# Prop 44: Requires nonprofit community health clinics to spend 90% of revenue on health care services

URL: https://www.californiapeople.org/props/prop-44

- number: 44
- title: Requires nonprofit community health clinics to spend 90% of revenue on health care services
- type: Initiative statute
- sponsor: SEIU-United Healthcare Workers West (SEIU-UHW)

**Our read: Lean no.** Clinics must spend 90% of revenue on care. The pay problem is real, but the sponsor union allegedly offered to drop it for members.

## Key findings
- **The pay problem is real.** In 2024 the CEOs of AltaMed and North East Medical Services each made about **$1.95M**. Three other clinic CEOs made $667K to $730K. [^1]
- **None of the 7 clinics funding the No campaign meets 90%.** Their combined ratio is **77.4%** on $3.28B in revenue, and two are under 65%. Several ran **14–17% surpluses**. [^1]
- LAO: clinics report spending **an average of about 80%** of revenue on health care services, though it varies by clinic. [^2]
- The sponsor is a union that tried the same rule as a bill (AB 1113), which **died in committee** (filed away Feb 2, 2026). [^3][^4] Clinics allege in federal court that it **offered to drop Prop 44 for union membership**. The union calls that "categorically false." [^3]
- The same union is behind Prop 40 [^3], and its dialysis measures failed three times (43%, 37%, 32% yes in 2018, 2020, 2022). [^5]

## Track record
**Clinics funding the No side (2024 filings)**
| Clinic | Share of revenue on program services | Notes |
|---|---|---|
| AltaMed | 83.9% | $1.72B revenue; CEO $1.95M; gave $6.1M to No |
| WellSpace Health | 77.9% | 16.6% surplus |
| TrueCare | 73.8% | CEO pay in the $667K–$730K range |
| North East Medical Services | 73.5% | CEO $1.95M (over $1M of it deferred/retirement) |
| Neighborhood Healthcare | 72.0% | 14.4% surplus |
| Innercare | 64.7% | 29.8% on management and fundraising |
| Family Health Centers of San Diego | 64.5% | 16.3% surplus |
Single-year numbers can include one-time items like capital grants, and the Attorney General would decide what counts. [^1][^2]

## What it does
- Private nonprofit safety net clinics must spend at least 90% of revenue on health care services, with other costs like administration capped at 10%. California has about 2,000 safety net clinics in all. [^2]
- A shortfall is paid as a penalty. It's refunded if the clinic complies within 5 years; otherwise it goes to clinic workforce programs. Waivers are possible. [^2]
- State enforcement costs run in the low tens of millions a year, paid by clinic fees. [^2]

## Money and conflicts
- **Yes $16.9M, all from SEIU-UHW. No $38.6M**, led by AltaMed ($6.1M) and the clinic association. [^6][^1]
- Both sides have a stake. The clinics are fighting a rule they'd fail. The union represents health workers and has sponsored initiatives aimed at health care employers before (the dialysis measures).
- The clinic association's claim that "nearly half of clinics could close" (with $1.7B in first-year penalties) comes from a study it paid for. [^3]

## Does it solve a lasting problem?
- It targets a real issue (executive pay, surpluses, overhead) with a blunt rule. It's unclear exactly which costs would count as health care services; the Attorney General would define that. [^2] A disclosure-and-audit approach could address pay without risking clinic cuts.

## If you vote yes: accountability
**Bottom line:** The Attorney General would define what counts as "health care services," and that definition decides which clinics pass. [^2] The clinics fighting the measure combined spend 77.4% of revenue on care, so watch whether they cut overhead or care. [^1]

### Who's accountable
- **The Attorney General** writes the definitions. That race (Bonta vs. Gates) is on this ballot.
- **The state** checks compliance using the financial reports clinics already file with the federal government, and collects fees from clinics to cover enforcement. The measure doesn't name a department. [^2]
- **Clinic boards.** Most are private nonprofits, so they aren't covered by the Public Records Act, but their federal tax returns (Form 990s) are public.

### What to watch
- Waivers: the measure allows temporary waivers, but doesn't say who grants them or on what grounds. [^2]
- Whether clinics close or cut services, as the clinic association predicts (in a study it paid for), or whether executive pay and surpluses shrink. [^3]

### Who to press, and what to ask for
- **Attorney General candidates:** will the definitions of "health care services" be written in public, with draft rules and comment periods?
- **Your local clinic's board:** ask for its ratio of care spending to revenue, and its executive pay, both reported on its Form 990.

### Records to look up
Anyone can file a California Public Records Act request (the state's version of FOIA), with no reason required. Agencies must respond within 10 days, or 24 in unusual cases. [^7] For private clinics, use public Form 990s instead, which you can search on ProPublica's Nonprofit Explorer. [^8]

> **To the Attorney General's office (after passage):** Under the California Public Records Act (Gov. Code § 7920.000 et seq.), I request all draft definitions, public comments, and communications with clinic operators or SEIU-UHW about defining health care services under Proposition 44.

## Both sides
- **For:** SEIU-UHW. It would put more money into patient care and less into executives, which matters more as federal cuts hit.
- **Against:** the clinic association, CMA, Planned Parenthood [^6], the Hospital Association, the Democratic, Republican and Working Families parties, and the editorial boards of the Sacramento Bee, SF Chronicle, OC Register and SD Union-Tribune. They say it would cut services or close clinics. [^3]
- Poll: about 1 in 3 support it (PPIC, Sept 2026). [^3]

## Official voter guide (condensed) with annotations
- Official title: Requires Community Health Clinics Spend 90% of Revenue on Program Services. Initiative Statute.
- Summary: Penalizes nonprofit community clinics serving underserved areas that spend less than 90% of revenue on "program services."
- Fiscal impact: State costs in the low tens of millions of dollars a year, covered by fees.
- A YES vote means: Certain private nonprofit health care clinics would have to spend at least 90 percent of their yearly revenue on health care services.
- A NO vote means: The new requirement on health care clinic spending would not go into effect.
- Argument for: Holds clinics and executives accountable by putting 90% of revenue into patient care, increasing transparency and reducing executive spending.
- Argument against: Would "shut down hundreds of community health clinics" and cut vital services for millions.
- Supporters: SEIU-United Healthcare Workers West (no supporters submitted a statement)
- Opponents: American Academy of Pediatrics CA, CA School Nurses Organization, CA Academy of Family Physicians, CA Medical Association

Annotations (what the booklet leaves out):
- (general) Same sponsor as Prop 40. SEIU-UHW pushed a near-identical bill in 2025 that died in committee. Opposed by the Democratic, Republican and Working Families parties alike. [^3]
- (con) "Hundreds of clinics" comes from a study the clinic association commissioned, not an independent one. The Legislative Analyst says effects are uncertain. Clinics average about 80% today. [^2][^3]
- (general) Clinics sued the union in federal court in Sept 2026, alleging it offered to drop Prop 44 in exchange for union access or dropping opposition to Prop 40. The union denies it. Unresolved allegation, not a finding. [^3]

## Sources
[^1]: California Today, Prop 44 guide with Form 990 data. https://californiatoday.com/guides/elections/california-proposition-44-2026/
[^2]: LAO, Prop 44 analysis. https://lao.ca.gov/ballot/2026/prop44-110326.pdf
[^3]: CalMatters, union and Prop 44 (Oct 7, 2026). https://calmatters.org/health/2026/10/union-billionaire-prop-44-clinic/
[^4]: Digital Democracy, AB 1113 status. https://calmatters.digitaldemocracy.org/bills/ca_202520260ab1113
[^5]: SoS Statement of Vote, 2018 Prop 8. https://elections.cdn.sos.ca.gov/sov/2018-general/ssov/ballot-measures-summary.pdf
[^6]: Official Voter Guide, Prop 44 arguments. https://vig.cdn.sos.ca.gov/2026/general/pdf/prop44.pdf
[^7]: First Amendment Coalition, CPRA deadlines. https://firstamendmentcoalition.org/resources/explainers/explainer-cpra-delays
[^8]: ProPublica Nonprofit Explorer (Form 990 search). https://projects.propublica.org/nonprofits/
[^9]: CalMatters guide, Prop 44. https://calmatters.org/california-voter-guide-2026/proposition-44-clinic-funding/
[^10]: SoS, Prop 44 contribution totals (through Oct 22, 2026). https://www.sos.ca.gov/campaign-lobbying/helpful-resources/measure-contributions/2026-ballot-measure-contribution-totals/proposition-44-requires-community-health-clinics-spend-90-percent-revenue-program-services-initiative-statute
[^11]: SoS Statement of Vote, 2020 Prop 23. https://elections.cdn.sos.ca.gov/sov/2020-general/sov/official-dec-vote-results-bm.pdf
[^12]: SoS Statement of Vote, 2022 Prop 29. https://elections.cdn.sos.ca.gov/sov/2022-general/sov/declaration.pdf
[^13]: Wikipedia, SEIU-UHW history (secondary). https://en.wikipedia.org/wiki/SEIU_United_Healthcare_Workers_West