California voters overwhelmingly rejected Proposition 44 on Tuesday, a ballot measure that would have mandated community health clinics spend at least 90% of their revenue on patient care. The proposal faced dire warnings that it could lead to the closure of hundreds of facilities serving millions of low-income residents.
Nearly 82% of voters opposed Proposition 44 as vote counts continued, signaling a decisive defeat for the initiative spearheaded by SEIU-United Healthcare Workers West. The union argued that the taxpayer-funded clinics were diverting too much money towards executive salaries and other non-patient care expenses.
"Money should not be directed towards excessive executive compensation or other non-essentials that we have seen within … our clinic system," union spokesperson Renée Saldaña told CalMatters.
Opponents, however, countered that the measure's strict spending requirements could cripple the state's healthcare safety net. An analysis commissioned by opponents estimated that clinics could face $1.7 billion in penalties in the first year alone, potentially leading to widespread closures and service reductions.
"By shutting down clinics, Prop. 44 will force millions of patients into already overcrowded emergency rooms — increasing wait times for everyone," Dr. Susanne J. Spano, president of the American College of Emergency Physicians’ California chapter, stated in the California Voter Guide.
Critics also raised concerns about the initiative's ambiguous definition of healthcare spending, suggesting that clinics could have been penalized for investments in medical equipment, essential staff, facility expansion, or maintaining financial reserves. The responsibility for determining which expenses qualified as patient care would have fallen to California's attorney general.
State officials projected that implementing and enforcing the measure would cost tens of millions of dollars annually, to be covered by the affected clinics through fees.
The campaign leading up to the vote was costly. Opponents, primarily the California Primary Care Association, raised approximately $39 million to defeat the measure, more than double the $17 million raised by its supporters.
"Today’s resounding defeat shows that health centers will not be bullied and that protecting the whole-patient, whole-community care we are known for will always be a priority," said Francisco Silva, president of the California Primary Care Association.
This election outcome represents another setback for SEIU-United Healthcare Workers West at the ballot box, following similar defeats of union-backed initiatives targeting dialysis clinics in 2018, 2020, and 2022.
The conflict also extended to the legal arena, with the California Primary Care Association filing a lawsuit in September accusing the union and its president, Dave Regan, of using the ballot initiative as leverage to pressure clinics into accepting union bargaining demands. The union has denied these allegations.