Many perspectives, 1 simple etiquette

Why the American Nurses Association California Opposes Proposition 23

Created: 01 October, 2020
Updated: 14 August, 2022
3 min read

This is an independent opinion. Have one of your own? Email it to hoa@ivn.us

Historically, nurses have advocated for increased access to care.

Type "nurses + increase access to care" into Google and you will find a slew of whitepapers, journals, expert testimonials, professional association policies, etc. supporting the interests of diverse communities.

For many professional associations, healthcare organizations and academic institutions in California, it is no different. But in 2018 there was a battle over what is now Proposition 23 (then named Proposition 8).

And there is no doubt that battle will continue again this year.

Here is ANA California’s analysis and stance on Proposition 23.

Perhaps a little unorthodox, let's start by introducing the arguments for those supporting Proposition 21. According the Yes on Proposition 23 website, voting “yes” would mean: 

  1. Requires a doctor on site
  2. Requires infection reporting
  3. Keeps clinics open
  4. Prohibits discrimination

Service Employees International Union (SEIU) - United Workers West is the sponsor of the website and the major funding donor behind YES on Proposition 23. SEIU–UHW spent $20 million in 2018 trying to pass a similar dialysis ballot measure (Proposition 8). Voters overwhelmingly rejected the Proposition. 

Now, here’s why the arguments from the Yes on Proposition. 23 side don’t add up. 

1. Requires a Doctor on Site

According to YES on Proposition 23, "In most dialysis clinics, low-paid workers are pressured to rush patients through treatment. Proposition 23 will help to ensure there is always a doctor on site — the difference between life or death if something goes wrong."

However, treatments are prescribed by patients’ nephrologists and delivered by trained nurses and techs. Under Proposition 23, the physician administrator would NOT be required to have specialty training in kidney care or dialysis.

One-hundred patient advocacy groups — including ANA California, and even California Medical Association (CMA), the leading lobbying association for physicians — oppose Proposition 23. ANA California's Krystal Salcedo, a hemodialysis registered nurse, was featured in NO on Proposition 23's video ads.

Find more Election 2020 coverage here

“Proposition 23 would unnecessarily increase health care costs and make the doctor shortage worse for all Californians by moving thousands of practicing doctors into non-caregiving roles in dialysis clinics,” said Peter Bretan, president of the California Medical Association.

The cherry on top... By taking thousands of physicians away from patient care and putting them into unnecessary bureaucratic roles in clinics, Proposition 23 makes California physician shortage worse and leads to ER overcrowding.

2. Requires Infection Reporting

According to YES on Proposition 23, "Patients have reported bloodstains, roaches, and flies in the clinics — which could put them at risk of infections and diseases. Proposition 23 will ensure patients and their families are informed about unsafe clinic conditions."

ANA California is a staunch supporter of quality care. However, the federal and state governments already 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. The regulations would be redundant.

3. Keeps Clinics Open

According to YES on Proposition 23, "Hospitals are required to get approval from the state to close or reduce services. Proposition 23 will ensure dialysis clinics are held to the same standard."

However, according to the Berkeley Research Group, nearly half of the 600 clinics in California would become financially unsustainable – resulting in clinic closures and cutbacks.

Why? Proposition 23 would increase dialysis treatment costs by $320 million every year. This is a staggering increase in costs that would be passed onto approximately 80,000 Californians. 

Quick Fact: Missing a single treatment increases patient risk of death by 30%.

4. Prohibits Discrimination

According to YES on Proposition 23, "Dialysis clinics should provide the same level of care for all patients, regardless of the type of insurance they have or the community they live in. Proposition 23 will ensure everyone gets equal treatment."

However, according to the National Kidney Foundation, "More than 90 percent of Americans with kidney failure... have Medicare."


Proposition 23 is a special interest measure that would seriously jeopardize access to care for tens of thousands of vulnerable dialysis patients, make our state’s physician shortage and ER overcrowding worse, all while increasing health care costs by hundreds of millions annually.

Vote NO on Proposition 23.