Proposition 44: California Spending Requirements for Federally Qualified Health Centers Initiative

SEIU-UHW measure to require more of health clinic revenues to go to services instead of executive pay

Source (https://www.sfgreenparty.org/endorsements/123-november-2026-endorsements)

Prop 44 is SEIU-UHW's fourth try at regulating a healthcare industry by ballot measure, after voters rejected all three of its dialysis initiatives (https://ballotpedia.org/California_Proposition_23,_Dialysis_Clinic_Requirements_Initiative_%282020%29). The target this time is nonprofit community clinics, where operators say the union is organizing (https://fresnoland.org/2025/08/13/healthcare-initiative/), and the tool is a rule that every clinic spend at least 90% of its revenue on "mission-related expenses."

A 90% floor sounds reasonable. But everything else a clinic pays for has to fit into the other 10%, and the Legislative Analyst's Office found that clinics today average about 80% (https://lao.ca.gov/ballot/2026/prop44-110326.pdf), so most community clinics in the state would owe a penalty. That penalty is the entire shortfall (https://growsf.org/voter-guide/san-francisco-voter-guide-november-2026-election/measures/prop-44/legal-text/#prop-44-90-percent-penalty). The measure also never defines its central term: the Attorney General writes the definition after the election (https://growsf.org/voter-guide/san-francisco-voter-guide-november-2026-election/measures/prop-44/legal-text/#prop-44-ag-guidance), so a clinic that pays for patient vans or community outreach could be penalized like a profiteer. An analysis commissioned by the clinics (https://protectpatientsca.com/wp-content/uploads/2025/11/BRG-Report-on-Clinic-Funding-Accountability-Transparency-Act-2025_1117.pdf) puts first-year penalties at $1.7B, and the clinics are suing in federal court (https://calmatters.org/politics/2026/04/healthcare-workers-clinics-ballot-measure/) to stop it.

The people who actually run the safety net, the California Primary Care Association, the California Medical Association, and Planned Parenthood (https://calmatters.org/politics/2026/06/california-ballot-measures-november-election/), all oppose it, at a moment when federal Medicaid cuts are already squeezing clinics that serve 4.2 million Medi-Cal patients (https://kffhealthnews.org/wp-content/uploads/sites/8/2026/05/Community-Clinic-complaint-vs.-SEIU-UHW-initiative.pdf). A labor dispute belongs at the bargaining table. Don't let it be settled by fining the clinics your neighbors depend on. Vote no.

Source (https://growsf.org/voter-guide/san-francisco-voter-guide-november-2026-election#prop-44)

This sounds good at first glance—nonprofit, federally-funded clinics that care for poor people should spend money on patient care, not on overhead or executive salaries. You might be picturing health care giants like Sutter and Kaiser that may very well be spending their money in the wrong places. BUT this also applies to smaller community clinics like La Clinica de la Raza, Lyon-Martin, and neighborhood health centers. Advocates for these vital health care facilities are opposing Prop 44 because they’re concerned that a lot of what they spend their money on to serve their patients and keep their doors open, like translation, janitorial services, and billing, wouldn’t count as “patient care.” If that’s the case, they could end up having to pay large fines at a time when they’re facing MAGA’s drastic federal cuts to Medicaid and health-care funding thanks to the “Big Beautiful Bill”🤮🤮🤮. Even if those activities do get to count toward the 90%, Prop 44 adds additional paperwork and bureaucratic burden to prove it. Oh, and these determinations would be made not by medical or public health experts but by the CA Attorney General. These clinics are barely keeping their doors open and we need them more than ever. 

Do we think clinics should do everything they can to care for patients? Sure. Do we think they should have to spend their time arguing with the state over which operational expenses should count as “patient care? No.

Source (https://www.theleaguesf.org/#Prop44)

No on Prop 44: Imposes Costly Mandates on Community Health Clinics

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Source (https://www.reformcalifornia.org/voter-guides/san-diego)

NO on Prop. 44

This measure requires community clinics that provide primary care to medically underserved areas and populations to spend at least 90% of their revenue on patient services, not management and overhead. It authorizes the Attorney General to publish guidance on qualifying expenditures and lets the Department of Public Health issue waivers. It authorizes monetary penalties and criminal charges. It is sponsored by a powerful labor organization seeking to expand its control over private clinics.

Vote NO on 44.

Source (https://www.hjta.org/2026votingguide#Ballot-Measure-Recommendations)

(Committee Vote: 3 NO, 2 YES, 2 ABSTAIN)

Requires covered nonprofit community health clinics to spend at least 90% of their revenue on health-care services, with enforcement mechanisms for clinics that fail to comply. CADC opposes Prop. 44 because members questioned whether a rigid statewide 90% requirement adequately accounts for administrative and operational costs. 

CADC 擔心對所有社區診所實行 “九成收入必須用於健保服務”的硬性規定過於嚴苛僵化，沒有顧及診所的行政及營運需要，因此反對提案 44。

Source (https://www.sfcadc.org/11_2026_propositions)

Prop 44 - Requires Community Health Clinics Spend 90% of Revenue on Program Services

Endorsement: NO on Proposition 44

This is SEIU’s fourth merry-go-round in recent years, attempting to further regulate the healthcare industry. Establishing more restrictive measures on community health clinics would penalize the clinics and increase a state escrow account. Increasing a state account to fund more pet projects is another insider move.

Vote NO on Proposition 44

Source (https://www.connectedsf.com/2026-voter-guide#prop-44)

Proposition 44: Requires Community Health Clinics to Spend 90% of Revenue on Program Services – NO. Proposition 44 would require covered nonprofit safety-net clinics to spend at least 90% of annual revenue on health-care services. Accountability is important, and patients deserve to know that resources reach care. But the state’s analysis reports that affected clinics currently spend an average of about 80%, with variation among clinics, and warns that clinics unable to meet the new rule might close. The measure also would impose penalties and charge clinics for state enforcement costs. Administration at a community clinic includes interpreters, billing, cybersecurity, compliance, outreach, and the infrastructure that keeps doors open. A rigid statewide formula could weaken the very clinics serving low-income patients, immigrants, rural residents, and communities of color. We will not gamble with the safety net.

Source (https://cahinaacp.org/our-vote-our-voice-where-we-stand-on-every-2026-ballot-measure)

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

California Church IMPACT recommends a NO vote

This proposition is sponsored by Service Employees International Union-United Healthcare Workers-West (SEIU-UHW-West), an organization California Church IMPACT has had a long and productive alliance with. That said, this measure raises questions worth addressing.

The measure would require all Federally Qualified Health Centers (FQHCs) to spend 90% of their revenue on direct care services. An FQHC is defined by:

• Being located in or serving a high-need community
• Being governed by a community board made up of at least 51% health center patients
• Providing comprehensive healthcare on a sliding fee scale based on ability to pay
• Holding status as a Health Center Program award recipient or “look-alike” (look-alikes receive Medi-Cal and Medicare reimbursement but no other federal funding)

All FQHCs in California are nonprofits. Conventional nonprofit operating costs run 20-35%, covering office and support staff; the remainder funds direct patient care, including wages for staff with direct patient contact. Operating costs vary by organization but can include the executive director, bookkeeping, medical coding, community outreach, fundraising, and equipment and supply management — in short, this funds the support infrastructure behind direct care.

As discussed in our analysis of Proposition 40, federal Medi-Cal and clinic funding has been drastically cut or eliminated, leaving the state to cover as much of the gap as it can. Support staff are already being laid off in some locations, and support services reduced. How to protect what remains — especially if Proposition 40 fails or underperforms — is a pressing concern across providers serving low-income communities.

We think it’s unrealistic to impose an arbitrary cap on funding for the support services behind direct care. There may well be room to review executive compensation, particularly amid a funding crisis, but clinics will protect patient services by mission first, and are already cutting support staff before anything else.

Even if federal funding resumes, or Prop. 40 revenue materializes, Proposition 44’s 90% mandate could still prove risky to clinics’ well-regulated functioning. If a clinic can’t adequately fund medical coding, supply management, or fundraising within the remaining 10%, care quality suffers too — support staff aren’t a frill.

Good management tends to favor lean staffing during hard times, but robust staffing is the healthier long-term goal. We believe standard nonprofit practices should guide operations in good times, not just lean ones — and that this measure is too rigid to serve clinics well over the long term.  
Recommend a NO vote

Source (https://churchimpact.org/index.php/2026/09/08/proposition-44-spending-requirements-for-federally-qualified-health-centers-initiative/)

Endorsement: NO on Proposition 44

This is SEIU’s fourth merry-go-round in recent years, attempting to further regulate the healthcare industry. Establishing more restrictive measures on community health clinics would penalize the clinics and increase a state escrow account. Increasing a state account to fund more pet projects is another insider move.

Vote NO on Proposition 44

Recommends to vote "No"

90% HEALTH CARE SPENDING FOR NONPROFIT SAFETY-NET CLINICS

Prop 44 could reduce access to health care for Californians who already have the fewest options. It would impose a rigid spending requirement on nonprofit safety-net clinics serving low-income and uninsured patients. Clinics that cannot meet the requirement could face substantial penalties or even close, shifting patients to other public safety-net providers and increasing public costs.

Prop 44 would require affected clinics to spend at least 90% of their annual revenue on health care services. Clinics currently report spending an average of about 80%, although the percentage varies. The Attorney General would decide which expenses count toward the 90% requirement, using existing federal reports as a starting point.

Clinics falling below 90% would have to pay the state the amount of the shortfall. Although they could seek a temporary waiver or recover the money if they later comply, the financial pressure could threaten clinics serving communities that already have limited access to care.

A rule intended to direct more money to patient care should not put the safety net itself at risk. Prop 44 could worsen health disparities rather than reduce them.

Source (https://lwvc.org/ballot-recommendations)

California voters have become accustomed to voting down state ballot measures seeking to impose onerous rules on dialysis clinics that would put many out of business.  

Those measures – in 2018, 2020 and 2022 – were placed by a particularly cynical health workers union abusing the initiative process to punish dialysis clinics that opposed unionization efforts. The point was never to pass the initiatives but to force dialysis clinics to spend hundreds of millions of dollars to defeat the measures nonetheless. 

That union, the Service Employees International Union-United Healthcare Workers West (SEIU-UHW) is back at it, this time with a new and broader target – community health clinics, or Federally Qualified Health Centers – whose employees it wants to unionize.  

Community health clinics serve a vital role in California’s healthcare system. 

As explained by the nonpartisan Legislative Analyst’s Office, “Many clinics are considered ‘safety net,’ as they mainly serve low-income and uninsured people. The care they provide is often low cost or free to patients.” There are 2,000 such “safety net” clinics across the state, making them a potentially lucrative source of power and revenue for the union. 

Enter Proposition 44, titled, “Requires Community Health Clinics Spend 90% of Revenue on Program Services. Initiative Statute.”

As the title suggests, the measure’s ostensible purpose is simple, to require clinics to spend 90% of their revenue on program services, along with penalties and enforcement mechanisms. 

Setting aside the actual purpose of Prop. 44, the measure makes little sense on its own terms. 

For one, why 90%? The LAO notes that such clinics already “spend most of their revenue on providing health care to patients,” with clinics on average reporting spending 80% of their revenue on patient services. 

Is there any reason to believe that mandating a 90% threshold would make things better? No. 

In fact, if implemented, clinics warn Prop. 44 could put many out of business simply by defining away legitimate spending as not counting toward the 90% threshold. While the SEIU-UHW insists the measure is needed to rein in runaway administrative spending, the arbitrariness of its threshold threatens the entire system. 

As the Berkeley Research Group notes, “The strict 90% ratio would not allow clinics to keep funding in reserves for major capital investments, such as opening new clinics, purchasing new equipment or technologies, investments into value-based care, and preparing for potential public health or other emergencies.” 

While the measure provides state authorities the ability to waive requirements in certain cases, such hurdles, coupled with the threat of fines, will only undermine the ability of community health clinics to effectively serve patients. Potentially hundreds of clinics could outright close as a result of Prop. 44, disrupting patient care and displacing patients. 

Passage of Prop. 44 would be an outcome that serves no one. 

But as with the dialysis measures of past years, passing Prop. 44 isn’t really the goal. 

Politico recently (https://www.politico.com/news/2026/07/07/a-grand-canyon-sort-of-disagreement-how-clinics-and-a-union-leader-sparred-over-prop-44-00988013) told the story. Francisco Silva, president of the California Primary Care Association, which represents hundreds of community health clinics, recounted the hardball tactics of SEIU-UHW’s leader Dave Regan. 

Regan, according to Silva, suggested the union might not go ahead with a ballot measure “if the clinics would stand aside to allow his union to sign 25,000 clinic staffers up as new union members.”

Regan, for his part, “acknowledged his union has been in talks with the clinic association over the past few years about facilitating statewide union elections,” but “insisted those discussions were separate from the ballot measure.” 

A representative from the California Primary Care Association reiterated the same story to our editorial board, while a spokesperson from the union likewise insisted there was no link between the unionization push and the measure. 

Given their history, no one should give Regan or SEIU-UHW the benefit of the doubt.

It’s evident what SEIU-UHW wants – more members, more dues, more power – and that it’s willing to threaten the healthcare of Californians across the state in pursuit of those ends. 

That’s why a diverse coalition has come together to reject this measure – including the California Democratic Party, the California Republican Party, the California Medical Association and the California Chamber of Commerce. 

Californians must not fall for SEIU-UHW’s thuggish tactics. Vote no on Proposition 44.

Source (https://www.dailynews.com/2026/09/08/endorsement-no-on-proposition-44-a-cynical-attack-on-community-health-clinics/)

Federal Community Health Clinics serve underserved, lower income, often rural communities, and ARE NEEDED! With PROP 44, it would require 90% of revenue from clinics to go to health services (now 80%). Sounds good “on paper” but could result in closures, or prohibit needed services. PROP is “bankrolled” by healthcare unions, namely SEIU United Healthcare Workers West, who desire more members to join, and contribute to their union trust fund. VOTE NO!

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Increases mandates and costs on community health clinics, threatening their ability to provide patient care. Clinics that miss the arbitrary 90% mandate pay penalties into a government account and hotwired to a narrow special interest group who is one of the politicians’ biggest campaign contributors. Trusted healthcare experts warn that Prop 44 would trigger $1.7 billion in penalties in the first year alone and force clinics across California to close their doors.

Imposes unreasonable standards upon federally funded health centers.

No more forced unionization in health care

Source (https://svgop.com/s/SVGOP-2026-Gen-Election-Endorsements.pdf)