What California Proposition 29 Required of Dialysis Clinics

California Proposition 29 was a 2022 ballot initiative that would have required kidney dialysis clinics to keep a physician, nurse practitioner, or physician assistant on-site whenever patients were being treated, and would have added new infection-reporting, ownership-disclosure, and closure rules. Voters rejected it on November 8, 2022, with 68.4% voting no and 31.6% voting yes.¹ It was the third dialysis measure Californians had turned down in five years.

What the Measure Would Have Required

The core rule was staffing. Every chronic dialysis clinic would have needed at least one physician, nurse practitioner, or physician assistant physically present during all hours patients received treatment, and that person had to have at least six months of experience in kidney disease care. Clinics unable to immediately hire someone qualifying would have had a one-year grace period to use telehealth coverage instead.²

The initiative also layered on several operational rules:

Clinics would have reported dialysis-related infection data to the California Department of Public Health every quarter, with that data published for the public.
Any physician with a 5% or greater ownership stake in a clinic would have been identified to patients at the start of treatment and reported to CDPH for public posting.
Clinics could not close or significantly reduce services without CDPH approval.
Clinics could not refuse care or treat patients differently based on who was paying, whether private insurance, Medi-Cal, or Medicare.

Violating the disclosure and reporting rules could have brought fines of up to $100,000 per violation.²

What It Would Have Cost

The Legislative Analyst’s Office estimated the on-site medical professional requirement alone would have added several hundred thousand dollars per year in operating costs at each clinic. Across California’s hundreds of facilities, costs to state and local government were projected in the tens of millions of dollars annually.²

Opponents warned the added expense could push clinics to close, especially in rural or underserved areas where margins were tight. Supporters said the two largest dialysis companies were profitable enough to absorb the costs without cutting access.

Who Backed It and Who Fought It

Proposition 29 was a fight between one labor union and two dialysis corporations, and the spending gap was wide.

The Service Employees International Union-United Healthcare Workers West funded nearly the entire “yes” campaign, contributing roughly $8 million. The union framed the initiative as a patient-safety measure, arguing clinics were chronically understaffed and that on-site medical professionals could respond faster to emergencies like cardiac events or dangerous drops in blood pressure.

The opposition raised over $74.5 million. DaVita Inc. contributed about $52.7 million and Fresenius Medical Care added roughly $27.3 million, making the “no” campaign one of the most expensive ballot measure efforts in California history.¹ Opponents argued existing federal and state rules already ensured adequate care, and that the real goal was to give the union bargaining leverage over the industry.

How It Compared to Existing Dialysis Rules

Dialysis clinics that accept Medicare already operate under federal rules enforced by the Centers for Medicare and Medicaid Services. Those conditions for coverage require clinics to maintain infection control programs, follow CDC recommendations for preventing transmission among hemodialysis patients, and meet staffing standards that include a medical director overseeing care.³ Clinics must also report infection data to the National Healthcare Safety Network to keep Medicare certification.²

Federal law does not require a physician, nurse practitioner, or physician assistant to be physically on-site during every treatment hour, and a medical director can oversee multiple facilities without being present at each one. Proposition 29 would have added that on-site requirement, layered state infection reporting on top of federal reporting, and created closure restrictions with no federal equivalent.

Why This Was the Third Dialysis Measure in Five Years

SEIU-UHW West had sponsored two earlier dialysis ballot measures, and all three failed by wide margins.¹

Proposition 8 in 2018 took a different approach, capping clinic revenues at 115% of their direct patient care and quality improvement costs and effectively requiring rebates to insurers when profits exceeded the cap.⁴ Voters rejected it by a wide margin.

Proposition 23 in 2020 was nearly identical to what later became Proposition 29, requiring an on-site physician during treatments, state infection reporting, and CDPH approval before closures. It failed 63.4% to 36.6%.⁵ Proposition 29 broadened the on-site requirement to include nurse practitioners and physician assistants and added the ownership disclosure provision, but voters rejected it by an even larger margin.

1
Ballotpedia. California Proposition 29, Dialysis Clinic Requirements Initiative (2022)
2
Legislative Analyst’s Office. Proposition 29 – Requires On-Site Licensed Medical Professional at Kidney Dialysis Clinics and Establishes Other State Requirements
3
Centers for Medicare & Medicaid Services. State Operations Manual Appendix H – Guidance to Surveyors: End-Stage Renal Disease Facilities
4
Legislative Analyst’s Office. Proposition 8 – Regulates Amounts Outpatient Kidney Dialysis Clinics Charge for Dialysis Treatment
5
Ballotpedia. California Proposition 23, Dialysis Clinic Requirements Initiative (2020)