Opponents to Proposition 8 have spent a record amount of money trying to get a central message out to California voters: If you vote “yes” on this ballot, people will die.

Californians on Nov. 6 will get to decide whether to cap dialysis centers' profits, a vote that opponents say will cause clinics to close and put people’s health and lives at risk. Medical groups have spent nearly $111 million to defeat the measure, and the amount could climb even further given that more than a week remains until the election.

The opposition campaign has flooded the public with emotionally charged TV, online, and radio ads featuring dialysis patients who warn that the ballot will “cause a lot of lives to be at stake” and “literally threatens my life.” Proposition 8, one ad says, “threatens the lives of over 66,000 kidney dialysis patients.”

The patients in question have kidney failure, which usually comes as a result of diabetes or high blood pressure, and means their organs can no longer process fluid and waste properly. To stay alive, patients receive dialysis treatment three times a week, for up to five hours. The only way most patients can stop treatment is if they can get a kidney transplant.

Opponents against Proposition 8, or the “Fair Pricing for Dialysis Act,” have raised more than any group on one side of a U.S. ballot issue since at least 2001. Before that, data on ballot spending weren’t tracked online.

Dialysis giants have spent the bulk of the cash, with DaVita Healthcare Partners spending $67 million and Fresenius Medical Care North America contributing $33.23 million. The two firms dominate the dialysis market in the U.S.

Opponents say clinics will close if the measure is passed because the profit cap doesn’t cover operating costs. In that scenario, they say, then patients may have to drive further for care or miss treatments, landing them in the emergency room for even more costly care. About 140,000 people in California are receiving dialysis.

“It is definitely not in the patient’s best interest to have their clinics close and to limit access to a life-sustaining treatment,” said Kathy Fairbanks, spokeswoman for the anti-Proposition 8 campaign. “You don’t want to cut off their access to dialysis. They will die.”

The coalition has brought major doctor and hospital groups to their side, as well as editorial boards for California newspapers, including the Los Angeles Times.

But they may still have to do more to convince voters. One SurveyUSA poll published Oct. 16 found that 47 percent of voters support the ballot, while 34 percent are opposed to it. Nineteen percent were undecided.

The amount of spending to kill the measure exceeds the last record, of $109 million, that drug companies spent to defeat Proposition 61 in California in 2016. That ballot would have allowed the California government to pay no more for drugs than what the Department of Veterans Affairs pays.

And Proposition 8 opponents are far outpacing the $18 million spent so far by the campaign supporting the measure, which is led by the Service Employees International Union, or SEIU.

“Funding makes a big difference, and opponents have outspent proponents seven-to-one on TV and radio ads,” said Andrea Harris, senior vice president of healthcare at Height Capital Market.

Supporters say opponents are not concerned about patients' well-being, but rather about their bottom lines.

“What is clear is that they will spend every dollar they can to protect their $4 billion in profits and what is getting lost is the patients,” Sean Wherley, SEIU-United Healthcare Workers West spokesman, said of the dialysis industry.

The SEIU has argued that dialysis care is in a “crisis” and that any money made above the profit cap would be returned to patients. The intent of the ballot, they say, is to encourage dialysis centers to put money into their facilities, whether by buying more supplies, hiring more staff, or improving patient health. Wherley said the SEIU was approached by dialysis workers who were concerned about poor patient care.

Dialysis clinics have for years been dogged by accusations that they are unsanitary and understaffed, and assertions that more government inspections are needed. An effort to put a ballot question on dialysis before Ohio voters this November failed, but Wherley said that SEIU would be looking at other states for more clinic regulations.

Fairbanks disputed allegations of poor care, pointing to data from the Centers for Medicare and Medicaid Centers showing that when it comes to dialysis, California has lower infection rates and mortality than other state, and ranks above average in the quality of patient care.

She said the true motivation of SEIU was to use the ballot initiative to get dialysis workers to unionize.

“They are using patients as political pawns and it’s just wrong,” she said.

The ballot measure follows another battle the dialysis industry faced in the California legislature.

Democratic Gov. Jerry Brown in September vetoed a bill that would have capped payments for dialysis to Medicare rates if an outside group, such as a foundation, was helping patients pay for premiums.

Harris said it was possible that if the ballot fails on Election Day then the legislature may take another swing at the dialysis industry. After the drug pricing ballot failed in 2016, California lawmakers passed a drug price transparency bill requiring manufacturers to provide notice of major increases.

“I would not be surprised if sentiment was similar toward the dialysis industry after lawmakers see that they spent $111 million to defeat the ballot,” Harris said.

A new governor is set to take the helm after the midterms, and the presumptive winner, Lt. Gov. Gavin Newsom, has a close relationship with unions.

The battle is a long-running one. Labor organizations and health insurance companies have accused a kidney foundation of gaming the system to pad the profits of dialysis giants. They say the American Kidney Fund, which helps pay patient premiums and is partially funded by dialysis giants, has improperly steered patients that were on Medicare and Medicaid to private coverage.

The dialysis companies and the American Kidney Fund have denied the accusations, which were scrutinized under Obama-era regulators. The American Kidney Fund said the help it gives patients to pay for medical coverage is vital, because the coverage patients get through Medicare only pays for 80 percent of their treatment. California also doesn't let dialysis patients get Medigap coverage to help make up the difference.

Alice Andors, American Kidney Fund spokeswoman, said in an email that patients who apply for premium help already have health insurance. Grants are approved according to a patients’ need, not what type of coverage they have, she said.

DaVita also disputed the allegations in a statement, saying, “For some patients Medicare is the best insurance, while for others commercial coverage is much better than Medicare.”