Election 2026 · State of California

Proposition 44: Spending rule for community health clinics

Published September 29, 2026 · Updated October 2, 2026

Proposition 44 would require private nonprofit safety net clinics, known as Federally Qualified Health Centers, to spend at least 90% of their revenue each year on health care services. Clinics that fall short would pay the state a penalty equal to the shortfall. They could get it back by complying within five years; otherwise the money would go to clinic workforce programs.

Summary by CityHallPass, not the official text or legal advice. The official text controls: California Official Voter Information Guide: Proposition 44.

What would Proposition 44 cost?

The Legislative Analyst estimates state enforcement costs in the low tens of millions of dollars a year, covered by fees on the affected clinics. There could be other uncertain state and local costs, for example if clinics spend more on Medi-Cal patients or if some clinics close.

What it means for the City of LA

The City of Los Angeles does not run health clinics, and clinics run by public agencies such as LA County are not covered. The measure would apply to the private nonprofit health centers that operate across the City: by our count of federal data, 87 organizations run 783 active service sites in LA County, 289 of them with a Los Angeles mailing address. The Legislative Analyst says costs to state and local governments are uncertain and could rise if clinics close. It does not estimate effects on the City.

The details

The question on your ballot

Imposes penalties on nonprofit Federally Qualified Health Centers (community clinics providing primary care to medically underserved areas and populations) that spend less than 90% of revenue on “program services” advancing their charitable purpose, including but not limited to patient services. Fiscal Impact: Increased state costs in the low tens of millions of dollars per year, covered by fees. Supporters: None submitted Opponents: American Academy of Pediatrics CA; CA School Nurses Org; CA Academy of Family Physicians; CA Medical Assoc.

What would change

Covered clinics are nonprofit clinic corporations that are Federally Qualified Health Centers, including “FQHC look-alikes.” Tribal and urban Indian clinics are excluded (text, Sec. 3.1). The Legislative Analyst counts about 2,000 safety net clinics in California, most of them private nonprofits and the rest run by public entities such as counties. It says some clinics “might close instead” of meeting the minimum, with uncertain effects on state and local costs (Legislative Analyst).

What it means for the City of Los Angeles

• Who runs the clinics. The City does not operate health clinics. Clinics run by public entities such as counties are not the private nonprofits the measure covers (Legislative Analyst).
• Clinics in LA. Federal records list 87 health center organizations with 783 active service sites in LA County, including 80 mobile vans. Of those sites, 289 have a Los Angeles mailing address, which undercounts the City because many City neighborhoods use their own postal names. The largest by number of sites are AltaMed (84 sites of all kinds), Northeast Valley Health Corporation (51) and JWCH Institute (48). These are our counts from HRSA’s health center site data.
• Local costs. The Legislative Analyst says clinic closures would create “other uncertain effects on state and local costs” (Legislative Analyst). The opponents’ argument says the measure could send more patients to emergency rooms (argument against). Neither estimates an effect on the City budget.
• LA clinics in the campaign. Health centers with sites in LA County gave at least $11.8 million (31.4%) of the money raised against the measure. AltaMed, which lists a Los Angeles address, is the largest single donor (Cal-Access, committee 1484266).

How it got on the ballot

Proposition 44 is a citizen initiative, number 1986 on the Secretary of State’s list (Attorney General file 25-0008A1), titled the “Clinic Funding Accountability and Transparency Act.” The proponents are Shawna Brown and Sean Fleming (Secretary of State, eligible measures; text, Sec. 1).

• 2025: SEIU-United Healthcare Workers West first tried to pass a version through the Legislature. That bill failed. It would have exempted clinics that set up labor-management cooperation committees, the Sacramento Bee reported (Sacramento Bee via MSN).
• Oct. 7, 2025: The Attorney General issued the circulating title and summary. Nov. 12, 2025: backers reported 25% of the 546,651 valid signatures needed (Secretary of State).
• April 2026: The union turned in petitions with more than a million signatures, Courthouse News reported. The California Primary Care Association and Open Door Community Health Centers sued the Secretary of State in federal court to keep it off the ballot (Courthouse News).
• May 18, 2026: It became eligible after the county signature sample (Secretary of State).
• August 2026: A federal magistrate judge dismissed the clinics’ suit against the Secretary of State on standing and immunity grounds, not on the merits (Courthouse News; Law360).

Related past measures. SEIU-UHW sponsored dialysis clinic measures in 2018, 2020 and 2022 that voters rejected, according to the Orange County Register’s editorial board and the opponents’ rebuttal (Orange County Register; rebuttal to argument in favor).

What each side says

In the state voter guide. Arguments are the opinions of their authors and are not checked for accuracy by any official agency (arguments and rebuttals).

Argument for, signed by Shawna Brown, the initiative’s proponent, and Brisa J. Barrera, a community clinic worker (argument in favor):

• “Some clinics spend less than half of their funding on patient care and services,” with money going to “bloated CEO salaries.”
• Transportation, interpretation, care coordination, outreach, equipment and mental health and dental care can count toward the 90%.
• “Clinics that meet the standard keep every dollar,” and penalties can be recovered.

The opponents’ rebuttal, signed by Brent K. Sugimoto (California Academy of Family Physicians), Kelly McCue (American College of Obstetricians & Gynecologists District IX) and Susanne J. Spano (American College of Emergency Physicians, California), says the measure is “written and funded entirely by one special interest” that “has spent $140 million pushing dozens of harmful ballot measures” (rebuttal).

Argument against, signed by Eric Ball (American Academy of Pediatrics, California), Katie Nilsson (California School Nurses Organization) and René Bravo (California Medical Association) (argument against):

• It would “Cut $1.7 billion from health clinics in the first year alone” and “Cause 88% of all clinics in the state to operate at a loss.”
• It restricts spending on nurse managers, translation, insurance help, imaging machines, technology and clinic expansion.
• Clinics “serve 1 in 4 Medi-Cal patients.”

The supporters’ rebuttal says the campaign against it “is funded by the same highly paid clinic executives who benefit from the current system” (rebuttal).

Outside the guide.

• SEIU-UHW spokesperson Renée Saldaña: “We want to cut what we see as wasteful spending and redirect that money so that patients can access this care when they need it” (Sacramento Bee via MSN).
• California Primary Care Association President Francisco Silva: “This is the time to actually grow health centers so we can serve that patient base, not to cut them back” (Sacramento Bee via MSN).

Checking the main claims against official records.

Who supports and opposes it

Supporters

• SEIU-United Healthcare Workers West, the sponsor (Cal-Access, committee 1483073; KQED).
• California Federation of Labor, the only other endorsing group as of Sept. 17, the Sacramento Bee reported (Sacramento Bee via MSN).
• The official ballot label lists no supporters (“None submitted”) (official guide).

Opponents

• American Academy of Pediatrics California, California School Nurses Organization, California Medical Association, California Primary Care Association, American College of Obstetricians & Gynecologists District IX, Planned Parenthood Affiliates of California, National Association of Social Workers California Chapter, American College of Emergency Physicians California and California Academy of Family Physicians (argument against).
• California Democratic Party and California Republican Party (Sacramento Bee via MSN; CAGOP endorsements; Inland Valley News).
• California Teachers Association and California Chamber of Commerce (Sacramento Bee via MSN).
• Reform California, which reported $25,500 in independent spending against it (Cal-Access raw data).
• The California Hospitals Committee on Issues gave $750,000 to the No committee (Cal-Access, committee 1484266).

Editorial boards.

• No: the Southern California News Group, in the Daily News and Orange County Register (Daily News; Orange County Register), and the San Diego Union-Tribune (San Diego Union-Tribune).
• We found no editorial board supporting it, and no LA Times editorial board position, as of Sept. 30, 2026.

Money for and against

Source: campaign statements of committee 1483073 and committee 1484266, read from the Cal-Access raw data export dated Sept. 30, 2026. The No committee also reported $9,819.66 in late contributions through Sept. 25. It took a $1 million loan in 2025 and repaid it in early 2026. The Secretary of State’s compiled totals ran only through Aug. 2 when checked on Sept. 30.

Who is giving

Method: every itemized contribution on the committees’ Form 460 statements through Sept. 19, 2026, plus late contribution reports through Sept. 25, from the Cal-Access raw data export, analyzed by CityHallPass. LA County matches are ours, made by comparing donor names with HRSA’s site list and checking each by hand.

For. Every dollar was an in-kind contribution from the SEIU-UHW Political Issues Committee, $16,929,633.88 in 18 entries from 2025 through June 2026. The committee reported no cash payments of its own (Cal-Access, committee 1483073). The Political Issues Committee’s own itemized receipts come almost entirely from SEIU-UHW’s nonprofit 501(c)(5) arm (Cal-Access). The Sacramento Bee reported that the union had not put major money into Proposition 44 since May and was focusing on the billionaire tax (Sacramento Bee via MSN).

Against. 149 donors gave $37,626,174.58. Organizations, nearly all health centers and their association, supplied $36,487,050.45 (97.0%); the ten largest donors gave 41.2%.

• AltaMed Health Services Corporation, $5,467,867.69 (14.5%)
• California Primary Care Association, $1,553,000, plus $482,766.13 from its Advocates committees
• Family Health Centers of San Diego, $1,511,285
• North East Medical Services and WellSpace Health, $1,500,000 each
• San Ysidro Health, $1,005,138.57, and Innercare, $1,000,000
• California Hospitals Committee on Issues, $750,000
• LA County health centers beyond AltaMed include Northeast Valley Health Corporation ($613,801.63), JWCH Institute ($560,860.78), Unicare Community Health Center ($501,681.38), APLA Health & Wellness ($365,323.73), Venice Family Clinic ($344,730.61) and Tarzana Treatment Centers ($322,452.92).

Source: Cal-Access, committee 1484266, analyzed by CityHallPass.

How the No money was spent. Target Enterprises was paid $30 million for TV, web and literature (89.3% of payments). Other payees include Bicker, Castillo & Fairbanks ($542,084.18), Amplified Strategies ($540,279), FM3 Research for polling ($246,625), Berkeley Research Group ($157,931.03) and the California Democratic Party ($259,500) (Cal-Access, committee 1484266).

Outside spending

Independent expenditures naming Proposition 44 on Form 496 through Sept. 29 (Cal-Access raw data):

• Opposing: Reform California with Carl DeMaio, ballot measure committee, $25,500 (campaign management, door hangers, slate mailers).
• Supporting: none reported.

Independent analysis

• Legislative Analyst. Enforcement costs in the low tens of millions a year, paid by fees. Other costs “are uncertain,” depending on how the Attorney General defines health care expenses and whether clinics meet the minimum. Clinics that spend more on direct care could raise state Medi-Cal costs (analysis).
• Brad Fulton, Indiana University, for the Sacramento Bee: 89% of 147 California clinic organizations would fail the threshold; of the 16 that met it, all but two had finances in the red. “Almost no health center in the U.S. meets Prop. 44’s standard” (Sacramento Bee via MSN).
• Berkeley Research Group, paid by the No campaign, said the 90% ratio “would not allow clinics to keep funding in reserves for major capital investments,” as quoted by the Orange County Register (Orange County Register; Cal-Access, committee 1484266).

If it passes

• When it starts. An initiative statute takes effect on the fifth day after the Secretary of State files the statement of the vote (Art. II, Sec. 10). The 90% rule applies from each clinic’s first full fiscal year that begins at least six months after passage (text, Sec. 8).
• Implementation. The Attorney General issues guidance on what counts, may do so by bulletin without formal rulemaking, and posts each clinic’s ratio online (text, Sec. 3.1).
• Changes. The Legislature can amend it only by a statute signed by the Governor that furthers its purposes; otherwise it takes another statewide vote (text, Sec. 9).
• Legal challenges. The clinic association has argued that the measure is preempted by federal law, and its general counsel said the dismissal of its first suit “is limited to the timing of the lawsuit, not the merits” (Courthouse News).

Key moments

We found no televised debate on Proposition 44 as of Sept. 30, 2026.

• Pre-election suit dismissed (August 2026). See How it got on the ballot (Courthouse News; Law360).

Polls

Source: PPIC Statewide Survey, September 2026. PPIC read respondents the ballot title and label. Support was about one in three across partisan groups. We found no other public poll on Proposition 44 as of Sept. 30, 2026.