SAN FRANCISCO (AP) — California voters have rejected a ballot measure to require a doctor or highly trained nurse at each of California’s 600 dialysis clinics.

With more than 10 million votes tallied Tuesday, Proposition 23 had just 36% of votes. It is the second measure seeking to regulate dialysis clinics placed on the ballot in recent years by unions that represent health care workers and drew more than $110 million in spending.

Opponents, financed by dialysis clinic companies, say that under that mandate, between two and three doctors would be required at every facility because most are open at least 16 hours a day, creating a financial burden that could lead some clinics to close.

Proposition 23 was the second attempt by the unions to increase regulation of dialysis clinics in California, where DaVita Inc. and Fresenius Medical Care — two of the country’s largest for-profit dialysis providers — operate about three-quarters of the state’s dialysis market.

In 2018, a separate initiative sought to cap dialysis clinics’ profits and force them to invest more of their profits in patient care. Voters rejected the measure, which became the most expensive initiative on the 2018 ballot and one of the most expensive in history, generating more than $130 million in campaign spending: $111 million from dialysis companies and $19 million from unions.

This time around, unions have raised nearly $9 million, while the coalition against Proposition 23 — led by DaVita and Fresenius, along with the California Medical Association and American Nurses Association-California — has raised more than $105 million.

The nonpartisan Legislative Analyst’s Office estimates dialysis companies make roughly $3 billion a year from their California operations.

Dialysis providers say most California clinics offer high-quality care and are regulated by federal and state authorities. They also point out that all patients already have a nephrologist — a kidney specialist who oversees their care — and that nephrologists direct each California clinic. Both initiatives have been part of a tactic to pressure dialysis companies to unionize workers.

Dialysis patients typically undergo four-hour treatments at least three times a week, during which machines remove the blood in the patient’s body, filter toxins out, then put the blood back in, temporarily performing the functions of the kidneys.

Rick Barnett, who runs the largest nonprofit dialysis provider in California, Satellite Healthcare, with 60 clinics, said a kidney specialist oversees the care of every dialysis patient, highly trained nurses and technicians staff the clinics and both federal and state officials conduct scheduled and random inspections.

“This is not about quality of care so, my question is, what problem are they trying to solve?” Barnett asked.

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