Proposition 23 is on the California ballot this election season, and seeks to require a doctor or other medical professional to be on-site during dialysis treatment, as well as prohibiting discrimination against patients based on their source of payment for treatment.

Proposition 23 requires “at least one licensed physician on-site during treatment at outpatient kidney dialysis clinics.” However, it also allows the 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.

Prop 23 also requires clinics to report dialysis-related infection data to state and federal governments, and prohibits clinics from closing or reducing services without approval from the state health department, a move that supporters state is meant to protect rural patients.

Additionally, Prop 23 bans clinics from giving patients different treatments based on how they pay, which could be the patient, a private entity, the patient’s health insurer, Medi-Cal, Medicaid, or Medicare.

According to the California Secretary of State Official Voter’s Guide, 80,000 Californians with End-Stage Renal Disease go to one of more than 600 commercial dialysis centers in the state three times a week, where they spend three to four hours connected to a machine that removes their blood, cleans it, and returns it to their bodies.

Dialysis is a required treatment that such patients must continue for the rest of their lives or until they receive a kidney transplant.

Two for-profit companies, DaVita and Fresenius, own about three-quarters of the clinics in California. DaVita Inc. has donated nearly $60 million to No on 23 campaign, while Fresenius has donated approximately $26 million to the same cause, together making up around 92 percent of total contributions received.

The estimated fiscal impact of the proposition, if it were to pass, is expected to increase state and local government costs in the low tens of millions of dollars annually.

Supporters of Proposition 23, including patients, argue that it combats poor hygiene in dialysis clinics by requiring infection reporting, and improves staffing, including requiring a doctor in clinics during treatment. Additionally, supporters stated that Prop 23 stops discrimination based on patients’ insurance and applies improvements to all clinics, regardless of the socioeconomic status of the surrounding neighborhood.

“This initiative will make common-sense improvements to dialysis treatment that will protect some of the most medically vulnerable people in our society,” reads an argument in favor of the initiative listed in the voter’s guide.

A full list of endorsements for Yes on 23 is available here.

Opponents, which include the American Nurses Association of California, the California Medical Association, and patient advocates, argue that Prop. 23 would “force many community dialysis clinics to shut down,” and would increase health care costs by hundreds of millions annually. Additionally, opponents argue that it would have a negative impact on the current healthcare worker shortage and overcrowding in emergency rooms.

“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,” said Dr. Peter N. Bretan,  president of the California Medical Association.

A full list of endorsements for No on 23 is available here.

The full language of Proposition 23 is available on the California Secretary of State website, here.

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