California Proposition 23, Dialysis Clinic Requirements Initiative (2020)

California Proposition 23
Election date November 3, 2020
Topic Healthcare
Status d Defeated
Type State statute	Origin Citizens
List of California measuresCalifornia Proposition 13 (March)California Proposition 14California Proposition 15California Proposition 16California Proposition 17California Proposition 18California Proposition 19California Proposition 20California Proposition 21California Proposition 22California Proposition 23California Proposition 24California Proposition 25Submit

California Proposition 23, the Dialysis Clinic Requirements Initiative, was on the ballot in California as an initiated state statute on November 3, 2020. Proposition 23 was defeated.

A "yes" vote supported this ballot initiative to require chronic dialysis clinics to: have an on-site physician while patients are being treated; report data on dialysis-related infections; obtain consent from the state health department before closing a clinic; and not discriminate against patients based on the source of payment for care.

A "no" vote opposed this ballot initiative to require chronic dialysis clinics to: have an on-site physician while patients are being treated; report data on dialysis-related infections; obtain consent from the state health department before closing a clinic; and not discriminate against patients based on the source of payment for care.

Election results

California Proposition 23
Result		Votes	Percentage
Yes		6,161,457	36.58%
No		10,681,171	63.42%

Results are officially certified.

Source

Overview

What would this ballot initiative have required of dialysis clinics?

The ballot measure would have required chronic dialysis clinics to:

• have a minimum of one licensed physician present at the clinic while patients are being treated, with an exception for when there is a bona fide shortage of physicians;
• report data on dialysis-related infections to the state health department and National Healthcare Safety Network (NHSN);
• require the principal officer of the clinic to certify under penalty of perjury that he or she is satisfied, after review, that the submitted report is accurate and complete; and
• provide a written notice to the state health department and obtain consent from the state health department before closing a chronic dialysis clinic.

The ballot measure would have also stated that a chronic dialysis clinic cannot "discriminate with respect to offering or providing care" nor "refuse to offer or to provide care, on the basis of who is responsible for paying for a patient's treatment."

How did this ballot initiative relate to 2018's Proposition 8?

See also: California Proposition 8 (2018)

In 2018, 59.9 percent of voters rejected California Proposition 8, which would have required dialysis clinics to issue refunds to patients (or patients' insurers) for profits above 115 percent of the costs of direct patient care and healthcare improvements. Proposition 8 (2018) and the Dialysis Clinic Requirements Initiative (2020) were designed to enact policies related to dialysis clinics, but the specific policies were different. Proposition 8 would have capped profits and required refunds, whereas this year's initiative would have addressed minimum physician staffing, data reporting, and clinic closures.

Proposition 8, like this year's dialysis-related ballot initiative, had the support of the SEIU-UHW West, a labor union for healthcare workers. Proposition 8 established a new front in the conflict between the SEIU-UHW West 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. Kent Thiry, CEO of DaVita, argued that "Proposition 8 puts California patients at risk in an effort to force unionization of employees." Sean Wherley, a spokesperson for the SEIU-UHW West, contended that dialysis workers "want these [initiative] reforms regardless of what happens with their union efforts."

Text of measure

Ballot title

The ballot title was as follows:

“

Establishes State Requirements for Kidney Dialysis Clinics. Requires On-Site Medical Professional. Initiative Statute.

”

Ballot summary

The ballot summary was as follows:

“

Requires at least one licensed physician on site during treatment at outpatient kidney dialysis clinics; authorizes California Department of Public Health to exempt clinics from this requirement if there is a shortage of qualified licensed physicians and the clinic has at least one nurse practitioner or physician assistant on site. Requires clinics to report dialysis-related infection data to state and federal governments. Prohibits clinics from closing or reducing services without state approval. Prohibits clinics from refusing to treat patients based on the source of payment for care.

”

Fiscal impact

The fiscal impact statement was as follows:

“

Increased state and local government costs likely in the low tens of millions of dollars annually.

”

Full text

The full text of the ballot initiative is below:

Readability score

See also: Ballot measure readability scores, 2020

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 18, and the FRE is -24. The word count for the ballot title is 15, and the estimated reading time is 4 seconds. The FKGL for the ballot summary is grade level 13, and the FRE is 33. The word count for the ballot summary is 82, and the estimated reading time is 21 seconds.

Support

Californians for Kidney Dialysis Patient Protection, also known as Yes on 23, led the campaign in support of the ballot initiative. The SEIU-UHW West sponsored the campaign.

Supporters

Political Parties

• California Democratic Party

Unions

• SEIU-UHW West

Arguments

Official arguments

The following is the argument in support of Proposition 23 found in the Official Voter Information Guide:

Official Voter Information Guide: Life-Saving Changes for Dialysis Patients Three times each and every week, 80,000 Californians with End Stage Renal Disease go to one of more than 600 commercial dialysis centers in the state where they spend three to four hours connected to a machine that removes their blood, cleans it, and returns it to their bodies. Dialysis literally is what keeps them alive, and they must continue the treatment for the rest of their lives or until they receive a kidney transplant. Because the lives of these fellow Californians are so dependent on dialysis that is done both safely and effectively, we give our absolute support to the Protect the Lives of Dialysis Patients Act, an initiative appearing on the Nov. 3 ballot. This initiative will make common-sense improvements to dialysis treatment that will protect some of the most medically vulnerable people in our society. The initiative does four major things: First, it requires a physician or nurse practitioner to be in the clinic any time patients are being treated, which is not currently required. Dialysis is a dangerous procedure, and if something goes wrong, a doctor or highly trained nurse should be nearby. Second, dialysis patients are prone to infections from their treatments that can lead to more serious illnesses or even death. This initiative requires clinics to report accurate data on infections to the state and federal governments so problems can be identified and solved to protect patients. Third, like all other life-saving health care facilities, the initiative says the dialysis corporations cannot close clinics or reduce their services unless approved by the state. This also is designed to protect patients, particularly in rural communities, to make sure they have access to dialysis treatment, and to stop the dialysis corporations from using closures to pad their bottom line. Fourth, it prohibits clinics from discriminating against patients because of the type of insurance they have, and it protects patients in every clinic. No matter if they are located in a wealthy neighborhood or a poor, rural, Black or Brown community, all clinics will be required to have a doctor or nurse practitioner on site, all clinics will be required to report their infection rates to the state and federal governments, and all dialysis corporations will be prohibited from discriminating against patients because of the type of insurance they have. Don't listen when the dialysis industry claims the initiative will create huge new costs or say patients will be harmed or claim that it will create a shortage of doctors—those fake arguments are just designed to use patients and the coronavirus pandemic as scare tactics in their dishonest public relations campaign. The fact is, these corporations can easily make these changes and still make hundreds of millions of dollars a year without disrupting our healthcare system. Proposition 23 will make the changes we need to truly protect dialysis patients. We urge you to vote YES! MEGALLAN HANDFORD, Dialysis Registered Nurse PASTOR WILLIAM D. SMART, JR. Southern Christian Leadership Conference of Southern California CARMEN CARTAGENA, Dialysis Patient

Opposition

Stop the Dangerous & Costly Dialysis Proposition, also known as No on Prop 23, led the campaign in opposition to the ballot initiative.

Opponents

The campaign Stop the Dangerous & Costly Dialysis Proposition provided a list of involved organizations on the campaign's website, which is available here.

Political Parties

• Republican Party of California

Corporations

• DaVita, Inc.
• Fresenius Medical Care

Organizations

• AMVETS, Department of California
• American Legion, Department of California
• California Medical Association
• California NAACP State Conference

Arguments

Official arguments

The following is the argument in opposition to Proposition 23 found in the Official Voter Information Guide:

Official Voter Information Guide: NURSES, DOCTORS AND PATIENTS URGE NO ON 23—THE DANGEROUS AND COSTLY DIALYSIS PROPOSITION Nearly 80,000 Californians with failed kidneys receive dialysis treatment three days a week to stay alive. Dialysis treatment does the job of the kidneys by removing toxins from the body. Missing a single treatment increases patient risk of death by 30%. Prop. 23 seriously jeopardizes access to care for tens of thousands of Californians who need dialysis to stay alive. That's why the American Nurses Association\California, California Medical Association and patient advocates OPPOSE Prop. 23. PROP. 23 WOULD FORCE COMMUNITY DIALYSIS CLINICS TO CUT SERVICES AND CLOSE—PUTTING LIVES AT RISK Proposition 23 would force dialysis clinics to have a physician administrator on-site at all times, even though they would not care for patients. Each dialysis patient is already under the care of their personal kidney physician and dialysis treatments are administered by specially trained and experienced dialysis nurses and technicians. This useless bureaucratic mandate would increase clinic costs by hundreds of millions annually, putting half of all clinics at risk of closure. “Prop. 23 dangerously reduces access to care, putting vulnerable dialysis patients at serious risk.”—Marketa Houskova, Doctor of Nursing Practice, RN, American Nurses Association\California PROP. 23 WOULD MAKE OUR PHYSICIAN SHORTAGE WORSE AND LEAD TO MORE EMERGENCY ROOM OVERCROWDING “Proposition 23 would take thousands of doctors away from hospitals and clinics—where they’re needed—and place them into bureaucratic jobs at dialysis clinics where they aren’t. This is not the time to make our physician shortage worse.” —Dr. Peter N. Bretan, MD, President, California Medical Association Emergency room doctors strongly oppose Prop. 23. It would force dialysis clinics to close—sending tens of thousands of vulnerable patients to emergency rooms, creating longer ER waits and reducing capacity to deal with serious emergencies. PROP. 23 WOULD INCREASE HEALTH CARE COSTS BY HUNDREDS OF MILLIONS According to a study by the Berkeley Research Group, Prop. 23 would increase health care costs by $320 million annually. This massive increase would be especially damaging when so many Californians struggle financially. DIALYSIS CLINICS ARE STRICTLY REGULATED AND PROVIDE HIGH QUALITY CARE The federal and state governments extensively regulate dialysis clinics. According to the federal Centers for Medicare & Medicaid Services, California dialysis clinics outperform other states in clinical quality and patient satisfaction. “Every dialysis patient is under the care of a physician kidney specialist, and dialysis treatments are administered by specially-trained nurses and technicians. It makes no sense to require physician administrators on-site full-time.” —Dr. Jeffrey A. Perlmutter, MD, President, Renal Physicians Association, representing 3,500 kidney doctors ANOTHER SPECIAL INTEREST ABUSE OF OUR INITIATIVE SYSTEM The same group promoting Prop. 23 spent $20,000,000 last election pushing a similar measure voters rejected. They’re at it again, pushing another dangerous dialysis proposition. DOCTORS, NURSES AND PATIENT ADVOCATES: NO ON 23! • American Nurses Association\California • California Medical Association • Chronic Disease Coalition • NAACP California • Latino Diabetes Association • Women Veterans Alliance • Minority Health Institute www.NoProposition23.com MARKETA HOUSKOVA, DNP, RN, Executive Director American Nurses Association\California LETICIA PEREZ, Kidney Dialysis Patient PETER N. BRETAN, MD, President California Medical Association

Campaign finance

See also: Campaign finance requirements for California ballot measures

The Californians for Kidney Dialysis Patient Protection PAC was registered to support the ballot initiative. The committee had raised $8.99 million from the SEIU-UHW West.

The Stop the Dangerous & Costly Dialysis Proposition PAC was registered to oppose the ballot initiative. The committee had raised $105.24 million, with $66.8 million from DaVita, Inc. and $29.8 million from Fresenius Medical Care.

	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Support	$8,899,701.08	$85,522.99	$8,985,224.07	$8,756,075.43	$8,841,598.42
Oppose	$104,940,335.64	$303,198.21	$105,243,533.85	$104,392,549.74	$104,695,747.95
Total	$113,840,036.72	$388,721.20	$114,228,757.92	$113,148,625.17	$113,537,346.37

Support

The following table includes contribution and expenditure totals for the committee in support of the ballot initiative.

Committees in support of Proposition 23
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Yes on 23 - Californians for Kidney Dialysis Patient Protection	$8,899,701.08	$85,522.99	$8,985,224.07	$8,756,075.43	$8,841,598.42
Total	$8,899,701.08	$85,522.99	$8,985,224.07	$8,756,075.43	$8,841,598.42

Donors

The following was the top donor to the support committee.

Donor	Cash Contributions	In-Kind Contributions	Total Contributions
SEIU-UHW West Political Issues Committee	$8,285,542.60	$28,752.11	$8,314,294.71
Service Employees International Union, United Healthcare Workers West (Nonprofit 501(c)(5))	$580,514.44	$0.00	$580,514.44
California Democratic Party	$0.00	$56,800.70	$56,800.70

Opposition

The following table includes contribution and expenditure totals for the committee in opposition to the ballot initiative.

Committees in opposition to Proposition 23
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
No on 23 - Stop the Dangerous & Costly Dialysis Proposition	$104,940,335.64	$303,198.21	$105,243,533.85	$104,392,549.74	$104,695,747.95
Total	$104,940,335.64	$303,198.21	$105,243,533.85	$104,392,549.74	$104,695,747.95

Donors

The following were the top donors to the opposition committees.

Donor	Cash Contributions	In-Kind Contributions	Total Contributions
DaVita, Inc.	$66,529,362.69	$293,625.50	$66,822,988.19
Fresenius Medical Care	$29,775,854.74	$9,572.71	$29,785,427.45
US Renal Care, Inc.	$7,635,118.16	$0.00	$7,635,118.16
Dialysis Clinic, Inc.	$600,000.00	$0.00	$600,000.00
Satellite Healthcare, Inc.	$400,000.00	$0.00	$400,000.00

Media editorials

Ballotpedia identified the following media editorial boards as taking positions on the ballot initiative. If you are aware of a media editorial board position that is not listed below, please email the editorial link to editor@ballotpedia.org.

Support

Ballotpedia had not identified media editorial boards in support of the ballot initiative.

Opposition

• The Bakersfield Californian Editorial Board: "Proposition 23 basically is a replay of a 2018 ballot battle, with voters decisively siding with dialysis centers. Rather than accepting that vote, union activists are taking another bite on the apple with Proposition 23. ... The regulation of patient care at dialysis clinics should be a matter of legislation of industry regulation, not a union negotiating ploy decided by voters."
• The Orange County Register Editorial Board: "So this isn’t about Californians’ well-being. The ballot measure wasn’t created by dialysis patients upset by their healthcare options. Its backer is SEIU-UHW West, a healthcare workers’ labor union that has not been successful in organizing employees in dialysis clinics. Its electoral plan is apparently to make the two companies that own most of the state’s clinics spend so much money fighting ballot initiatives every two years that they have a hard time staying in business. That kind of chicanery makes a mockery of California’s initiative system and of your time as a citizen and voter."
• Mercury News & East Bay Times Editorial Boards: "Just as they did two years ago, leaders of a large labor union are trying to use a statewide election to go after the kidney dialysis industry. California voters saw through the political blackmail by the Service Employees International Union in 2018, when 60% of voters rejected Proposition 8, a misguided effort to regulate the industry. ... Votes should send union leaders a strong signal that nuisance ballot measures have no business being on the California ballot."
• The Press Democrat Editorial Board: "We don’t have a position on whether dialysis clinics should be unionize. That’s a matter for the employees and their employers. But targeting clinic owners who resist union organizing efforts is a clear-cut abuse of the initiative process. Given rising rates of diabetes, which can cause kidney failure, California is going to need more dialysis clinics, not fewer. Proposition 23 is likely to result in some clinics closing and create disincentives for opening new ones without improving care for people whose lives depend on kidney dialysis."
• San Francisco Chronicle Editorial Board: "The lives of some 80,000 Californians with kidney failure depend on dialysis, which typically entails three treatments a week lasting four hours each. That they are at the center of a battle over financial spoils for the second time in as many years is an unfortunate comment on the nation’s health care system as well as the state’s initiative process. Vote no in the hope of discouraging any further reliance on this tactic."
• Los Angeles Times Editorial Board: "For the second time in two years, California voters will be asked to play the role of healthcare regulators and set rules for how dialysis clinics operate in this state. And once again, they’ll be offered a seemingly appealing way to make clinics safer. But just as they smartly rejected a ballot measure in 2018 that sought to increase clinics’ spending on nurses and technicians, they should reject an initiative this year to increase clinics’ spending on doctors. Proposition 23 — like Proposition 8 in 2018 — would raise costs without delivering a meaningful improvement in the quality of care."
• San Mateo Daily Journal Editorial Board: "This is a labor dispute and should not be on the ballot."
• The San Diego Union-Tribune Editorial Board: "The San Diego Union-Tribune Editorial Board acknowledges how much unions have helped their members, but their negotiations — and life or death medical decisions — shouldn’t spill over into the voting public and the state’s initiative process. That’s an abuse of power. Voters should send a clear message not to try this again. No on Proposition 23."
• The Desert Sun Editorial Board: "This latest ballot measure takes a different tack, but the goal of its backers seems the same. State voters are not equipped to effectively regulate what is indeed a life-saving procedure for some 80,000 of their fellow Californians. Those responsibilities must be left to lawmakers and state and federal regulators. If reforms are needed in this industry, then they must flow from those best able to vet them rather than from the ballot box. This type of nuisance initiative only serves to increase skepticism about California’s initiative process. Vote “no” on Proposition 23 to send a strong message against such cynical tactics."
• The Sacramento Bee Editorial Board: "Dialysis is one area of health care that is working well. But now a state proposition threatens to upset that network. ... Dialysis centers operate well and provide life-sustaining treatments for their patients. Prop. 23 would put that in jeopardy. The Sacramento Bee Editorial Board recommends a no vote."

Polls

See also: 2020 ballot measure polls

California Proposition 23, Dialysis Clinic Requirements Initiative (2020)
Poll	Support	Oppose	Undecided	Margin of error	Sample size
SurveyUSA (likely voters) 9/26/2020 - 9/28/2020	49.0%	23.0%	28.0%	+/-5.4	588
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

California Proposition 8 (2018)

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

In 2018, the campaign Californians for Kidney Dialysis Patient Protection supported a ballot initiative to require 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. On the ballot as Proposition 8, 59.9 percent of voters rejected the proposal. On November 7, 2018, Californians for Kidney Dialysis Patient Protection announced that a similar ballot initiative would be filed for 2020.

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. The SEIU-UHW West sponsored Californians for Kidney Dialysis Patient Protection, which raised $18.94 million. The California Democratic Party and California Labor Federation supported the campaign. Opponents, organized as Patients and Caregivers to Protect Dialysis Patients, raised $111.48 million, with DaVita and Fresenius Medical Care North America providing 90 percent of the campaign's funds.

Conflict between labor and dialysis businesses

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. Kent Thiry, CEO of DaVita, argued that "Proposition 8 puts California patients at risk in an effort to force unionization of employees." Kathy Fairbanks, an opposition spokesperson, similarly stated, "[Sponsors] want to bring the dialysis community to the table and unionize it. This is just leverage." Wherley, a spokesperson for the SEIU-UHW West, contended that dialysis workers "want these [initiative] reforms regardless of what happens with their union efforts." 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."

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. Wherley said the union was taking a two-pronged approach, wanting to make "sure we have as many options available as possible." 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.

Comparison of most expensive ballot measures

See also: What were the most expensive ballot measures in California?

Based on available reports on Cal-Access, which provides information on campaign finance from 1999 to present, the most expensive ballot measures in California were Proposition 26 and Proposition 27—measures related to in-person and mobile sports betting on the ballot in 2022. The campaigns surrounding the measures reported $463.3 million.

Before Propositions 26 and 27, campaigns surrounding Proposition 22, a 2020 measure related to app-based drivers and labor regulations, raised a combined total of $224.2 million.

The following table illustrates the top nine most expensive ballot measures in California since 1999.

Top nine most expensive California ballot measures since 1999
Measure	Year	Total	Support	Opposition	Outcome
Propositions 26 and 27	2022	$463,378,417	$301,387,802	$161,990,615	d
Proposition 22	2020	$224,253,017	$205,369,249	$18,883,768	a
Proposition 33	2024	$175,776,441	$50,713,045	$125,063,395	d
Propositions 94, 95, 96, and 97	2008	$154,554,073	$115,063,876	$39,490,197	a
Proposition 87	2006	$150,770,683	$58,130,783	$92,639,900	d
Proposition 15	2020	$144,006,081	$69,208,909	$74,735,622	d
Proposition 8	2018	$130,426,208	$18,943,228	$111,482,980	d
Proposition 61	2016	$128,276,770	$19,170,610	$109,106,160	d
Proposition 21	2020	$124,424,014	$40,852,357	$83,571,657	d
Proposition 79	2005	$121,826,243	$40,516,352	$81,309,891	d

What is dialysis treatment?

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.

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 known 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.

• 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.

Path to the ballot

See also: 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 2020 ballot:

• Signatures: 623,212 valid signatures were required.
• Deadline: The deadline for signature verification was June 25, 2020. However, the process of verifying signatures can take multiple months. The recommended deadlines were March 3, 2020, for an initiative requiring a full check of signatures and April 21, 2020, for an initiative requiring a random sample of signatures.

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.

Stages of this initiative

On October 24, 2019, Sarah Steck and Elliott Petty filed the ballot initiative. Attorney General Xavier Becerra (D) released ballot language for the initiative on December 31, 2019, which allowed proponents to begin collecting signatures.

On January 28, 2020, proponents announced that the number of collected signatures surpassed the 25-percent threshold (155,803 signatures) to require legislative hearings on the ballot initiative. In 2014, Senate Bill 1253 was enacted into law, which required the legislature to assign ballot initiatives that meet the 25-percent threshold to committees to hold joint public hearings on the initiatives not later than 131 days before the election.

In late April 2020, the campaign filed 1,012,034 signatures for the ballot initiative. At least 623,212 (61.58 percent) of the signatures needed to be valid. On June 15, 2020, the office of Secretary of State Alex Padilla announced that a random sample of signatures projected that 73.05 percent were valid. Therefore, the ballot initiative qualified to appear on the ballot at the general election.

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 $5,524,184.44 was spent to collect the 623,212 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $8.86.

How to cast a vote

See also: Voting in California

Click "Show" to learn more about voter registration, identification requirements, and poll times in California.

How to cast a vote in California

The information below covers regular voting policies in the state. Information may have not applied to the election on November 3, 2020, because of temporary changes in response to coronavirus. Click here to read about changes made for the 2020 elections. 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. Registration 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-registered voters are automatically registered to vote when they turn 18. 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. Learn more by visiting this website. 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, which are counted once county election officials have completed the voter registration verification process. The state refers to this process as Same Day Voter Registration. 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. An individual applying to register to vote must attest that they are a U.S. citizen under penalty of perjury. As of November 2024, two jurisdictions in California had authorized noncitizen residents to vote for local board of education positions through local ballot measures. Only one of those jurisdictions, San Francisco, had implemented that law. Noncitizens voting for board of education positions must register to vote using a separate application from the state voter registration application. All 49 states with voter registration systems require applicants to declare that they are U.S. citizens in order to register to vote in state and federal elections, under penalty of perjury or other punishment. Seven states — Alabama, Arizona, Georgia, Kansas, Louisiana, New Hampshire, and Wyoming — have laws requiring verification of citizenship at the time of voter registration, whether in effect or not. In three states — California, Maryland, and Vermont — at least one local jurisdiction allows noncitizens to vote in some local elections. Noncitizens registering to vote in those elections must complete a voter registration application provided by the local jurisdiction and are not eligible to register as state or federal voters. Verifying your registration The secretary of state's My Voter Status website allows residents to check their voter registration status online. Voter ID requirements California does not require voters to present identification before casting a ballot in most cases. 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. On September 29, 2024, Gov. Gavin Newsom (D) signed SB 1174 into law prohibiting any jurisdiction in the state from adopting a local law that requires voters to present ID before voting. The following list of accepted ID was current as of October 2024. 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. ”

See also

2020 measures

• 2020 ballot measures
• Healthcare on the ballot
• Business regulation on the ballot

California

• California ballot measures
• California ballot measure laws

News and analysis

• Ballot measure lawsuits
• Ballot measure readability
• Ballot measure polls

External links

Information

• Petition #19-0025
• Official Voter Information Guide

Support

• Californians for Kidney Dialysis Patient Protection
• Californians for Kidney Dialysis Patient Protection Facebook
• Californians for Kidney Dialysis Patient Protection Twitter

Opposition

• Stop the Dangerous & Costly Dialysis Proposition
• Stop the Dangerous & Costly Dialysis Proposition Facebook
• Stop the Dangerous & Costly Dialysis Proposition Twitter