Yet again, for the third time, because of California's direct-democracy proposition system, California voters are being asked to vote on whether dialysis clinics should be better regulated and have medical staff on site. At its heart, this is a unionization fight, but it's one that keeps coming up because there is so much money on the table — and because the arguments are compelling.

Now that Californians are being asked, for the third election in a row, to vote on whether dialysis clinics should be better regulated across the state. And, yet again, Big Dialysis — essentially two companies that operate the majority of the state's clinics — are spending millions to fight this proposition, Prop 29, which was put on the ballot by the nurses' and service-workers union. You've no doubt seen this year's ads featuring dialysis patients insisting they will die if this proposition passes, which are playing on network and cable TV and on YouTube. It's less likely you've seen ads from the Yes on 29 campaign, because the unions don't have that kind of cash to spend.

Here's what you should know:

What is Prop 29 and how is it different from 2020's Prop 23? At base, Prop 29 is the same as Prop 23 from two years ago — and it was put on the ballot by the same union, SEIU-United Health Care Workers West. Prop 29 seeks to regulate dialysis clinics, of which there are about 650 in the state, forcing them to keep a licensed medical professional — a nurse practitioner, physician's assistant, or doctor — on site at all times, and forcing greater transparency about infections that occur at these clinics. Unlike the 2020 prop, Prop 29 doesn't require doctors to be staffing every clinic, expanding the definition of healthcare provider to include trained nurses. It also requires clinics not to deny service to the uninsured, and it requires state consent before a company closes a clinic.

Prop 29 also adds a new provision that requires doctors to disclose if they have more than a 5% financial stake in a dialysis clinic.

How does it work now at these clinics? California's dialysis clinic industry is a big one, with the two biggest companies, DaVita and Fresenius, controlling most of the 650 licensed clinics in operation. People experiencing kidney failure can go to these clinics in lieu of a doctor's office or hospital to receive regular treatments — dialysis machines pump out and clean their blood and pump it back in. The clinics are staffed by medical technicians, not licensed nurses or doctors, and these non-unionized workers supervise patients' in their dialysis treatments. The companies argue that you do not need a nurse or doctor on site to perform CPR or call 911 in case of an emergency — and this is the direction that some healthcare is going anyway. (See the quote in this KQED interview, from health reporter April Dembosky.) The union argues that cases of low blood pressure, cardiac arrest, or infection may be more common than we know, and trained medical professionals should be at these clinics to insure patient safety.

It should be noted that the state's doctors' lobby opposes Prop 29.

Will patients really die or will clinics close if Prop 29 passes? Obviously, this is a scare tactic the companies have used before in their campaigns to defeat the two previous propositions, and it's worked. Voters rejected Prop 8 in 2018 and Prop 23 in 2020 after similar, heavy rounds of dramatic advertising featuring dialysis patients who don't want their clinics to close. While state analysts say the companies will have to spend hundreds of millions of dollars to comply with the new regulations, the union argues that they can afford it, and that rather than close clinics they may just pass the extra costs on to insurers.

"There’s a ton of money in this industry,” says David Miller, research director for SEIU-United Health Care Workers West, speaking to KCRA.

Bryan Wong, a medical director for DaVita in Oakland, tells KQED that the clinics that would be likeliest to close would be those in rural areas, where the density of clinics is less — thus the scare-tactic ads.

As stated above, the proposition tries to safeguard against this by requiring state consent to close any clinics, but unintended consequences are always a possibility.

"There's a key argument against Prop 29, which is basically that health care is just incredibly complicated, that the regulations should be crafted by lawmakers in a very nuanced way, says KQED's Kevin Stark.

And one dialysis patient who is against Prop 29, DeWayne Cox, tells KQED, "When I see these propositions that are put before the voters, who have no idea what we go through and what's necessary to keep us alive. It makes me angry because they're playing politics for whatever their reasons are, but they're putting patients like me in the middle of it."

Cox has been a spokesperson against the proposition to multiple outlets, including the Chronicle.

The Chronicle also spoke with Cecilia Gomez-Gonzalez, who was a caretaker for her parents for 12 years before she lost both of them to dialysis complications. "Many times, my daddy bled while receiving treatment, and I was there to catch it and do something to help immediately," Gomez-Gonzalez told the paper. "Technicians are always around, but they don’t sit on top of each patient because they have so many."

Will we have to just to keep voting on this over and over? Given that Big Dialysis won this fight twice, including in a general election year by a two-to-one margin, it seems likely they will win again — and it seems likely that if they lose, they'll get a prop on the ballot in 2024 that overturns this one.

It is also highly likely that if the union loses again, they will continue sticking it to the dialysis companies in 2024, and make them spend millions to fight a fourth prop fight — unless the union gets appeased some other way, and the companies compromise and hire some nurses.

"You know, if you're looking at it from the sort of... political lens, like this is where the leverage on the union fight is. Like this is now the third time they've done this," says KQED's Kevin Stark. "Each time the companies are dumping in tens of millions of dollars to fight it, and that's a check that they are going to have to keep writing until they sort this out."

Previously: Dialysis AGAIN? Why There Is Yet Another Dialysis Measure on the California Ballot