Tue, May

What CA Prop 29 is About


GELFAND’S WORLD - Proposition 29 has little going for it other than it has the support of the California Democratic Party and of the union that paid signature gatherers to get it put on your ballot.

That points to a lesson of its own, that we shall consider below. 

What is this proposition about? Your kidneys filter out impurities such as urea that your body is producing constantly. The output is expelled as urine, and without such a system operating in your body, you will die. People who go into kidney failure are in trouble, and the remedy is dialysis. The dialysis patient is hooked up to a machine which takes out blood, filters out the impurities, and eventually returns it to the bloodstream. There is no such thing as an artificial kidney that you could wear around -- you have to have a dialysis machine installed in your home or you have to go to a dialysis clinic. According to the state and the proponents of this proposition, there are about 80,000 dialysis patients in California, and they generally need to go in for dialysis 3 times a week. 

When dialysis was becoming a reality, there was a problem because there weren't enough machines to serve the number of end stage kidney patients. Since that time, the federal government has taken over most of the payments (Medicare and Medical) and the dialysis industry has become large and lucrative.

In two previous election cycles (2018 and 2020) the SEIU tried to get an initiative passed that would regulate the industry in one way or the other. Each time, the proposition was defeated resoundingly. One possible reason for these defeats is that the previous propositions were interpreted as union attempts to get the whole industry organized under their banner. This year's proposition has the same sponsor and is interpreted likewise. The main difference would be a new requirement for medical staffing. 

As in all the other propositions, television advertising (mainly against) doesn't really tell you what the proposition would actually do. 

So what does Prop 29 do? It's not that complicated. It has a few reporting requirements (clinics would have to report infectious complications to the state on a monthly basis, which simply duplicates what the federal government already does). But the kicker is that it would require that every dialysis clinic in California have a full-time doctor, nurse practitioner, or physician's assistant present at all times that the clinic is attending patients. 

Does this proposed requirement address a critically important problem? One might think that if for-profit dialysis clinics were losing more patients than dialysis clinics associated with large medical centers, then we would be hearing about it. It would certainly be a scandal. Television stations would be trumpeting their findings and accusations. 

So what do the proposition's proponents say about this? Basically nothing. We are left to conclude that there is no substantial medical basis for instituting the proposed requirement. The need is entirely speculative. Dialysis patients and taxpayers would be better served by a careful epidemiological study of the outcomes of for-profit vs other dialysis centers. Remember that every million dollars devoted to unneeded staffing could be used in some other way, or simply go as the rightful profit for the investors. 

The pro-Prop 29 statements talk about how much money the industry is making, how much money the CEOs make, and then suggest that there is room for improvement in services. Dialysis patients on the pro-proposition side point out that they have seen complications (such as post-treatment bleeding) occur among their fellow dialysis recipients, but we are not hearing from the medical profession or county health officers why things would be better with a nurse present. 

In short, we voters are not being told how frequent such complications are among patients who are getting the best possible treatment, and we are not hearing how frequent such problems are in lesser clinics. If there were such issues, we surely would have heard about them by now. 

There is another issue that the proponents aren't being straight about. Suppose there is a complication. What can you do about it, even in a fully staffed dialysis clinic? 

The critics point out that the standard procedure for an emergency complication, even when a doctor is present, is to call 911. They point out that dialysis clinics are not equipped as emergency rooms, and do not carry the staffing that such facilities need in order to function. 

In brief, the proponents have not made much of a case other than some mild speculation that some outcomes would be better if a nurse practitioner were present at all times. 

The main effect of Prop 29 would be that clinics would have to pay medical professionals to be present at all times, which would amount to hundreds of thousands of dollars per year. The state analyst report suggests that the result would be less disastrous than the inflammatory anti-Prop-29 television ads. Clinics would look for higher payments from insurers such as Medical, or would enjoy lower profits, or rarely would shut down due to the inability to break even. The anti-Prop-29 side -- basically the major corporations which run dialysis clinics -- are featuring people who claim to be dialysis patients and who state that if their clinics close down, they will die. 

One might pause for a moment and reflect that a dialysis patient whose clinic is closing down would presumably look for an alternate clinic. We do know that there are lots of such clinics in California. We must concede, however, that a clinic serving a sparse area in the Mojave desert or east of the Sierras would make for a problem for its patients should it suddenly close down. Even then, there is such a thing as in-home dialysis. One might also ask whether society owes dialysis services to everyone, no matter how far off the grid you live. The answer isn't all that obvious. 

The main issue with passage of Prop 29 is that the large corporations that run most of the dialysis clinics would lose revenue due to increased staffing requirements. Would Prop 29 be so damaging that there would be a large scale closure of dialysis clinics because the business would become a money loser? Would only charity hospitals treating emergency cases continue to run dialysis clinics? This scenario seems unlikely. 

As usual, we have a situation in which both sides are being misleading because they are not telling the whole story. On the balance, the rational vote is NO on Prop 29 because it will add to overall medical costs without offering any apparent improvement. 

There are a couple of additional issues. 

This is another example where the initiative process is being used for private ax grinding. If there were any reason to think that dialysis clinics in California were being run in a dangerous or negligent way, the news media would pick up on it and somebody in the state legislature would hold hearings. We don't seem to be seeing either of those things happening. 

The overall argument is simplicity itself. Matters which are properly handled by the state legislature should be left to the legislature unless the situation is grave and the legislature is itself negligent in its unwillingness to handle the problem. Other than that, private parties with an ax to grind should not attempt to do so through the ballot. 

I mentioned at the beginning of this piece that the California Democratic Party is one of the (few) listed endorsers of Proposition 29. Let this be a lesson to party insiders -- going hyper-partisan by rewarding your best friends and scuttling the real public interest does not increase public esteem for you or what you stand for. You should look carefully at how much esteem the U.S. Supreme Court has lost due to its hyper-partisan decisions over the past year. This might also be a useful lesson to voters in general: Don't take party endorsements seriously, because they are too connected to their own special interests. 

Notice by the way that the state legislature did take action when the Supreme Court overturned the Roe v Wade decision. The prevailing legislative philosophy on this issue is that the government leave doctor-patient relationships alone, to be decided as a private matter. Perhaps the California Democratic Party could think about this philosophy the next time that the SEIU tries to put another dialysis initiative on the ballot. 

As in the other articles in this series, the other major lesson is that we should avoid signing those petitions that people hand us in the supermarket parking lot.


(Bob Gelfand writes on science, culture, and politics for CityWatch. He can be reached at [email protected])



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