit card; military identification card; student identification card; health club identification card; insurance plan identification card; or public housing identification card. Any of the following documents, provided that the document includes the name and address of the individual presenting it, and is dated since the date of the last general election…: utility bill; bank statement; government check; government paycheck; document issued by a governmental agency; sample ballot or other official elections document issued by a governmental, agency dated for the election in which the individual is providing it as proof, of residency or identity; voter notification card issued by a governmental agency; public housing identification card issued by a governmental agency; lease or rental statement or agreement issued by a governmental agency; student identification card issued by a governmental agency; tuition statement or bill issued by a governmental agency; insurance plan card or drug discount card issued by a governmental agency; discharge certificates, pardons, or other official documents issued to the individual by a governmental agency in connection with the resolution of a criminal case, indictment, sentence, or other matter; public transportation authority senior citizen and disabled discount cards issued by a governmental agency; identification documents issued by governmental disability agencies; identification documents issued by government homeless shelters and other government temporary or transitional facilities; drug prescription issued by a government doctor or other governmental health care provider; (R) property tax statement issued by a governmental agency; vehicle registration issued by a governmental agency; or vehicle certificate of ownership issued by a governmental agency.[18]

”

Related measures

Local measures

• Livermore, California, Measure U, Healthcare Cost Limitations (November 2018)
• Palo Alto, California, Measure F, Healthcare Cost Regulations (November 2018)

Not on the ballot

• Ohio Limits on Dialysis Clinics' Revenue and Required Refunds Initiative (2018)

State profile

Demographic data for California
	California	U.S.
Total population:	38,993,940	316,515,021
Land area (sq mi):	155,779	3,531,905
Race and ethnicity**
White:	61.8%	73.6%
Black/African American:	5.9%	12.6%
Asian:	13.7%	5.1%
Native American:	0.7%	0.8%
Pacific Islander:	0.4%	0.2%
Two or more:	4.5%	3%
Hispanic/Latino:	38.4%	17.1%
Education
High school graduation rate:	81.8%	86.7%
College graduation rate:	31.4%	29.8%
Income
Median household income:	$61,818	$53,889
Persons below poverty level:	18.2%	11.3%
Source: U.S. Census Bureau, "American Community Survey" (5-year estimates 2010-2015) Click here for more information on the 2020 census and here for more on its impact on the redistricting process in California. **Note: Percentages for race and ethnicity may add up to more than 100 percent because respondents may report more than one race and the Hispanic/Latino ethnicity may be selected in conjunction with any race. Read more about race and ethnicity in the census here.

Presidential voting pattern

See also: Presidential voting trends in California

California voted for the Democratic candidate in all six presidential elections between 2000 and 2020.

More California coverage on Ballotpedia

• Elections in California
• United States congressional delegations from California
• Public policy in California
• Endorsers in California
• California fact checks
• More...

See also

2018 measures 2018 ballot measures Healthcare on the ballot Business regulation on the ballot 2018 legislative sessions

California California ballot measures California ballot measure laws

News and analysis Ballot measure lawsuits Ballot measure readability Ballot measure polls

External links

Information

• Initiative Petition #17-0014

Support Yes on 8 website Yes on 8 Facebook Yes on 8 Twitter

Opposition No on Prop 8 website No on Prop 8 Facebook No on Prop 8 Twitter

Footnotes

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