California ballot measure · November 3, 2026

California Proposition 44, explained

Spending requirement for community health clinics. A ballot measure is a yes-or-no question put directly to voters — no candidate is involved, and the wording on the ballot is the wording that becomes law. This page shows that wording first, then what it actually changes.

The official wording

REQUIRES COMMUNITY HEALTH CLINICS SPEND 90% OF REVENUE ON PROGRAM SERVICES. INITIATIVE STATUTE. 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.

This is what appears on the ballot. Everything below explains it.

What it actually means

Requires private nonprofit Federally Qualified Health Centers, the community clinics that serve mostly low-income and uninsured patients, to spend at least 90% of their revenue each year on health care and related program services. Clinics that fall short would pay a penalty equal to the shortfall, refundable if they comply within five years.

If you vote YES

Affected clinics would have to spend at least 90% of total revenue on program services, limiting administrative and other costs to 10%; these clinics currently report spending about 80% on average.
The Attorney General would issue guidance on which expenses count, starting from clinics' existing federal reports; the Department of Public Health could grant temporary waivers in exceptional circumstances.
A clinic below 90% would pay the state the amount needed to reach it, refunded if it complies within five years; unrefunded penalties would go to clinic workforce programs.
False reports or artificially inflating the spending ratio could bring criminal charges.
State enforcement would cost low tens of millions of dollars a year, paid by fees on affected clinics.

If you vote NO

Nonprofit community clinics would continue to operate under existing federal and state rules, including annual reporting of revenue and expenses, with no minimum share of revenue required for program services.
No new state enforcement program or fees on clinics would be created.

The numbers that matter

State enforcement cost: Low tens of millions of dollars a year, covered by clinic fees
Current average spending on health care services: About 80% of revenue
Safety net clinics in California: About 2,000, mostly private nonprofits

Why supporters say YES

Clinics receive billions in public money, yet some spend less than half on patient care while money goes to executive pay and overhead; the rule directs dollars to care and requires public reporting.
— Official argument in favor, signed by initiative proponent Shawna Brown and community clinic worker Brisa J. Barrera (measure sponsored by SEIU-United Healthcare Workers West)
Transportation, interpretation, care coordination, outreach, clinical staff, equipment and IT can count toward the 90%; what is limited is excessive CEO pay, events, consultants and unnecessary administration.
— Official rebuttal, signed by Shawna Brown and Brisa J. Barrera

Why opponents say NO

The requirement would cut $1.7 billion from clinics in the first year, leave 88% operating at a loss and force clinics to reduce services or close, sending more patients to emergency rooms.
— Official argument against, signed by the American Academy of Pediatrics California, the California School Nurses Organization and the California Medical Association
Community clinics are already strictly regulated and audited with patient board members; the measure is a pressure tactic by one union that has funded many ballot measures against health care providers.
— Official rebuttal to the argument in favor, signed by the California Academy of Family Physicians, the American College of Obstetricians and Gynecologists District IX and the American College of Emergency Physicians California

What’s genuinely uncertain

The practical effect depends on how the Attorney General defines qualifying expenses, which is not settled by the measure itself.
The $1.7 billion and 88% figures are from studies cited by opponents, not the Legislative Analyst. The Analyst says some clinics might close and others might spend more on direct care, raising Medi-Cal costs, with uncertain effects.
The California Primary Care Association and Open Door Community Health Centers filed a federal lawsuit on April 30, 2026 arguing the measure conflicts with federal rules for these clinics; Ballotpedia lists no ruling, and the measure remains on the ballot.
The voter guide's summary lists no supporters, though an official argument in favor was submitted by the proponents.

The bottom line

More of clinics' revenue directed to program services with enforceable penalties, against the risk that clinics which cannot meet a fixed 90% threshold cut services or close.

One neutral sentence describing the tradeoff — not a recommendation.

Sources:vig.cdn.sos.ca.gov ballotpedia.org

Checking it against the official text

The California Secretary of State publishes the certified measures and, in most states, an official voter guide with fiscal notes. That is the authoritative version. Everything here is an explanation of it, not a substitute for it.

Confirm this with the official source

Your ballot is determined by your election authority, not by us. Verify your registration, precinct, and sample ballot at California Secretary of State.

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