Voting on EMT Breaks, Children's Hospitals and Dialysis Profits. Propositions 4, 8 and 11 Explained

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Should EMT and ambulance workers be able to take uninterrupted off-duty breaks? That's one of three health-related propositions Californians are voting on this November.  (David McNew/Getty Images)

This whole week, Bay Curious is exploring the 11 statewide propositions on the California ballot for a mini-series we're calling "Bay Curious Prop Week." Each day, we're dropping episodes looking at what the propositions are and how they came to be on the ballot in the first place. If you want to learn more about what's on your California ballot, check out KQED's 2018 Voter Guide.

We'll also be hosting a series of Facebook Live Q&As.
Prop 5, Property Tax Transfer - 12 p.m., Oct. 17
Prop 10, Rent Control - 12 p.m., Oct. 24

You can replay our Q&A on Proposition 6, the gas tax repeal.

Below is a transcript of our episode on Propositions 4, 8 and 11 — the three health-related propositions on the November ballot.

OLIVIA ALLEN-PRICE: Hey guys! Here we are, day four of Bay Curious Prop Week. I'm Olivia Allen-Price. If you're just tuning in, all week we've been breaking down the 11 statewide initiatives on this November's ballot. Today, we'll look at the three health-related props. They're easy to overlook but could have a big impact on you or someone you love. Stick around.


Theme music 

ALLEN-PRICE: All righty. Let's dive in. The three props we'll get to today are Proposition 11...

VOICE OVER: Should EMTs and paramedics be allowed to take off-duty breaks?

ALLEN-PRICE: Proposition 4...

VOICE OVER: Should California issue bonds to help with improvements at children's hospitals?

ALLEN-PRICE: And Proposition 8...

VOICE OVER: Should the state cap how much profit dialysis clinics can make?

ALLEN-PRICE: First up on today's tour is Prop 11. I headed to the newsroom and asked health reporter April Dembosky to let us know what it's all about.

APRIL DEMBOSKY: Prop 11 asks voters to decide if EMTs and paramedics — the people who work on ambulances — should be allowed to take uninterrupted off-duty breaks. So when they take a rest break or go out on their lunch break, are they allowed to turn off their pagers and radios so they can get a true break.

ALLEN-PRICE: Now this is one of those props that is so specific and kind of in the weeds that it makes me think that there must be a story behind it.

DEMBOSKY: You are absolutely right. So here's the status quo of how it works for ambulance drivers. They are on a 12-hour shift. You know, they're responding to emergencies. Maybe they have a lull. They drive up to McDonald's or Starbucks to take a break.

JASON BROLLINI: If I'm lucky, I can sit for 30 minutes and get a meal.

ALLEN-PRICE: This is Jason Brollini. He leads one of the main ambulance drivers unions.

BROLLINI: What a more common experience is, we order our food, and we're interrupted at some point. Sometimes those interruptions are for true emergencies, but sometimes they're not. Sometimes they're non-emergency calls where there isn't a life-threatening incident that needs to be mitigated.

DEMBOSKY: This is the way it's been working in California for many, many years. But in 2016, there was a court case in California, and it was actually on behalf of security guards. Security guards also have to be on duty while they take breaks. And they said, "Hey, if I have to be on duty, I'm not actually on break." And the Supreme Court agreed with them, said yep, when you look at California's labor code, if you want to have a break, you have to actually be off duty. And so the ambulance industry looked at this and they thought, "Oh no, this is going to apply to us, too." And so they said we don't want to do that. We're going to have this proposition instead to try to carve out a law that is specifically for paramedics and EMTs to just continue doing their job the way they always have.

ALLEN-PRICE: So this is really a preemptive proposition.

DEMBOSKY: Sort of because there were actually negotiations in the Legislature between ambulance companies and the unions who represent EMTs and paramedics. They tried to address this head on, and negotiations between those two parties broke down, and that's why the ambulance industry then put Proposition 11 on the ballot.

ALLEN-PRICE: So ambulance drivers and workers, what's their take on this?

DEMBOSKY: The ambulance staff, for the most part, says totally, we don't want anybody getting hurt. If I'm on my lunch break and there's a kid choking a couple blocks down the street...

BROLLINI: We are going to go to that call. 100 percent of the time.

DEMBOSKY: But at the same time, they're saying we work these 12-hour shifts. Sometimes work is so busy that it's six or seven hours before I get to take a lunch break.

BROLLINI: Starting to get dizzy and lightheaded because my blood sugar is low.

DEMBOSKY: Not only that, I just responded to this really stressful call, like, I could really use a few minutes to just decompress, get back to my baseline, eat some food. And so they want the workers to be at the top of their game.

ALLEN-PRICE: You know, why is the ambulance industry different from any other industry where people are entitled to a break? What makes them kind of unique here?

DEMBOSKY: Well it's definitely the public safety issue, you know.

ALLEN-PRICE: While it is public safety, about 75 percent of California’s 911 calls are answered by private companies. Carol Meyer works for McCormick Ambulance Service.

CAROL MEYER: There is an individual who has a heart attack, and we can’t call that vehicle, we have to call the next vehicle that is available and not on a break. And minutes make a big difference when it’s life and death.

DEMBOSKY: Most ambulance companies have contracts with the counties where they work. You know, part of what they're concerned about is that if you have one or two ambulances from your fleet that are just totally out of service, that could compromise how well and how quickly you can respond to those calls.

MEYER: Having those vehicles available so that if something happens they can be called is critical.

DEMBOSKY: So there's a serious public safety issue, but it really does come down to money, and the Legislative Analyst's Office estimated costs could go up 25 percent in order to have just enough extra ambulances on the road to cover people. And so when you start looking at cutting into those profit margins, you have these companies deciding whether or not it's worth it for them to continue providing this service.

ALLEN-PRICE: So in a nutshell, a yes vote on Prop 11 would mean you think EMTs and paramedics should stay on call during their breaks. A no vote means in your eyes, ambulance companies should follow the same labor laws as everybody else. Next up is Proposition 4, one of the four bonds on the ballot this year. Now a bond is basically an IOU. The state sells a piece of paper that says if you give us the money we need now, we promise to pay you back later with interest. It's a quick way for governments to get cash for big projects, and it's a pretty safe investment for the people buying the bonds, too. Health reporter Laura Klivans explains what this bond, Proposition 4, would do.

LAURA KLIVANS: So this proposition is about the state being able to sell $1.5 billion in bonds so that they can use that to fund infrastructure improvements for children's hospitals.

ALLEN-PRICE: The money from this bond will be used for capital improvements — essentially fixing up hospital buildings. Right now, a lot of hospitals are in the process of making seismic updates. These are required by the state to make their buildings safer in the event of an earthquake.

KLIVANS: The majority of the money will go to private nonprofit children's hospitals. About 70 percent of it will. And then a good portion of it, about 18 percent, goes to the UC children's hospitals and then other hospitals will get some of it too. And those are hospitals that will have, like, a children's wing or a specific children's program.

ALLEN-PRICE: Laura talked to Ann-Louise Kuhns, the president of the California Children's Hospital Association. She says for an example of where this money could go locally, look to Children's Hospital Oakland.

ANN-LOUISE KUHNS: You know, they provide some of the most specialized care for some of the most medically fragile kids in the state.

KLIVANS: They have a sickle cell program, and it's one of two in the state. And they see about 700 patients a year.

KUHNS: And most of those patients are covered by Medi-Cal.

KLIVANS: Which is a program for low-income families.

KUHNS: Just the operational costs of running that center... just to run it the hospital loses about $3.5 million every year because what they receive from Medi-Cal isn't sufficient to cover their costs.

KLIVANS: And part of the space that they use for that program is using buildings and facilities that are over 100 years old.

KUHNS: So they need to make infrastructure improvements. They need to modernize their pediatric intensive care unit and as well as their neonatal intensive care unit.

KLIVANS: So that's what this bond would do. It would upgrade, like, the sickle cell wing at Children's Hospital Oakland.

ALLEN-PRICE: So this is not exactly like a new bond initiative. We've seen similar bonds in 2004 and 2008 for children's hospitals. Why is this a thing that just keeps coming onto our ballot?

KLIVANS: Great question. I also was curious about that, so I asked the folks behind the proposition, and they think that, no, we're going to meet seismic requirements and then it's going to be a while before we need any kind of money for infrastructure again like this.

ALLEN-PRICE: Is anyone against this?

KLIVANS: I think people who would be against this are folks that realize that bonds come from somewhere. It's not just free money. They need to be repaid. They need to be repaid with interest. And how is this money held accountable?

ALLEN-PRICE: You are a yes on Prop 4 if you think the state should use bonds to help to fund improvements at children's hospitals. And you're a no if you think they should find that money some other way.


ALLEN-PRICE: All righty. Last up we arrive at Proposition 8. It's about reimbursement payouts from dialysis clinics. If that sounds super wonky to you, it's because it is. But if passed, it would be groundbreaking regulation in the health care industry. People across the country are watching this one. I dropped in on health editor Carrie Feibel to learn more about it.


ALLEN-PRICE: How's it going?

FEIBEL: Well, thanks.

ALLEN-PRICE: Could you start by telling us what is dialysis and who uses it?

FEIBEL: So dialysis is basically a machine that replaces your kidney, and for people who have failing kidneys — and many of them are waiting for a kidney transplant that hopefully they'll get but some of them don't — but they can live many, many years getting dialysis. It just cleans their blood of all the toxins and other things that our kidneys are usually doing. But you need to get it three times a week, three-to-four hours each. Which means that there has to be dialysis clinics near where people live, and there's almost 600 clinics across California. So it's a big industry.

ALLEN-PRICE: And these are all private clinics for the most part? Or...

FEIBEL: There's a few that are owned by county hospitals and such. But for the most part they're private clinics owned by for-profit companies, and there's been more scrutiny lately on, you know, what the dialysis industry is up to and how much profit they're making and that's what brings us to this proposition.

ALLEN-PRICE: All right, so let's get to this Prop 8. What are voters being asked to weigh in on here?

FEIBEL: Well this is a big deal at least in health care because basically California, if this passes, would be able to cap the amount of revenue a dialysis clinic company could get per patient and that would therefore indirectly cap how much profit and overhead they could take out of that clinic.

ALLEN-PRICE: This wouldn't directly tell dialysis clinics what they can charge patients. Instead it would tell them they can only take in 15 percent more money than they spend on patient treatment. If they go over that 15 percent cap...

FEIBEL: Then they would have to rebate whoever paid for the dialysis, maybe the patient but more likely their insurance company.

ALLEN-PRICE: So who's on which side of the story? Who's for and against?

FEIBEL: The main sponsor of this is a union that has been trying to unionize dialysis clinic workers for a long time, and their hope is that this revenue cap would force the companies to reinvest in the clinic — put it into higher wages or better training for the workers or more drugs and tubing and supplies for the machines, which ultimately, the hope is, that would make a safer, more stable experience getting dialysis.

ALLEN-PRICE: So this would, in effect, force these companies to reinvest more of the funds than perhaps they're reinvesting now. At least that's what the unions think.

FEIBEL: That's what the unions think, and that's the whole thrust of it. And the dialysis companies say no that's not what's going to happen. What you're actually going to do is really get into our business sheets and force us to close clinics. So it's really unclear what the business ripple effect will be of this. And I think that the dialysis industry across the country is definitely watching this. If this happens here, they are afraid of a domino effect in all the states that could sort of potentially impact their bottom lines.

ALLEN-PRICE: So it's a pretty radical ballot initiative really.

FEIBEL: It's an experiment, for sure, pushing a big lever on an industry that's important to a lot of Californians health.

ALLEN-PRICE: A vote for Prop 8 says you think this experiment is worth trying to get dialysis clinics to invest more in patient care. A no vote says this is too risky and could actually hurt patients by forcing clinics to shut down. That's 10 props down and one more to go for Prop week. Today's show was produced by Ryan Levi. Tomorrow we take on Prop 10 and the topic of rent control. Bay Curious is made in San Francisco at KQED. I'm Olivia Allen-Price.