Proposition 44, which would require most community clinics to spend at least 90% of their annual revenue providing healthcare services, could have dire consequences for millions of Californians who rely on these safety-net clinics. If there were other options besides “yes” or “no” for ballot measures, I’d mark this one as “we shouldn’t even be voting on this stuff.”
Proposition 44 is the brainchild of SEIU-United Healthcare Workers West (UHW), the union also backing Proposition 40, the billionaire wealth tax. A spokesperson told me the latter would backfill deep federal cuts by earmarking nearly all of the revenue for state healthcare programs, and the former would help ensure the money is spent on patient care instead of administrative bloat.
But the fact that it applies only to most of the roughly 2,000 community clinics across California that serve primarily low-income patients is telling. UHW has been trying to unionize these clinics, and this appears to have been placed on the ballot as a bargaining chip. Though the union denies any connection between negotiations and the initiative, Politico reported in July that there were talks earlier this summer between UHW and the California Primary Care Association, the trade group representing the centers, to remove the measure from the Nov. 3 ballot in exchange for concessions.
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This wouldn’t be the first time the union used a ballot measure as a negotiating tactic. Three times between 2018 and 2022, the union qualified initiatives that would have capped revenues at for-profit dialysis centers and forced them to hire expensive, unnecessary medical staff. All of the propositions failed.
I was the Los Angeles Times’ letters editor during those elections and read plenty of missives purportedly from dialysis patients on both sides of those initiatives. As it also happens, I have more than a journalistic interest in this topic: Kidney disease runs in my family, eventually rendering many of my relatives dependent on dialysis.
Those measures could have compounded the misery of patients much more if the clinics had to close, as advocates for dialysis patients warned. Now voters are once again being warned that a measure appearing reasonable on its face – who doesn’t want more spending on patient care? – risks shuttering clinics that serve vulnerable patients.
According to a study commissioned by the California Primary Care Association, more than 90% of the organizations operating the affected community clinics would fall out of compliance with Proposition 44’s spending requirement, triggering a staggering $1.7 billion in penalties in the first year alone. That would push almost all of the penalized organizations into operating at a loss, putting many of their clinics at risk of closure.
Mariel Garza
It’s not surprising, then, that UHW stands all but alone in its support for Proposition 44. Planned Parenthood Affiliates of California, the California Medical Association and even the state’s Democratic Party, which endorsed all three of the union’s dialysis center measures, oppose Proposition 44.
The biggest problem is the 90% spending minimum, a number that a UHW spokesperson pegged to a 85% rule that Obamacare imposes on large-group insurers. But as Ninez A. Ponce, director of the UCLA Center for Health Policy Research, told me, even the Obamacare rule might have had adverse unintended consequences. She flagged a 2025 research paper linking the rule to increasing costs and expressed concern about setting an even higher floor for nonprofit community clinics.
Ponce, who isn’t associated with the campaign against Proposition 44 but calls herself “a friend of community health clinics,” said these clinics deserve some measure of freedom to spend revenue on care for their high-needs populations. Instead, as opponents worry, clinic administrators might have to wonder if the money they spend on janitorial services – not exactly optional in places where sick people congregate – count toward their 10% allotment for non-medical expenditures.
Dahni K. Tsuboi
The same goes for other services – healthcare enrollment navigators, transportation to appointments and other “extras” – that may not fall under the umbrella of what Proposition 44 deems as advancing the mission of the clinic.
A union spokesperson assured me those services would be allowed. Problem is, the initiative’s language offers no such clear assurance. It requires the state attorney general to provide guidance on how to classify spending, so voters will have to pass Proposition 44 to get a better sense of how their decision will affect clinics’ bottom lines.
That’s a terrible way to enact far-reaching policy. If community clinic spending truly required some kind of legal remedy, it should be debated and carefully crafted by legislators, informed by expert testimony in committee hearings. Instead, Proposition 44 looks like another attempt by UHW to get voters to give them what the clinics will not.
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