California Proposition 46, Medical Malpractice Lawsuits Cap and Drug Testing of Doctors (2014)

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Proposition 46
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Type:Initiative
Topic:Healthcare
Status:On the ballot
2014 propositions
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June 3
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Local measures

California Proposition 46, the Medical Malpractice Lawsuits Cap and Drug Testing of Doctors Initiative, is on the November 4, 2014, ballot in California as an initiated state statute.

If approved by voters, the initiative will:[1]

  • Increase the state's cap on damages that can be assessed in medical negligence lawsuits to over $1 million from the current cap of $250,000.
  • Require drug and alcohol testing of doctors and reporting of positive tests to the California Medical Board.
  • Require the California Medical Board to suspend doctors pending investigation of positive tests and take disciplinary action if the doctor was found impaired while on duty.
  • Require health care practitioners to report any doctor suspected of drug or alcohol impairment or medical negligence.
  • Require health care practitioners to consult the state prescription drug history database before prescribing certain controlled substances.

Supporters of the initiative refer to it as the Troy and Alana Pack Patient Safety Act of 2014, after two children who were killed by a driver under the influence of abused prescription drugs.[2]

The measure, if approved, would create the first law in the United States to require the random drug testing of physicians.[3]

Supporters of Proposition 46 argue that medical negligence is too common and pain and suffering damage awards are too low. Opponents say the initiative isn’t about protecting patients, but increasing medical lawsuit payouts to trial lawyers.

Text of measure

See also: Ballot titles, summaries and fiscal statements for California's 2014 ballot propositions

Ballot title:[4]

Drug and Alcohol Testing of Doctors. Medical Negligence Lawsuits. Initiative Statute.

Official summary:

The long-form summary reads:[4]

  • Requires drug and alcohol testing of doctors and reporting of positive test to the California Medical Board.
  • Requires Board to suspend doctor pending investigation of positive test and take disciplinary action if doctor was impaired while on duty.
  • Requires doctors to report any other doctor suspected of drug or alcohol impairment or medical negligence.
  • Requires health care practitioners to consult state prescription drug history database before prescribing certain controlled substances.
  • Increases $250,000 cap on pain and suffering damages in medical negligence lawsuits to account for inflation.[5]

Fiscal impact statement:[4]

(Note: The fiscal impact statement for a California ballot initiative authorized for circulation is jointly prepared by the state's Legislative Analyst and its Director of Finance.)

  • Increased state and local government health care costs from raising the cap on medical malpractice damages, likely ranging from the tens of millions of dollars to several hundred million dollars annually.
  • Uncertain, but potentially significant, state and local government savings from new requirements on health care providers, such as provisions related to prescription drug monitoring and alcohol and drug testing of physicians. These savings would offset to some extent the health care costs noted above.[5]

Controversy

The San Diego Union-Tribune argued that the first sentence of the ballot title - "Drug and alcohol testing of doctors." - was intentionally placed first by Attorney General Kamala Harris (D). The editorial board continued, "That’s right — Attorney General Kamala Harris intentionally deceived ballot signers by highlighting one of the fig leaves that trial lawyers attached to the measure to hide their real intent. It’s in keeping with her long history of using misleading ballot titles and summaries to help measures her allies like and hurt measures they don’t."[6]

Background

MICRA

The Medical Injury Compensation Reform Act (MICRA) was signed in 1975 by Gov. Jerry Brown (D). MICRA capped noneconomic pain and suffering damages, as a result of medical malpractice, at $250,000. He did so in response to doctors who complained about medical malpractice awards being too high. If MICRA was pegged to inflation, the noneconomic cap would now be set at $1.1 million. The 2014 noneconomic cap of $250,000 would have been $57,600 in 1975.[2] Under MICRA, there is no cap on economic damages, such as compensation for medical bills or lost wages.[7]

Support

California Yes on 46 2014.png

The organization leading the campaign in support of the measure is known as Yes on 46.[8]

Political consultant Chris Lehane was hired to advise supporters.[1] He served as a special assistant counsel to President Bill Clinton (D).[9]

Supporters

Officials

Organizations

Individuals

  • Candace Lightner, founder of Mothers Against Drunk Driving[15]
  • Erin Brockovich, consumer advocate[16]

Arguments


Consumer Watchdog's video with Bob Pack explaining the initiative.

Yes on 46 made the following arguments in an FAQ:

Will indexing the cap raise health care costs on patients?
  • Medical malpractice costs (payments and insurance) represent only a very small fraction of health care costs. In fact, California’s medical malpractice cap has not reduced health care costs; indexing the cap will not raise costs because malpractice-related costs are such an infinitesimally small portion of health care costs. The CBO has found that the package of limitations on liability advocated by the AMA cannot possibly reduce healthcare costs by more than ½ of 1%. In contrast, the Affordable Care Act contains several reforms that are already reducing healthcare costs by more than that amount: Accountable Care Organizations, Patient-Centered Medical Homes, pay for performance initiatives, and bundled payments.

Will medical malpractice insurance rates skyrocket if the cap is raised, resulting in doctors fleeing California and a reduction in access to care?

  • This is simply false; medical malpractice insurers in California have consistently had such high profits that they would continue to make above-average profits even if the MICRA cap were indexed to inflation. The insurance industry earned a 6.5% return on net worth during the last ten years. California medical malpractice insurers, however, earned a 16.7% return – more than 250% of the industry average. Moreover, in each of the last eight years California malpractice insurers had loss ratios of 38% or less – meaning that they always had at least 62 cents of each premium dollar, plus all investment income, left over for expenses and profit.
  • Proposition 103 gave the California State Insurance Commissioner the power to regulate many types of insurance rates, including medical malpractice insurance. Indeed, in 2012, the Insurance Commissioner found that California’s medical malpractice insurers were charging doctors too much in premiums and he slashed their rates, saving California’s doctors over $52 million in premiums. California already has an effective and successful system to regulate medical malpractice insurance premiums – a system that won’t change because of an adjustment of the cap.

Will raising the cap lead to the closure of community health centers?

  • Indexing the cap for inflation will NOT increase the malpractice insurance costs of community health centers because health centers and free clinics are both protected by the Federal Tort Claims Act. Under the FTCA, individuals injured by the negligent acts of federal employees may seek and receive compensation from the federal government. Health centers and free clinics are therefore no longer liable for medical malpractice, and have no need to buy medical malpractice insurance.

Isn’t it true that the Pack Act isn’t about patient safety, but profits for attorneys?

  • A Harvard University study found that medical malpractice causes 300,000 injuries annually in hospitals alone. The deterrent effect of patient protection laws can save the health care system from these human and financial losses.
  • Medical malpractice litigation deters physicians and hospitals from committing medical errors and encourages them to gather and analyze information about past errors, thereby reducing the future costs associated with such errors. Without strong financial repercussions for malpractice, there is no incentive for doctors and hospitals to fix bad behavior.
  • MICRA’s original strict attorneys fee structure is left entirely in place by the Pack Act.

Isn’t it true that, since current law allows unlimited economic damages, there’s no need for a higher cap on non-economic “pain and suffering” damages?

  • Economic damages are limited to wage loss and future medical bills. In cases where the victim doesn’t have wages (children, the disabled, the elderly, stay-at-home moms) or where the victim dies (and therefore there are no future medical bills to pay), there are zero economic damages. This means that the most vulnerable among us can recover at most $250,000, while those with higher incomes have other avenues for financial redress.

[5]

Yes on 46[17]

Consumer Watchdog issued a flyer following their signature submission on March 24, 2014. The flyer made the following arguments:[18]

  • "According to a study published in the Journal of Patient Safety, medical negligence is the third leading cause of death in the country behind only heart disease and cancer. As many as 440,000 people die each year from preventable medical negligence. That’s like a 747 crashing every 10 hours."
  • "The California Medical Board estimates that almost one-in-five doctors (18%) suffer from drug and/or alcohol abuse at some point during their careers – and leading medical safety experts have called for random drug testing to curb substance abuse and ensure patient safety."
  • "The Journal of the American Medical Association found that doctors are the biggest suppliers for chronic prescription drug abusers, and called for the mandatory usage of state prescription drug databases... A 2012 Los Angeles Times investigation found that drugs prescribed by doctors caused or contributed to nearly half of recent prescription overdose deaths in Southern California."

Donors

Total campaign cash Campaign Finance Ballotpedia.png
as of September 8, 2014
Category:Ballot measure endorsements Support: $7,836,660
Circle thumbs down.png Opposition: $56,394,852

Four ballot measure campaign committees are registered in support of the initiative as of September 8, 2014:[19]

Note: Consumer Watchdog Campaign - Yes on 45 and 46, A Coalition of Consumer Advocates, Attorneys and Nurses is supporting Proposition 46 and Proposition 45.
Committee Amount raised Amount spent
Consumer Watchdog Campaign - Yes on 45 and 46, A Coalition of Consumer Advocates, Attorneys and Nurses $2,362,407 $1,996,183
Consumer Watchdog Campaign - Yes on 46 $75,000 $0
Families for Patient Safety $0 $725
Yes on Prop. 46, Your Neighbors for Patient Safety $5,399,253 $1,479,698
Total $7,836,660 $3,476,606
Note: Of the $5,399,253 raised by Yes on Prop. 46, Your Neighbors for Patient Safety, $75,000 or 1.4 percent is held as unpaid or unforgiven loans.

The following are the donors who contributed $50,000 or more to the campaign supporting the initiative as of June 30, 2014:[19]

Note: Some of these donors gave their money to a committee that was simultaneously supporting more than one ballot measure. When that is the case, it is not generally possible to break down how much of that donor's money specifically was spent on the campaign for a particular proposition. Those contributions are listed below with shading; readers should not assume that all or even most of a donation to a multi-purpose committee was used for expenditures related to this particular proposition.
Donor Amount
Consumer Attorneys Issue PAC $1,108,000
Consumer Watchdog $267,148
Greene Broillet & Wheeler, LLP $125,000
Casey, Gerry, Schenk, Francavilla, Blatt & Penfield, LLP $100,000.00
Bruce G. Fagel, A Law Corporation $85,000.00
Bisnar/Chase Personal Injury Attorneys, LLP $75,000.00
Christopher B. Dolan $75,000.00
CA Nurses Association Initiative PAC $50,000
Shernoff, Bidart, Echeverria, Bentley, LLP $50,000
Robinson Calcagnie Robinson Shapiro Davis, Inc. $50,000
Wylie Aitken, a Law Corporation $50,000
Cotchett, Pitre & McCarthy, LLP $50,000
Don A. Ernst $50,000
Gillin Jacobson Ellis & Larsen $50,000
Law Offices of Walkup, Melodia, Kelly & Schoenberger $50,000
Waters & Kraus, LLP $50,000

Campaign advertisements

See also: California Proposition 46 (2014) campaign advertisements

All campaign advertisements for campaigns in favor of the measure can be found here.

Consumer Watchdog issued the following video advertisement series titled, "Pee in a Cup, The Musical."[20]


Consumer Watchdog's "Pee in a Cup, The Musical" (Part 1).

Consumer Watchdog's "Pee in a Cup, The Musical" (Part 2).

Consumer Watchdog's "Pee in a Cup, The Musical" (Part 3).

Opposition

California No On 46 2014 update.png

No on 46 is leading the campaign in opposition to the initiative.[21]

Democratic political consultant Gale Kaufman was hired by a coalition of insurers, hospitals and doctors to oppose the measure.[1] Kaufman served as the primary consultant for No on Proposition 6 and 9 in 2008.[22]

Opponents

See also: A full list of opponents

Organizations

The following are health and healthcare-related organizations opposing the initiative:[23]

  • California Republican Party[24]
  • California Hospital Association[25]
  • California Dental Association
  • California Medical Association
  • American College of Emergency Physicians, California Chapter
  • American Congress of Obstetricians & Gynecologists
  • Medical Oncology Association of Southern California
  • California Academy of Eye Physicians and Surgeons
  • California Ambulance Association
  • California Association of Health Facilities
  • California Academy of Physician Assistants
  • California Ambulatory Surgery Association
  • American Nurses Association, California
  • California Assisted Living Association
  • California Academy of Cosmetic Surgery
  • California Rheumatology Alliance
  • California Society of Periodontists
  • California Dialysis Council
  • Association of Orthopedic Technologists of California
  • Association of California Healthcare Districts
  • California Association of Marriage and Family Therapists
  • California Association of Oral and Maxillofacial Surgeons
  • California Association for Health Services at Home
  • California Association of Psychiatric Mental Health Nurses in Advanced Practice
  • California Nurse-Midwives Association
  • California Society of Plastic Surgeons
  • California Orthotic & Prosthetic Association
  • California Podiatric Medical Association
  • California Psychiatric Association
  • California Society of Addiction Medicine
  • California Society of Pathologists
  • California Society of Pediatric Dentistry
  • California State Oriental Medical Association
  • California Clinical Laboratory Association
  • NORCAP
  • American Osteopathic Association
  • Operating Room Nursing Council of California
  • Osteopathic Physicians & Surgeons of California
  • Partnership HealthPlan of California
  • California Family Health Council
  • California Association of Physician Groups
  • Infectious Disease Association of California
  • California Orthopaedic Association
  • California Pharmacists Association
  • California Society of Anesthesiologists
  • California Chapter of the American College of Cardiology
  • California Neurology Society
  • California Academy of Family Physicians
  • California Association for Nurse Practitioners
  • California Academy of Preventive Medicine
  • California Society of Health-System Pharmacists
  • Northern CA Chapter of the American College of Surgeons
  • American College of Surgeons-Southern CA Chapter
  • San Diego Chapter of the American College of Surgeons
  • California Association of Nurse Anesthetists
  • California Urological Association
  • California Radiological Society
  • California Thoracic Society
  • California Society of Dermatology & Dermatologic Surgery
  • Society of OB/GYN Hospitalists (SOGH)
  • American Academy of Orthopaedic Surgeons
  • CA Association of Neurological Surgeons
  • CA Association of Oral and Maxillofacial Surgeons
  • California Optometric Association
  • California Otolaryngology Society
  • California Society of Anesthesiologists
  • California Orthotic & Prosthetic Association
  • Association of Northern California Oncologists
  • Hemophilia Council of California
  • American College of Physicians California Services
  • Chinese Community Health Care Association
  • CA Chiropractic Association
  • Southern California HMO Podiatric Medical Society
  • American Academy of Pediatrics, California
  • National Association of Social Workers–CA
  • Children’s Specialty Care Coalition
  • California Children’s Hospital Association
  • Children’s Physicians Medical Group
  • A New PATH (Parents for Addiction Treatment & Healing)

The following are other organizations opposing the initiative:[23]

Unions

  • California State Building & Construction Trades Council[28]
  • Service Employees International Union (SEIU) California[23]
  • SEIU United Long Term Care Workers (ULTCW)
  • SEIU-USWW (United Security Workers West)
  • SEIU 1000
  • SEIU - Committee of Interns and Residents
  • AFSCME California PEOPLE
  • Union of American Physicians and Dentists (AFSCME Local 206)
  • IBEW Ninth District
  • IBEW Local 11
  • IBEW Local Union 441
  • IBEW Local Union 477
  • IBEW Local Union 551
  • Southern California Pipe Trades Health & Welfare Fund
  • Plumbers & Pipefitters Local Union 228
  • Plumbers & Steamfitters Local Union 398
  • Plumbers and Pipefitters UA Local Union 442
  • Plumbers & Pipefitters Local 447
  • Southern CA Pipe Trades DC 16
  • Plumbers, Pipe and Refrigeration Fitters UA Local 246
  • International Brotherhood of Boilermakers
  • Boilermakers Local 92
  • Boilermakers Local 1998
  • Sheet Metal, Air, Rail and Transportation Workers (SMART), Sheet Metal Workers’ Local Union No. 104
  • Sprinkler Fitters UA Local 483

Arguments


Vote No on 46's "The Truth About Proposition 46" video.

Vote No on 46 issued an abundance of critiques of Proposition 46 on their website. The following are their basic "Why Voters Should Oppose" arguments:

OPPOSE THE “MICRA” BALLOT MEASURE
A costly threat to your personal privacy Californians can’t afford.

Costly for Consumers

  • Trial lawyers drafted a November 2014 ballot measure seeking to change current law to file more medical lawsuits against health care providers.
  • If they get their way, medical lawsuits and payouts will skyrocket. Someone will have to pay those costs. And that someone…is you.

Threatens People’s Personal Privacy

  • Money isn’t the only thing this ballot measure will cost you. It could cost you your personal privacy, and the doctors you trust and depend on.
  • This measure forces doctors and pharmacists to use a massive statewide database filled with Californians’ personal medical prescription information. A mandate government will find impossible to implement, and a database with no increased security standards to protect your personal prescription information from hacking and theft – none.
  • And who controls the database? The government – in an age when government already has too many tools for violating your privacy.

Jeopardizes People’s Access to their Trusted Doctors

  • If California’s medical liability cap goes up, you could also lose your trusted doctor. It’s true. Many doctors will be forced to leave California to practice in states where medical liability insurance is more affordable.
  • Even respected community clinics, including Planned Parenthood, warn that specialists like OB-GYNs will have no choice but to reduce or eliminate vital services, especially for women and families in underserved areas.

Increased costs. Losing your doctor. Threatening your privacy.
Exactly what happens when trial lawyers play doctor.

  • That’s why a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, local leaders, public safety officials, businesses and working men and women urge Californians to oppose the “MICRA” ballot measure.

[5]

Stop Higher Health Care Costs - No On 46![30]

Other arguments against the initiative include:

  • Kimberly Stone, president of the Civil Justice Association of California, said, “If you’re a highly-paid doctor in Los Angeles or San Francisco, it would be OK. You could pass those costs on to your patients. But if you’re an anesthesiologist or an OBGYN in a rural area or a low-income area, a dramatic increase in your medical malpractice insurance premiums could make a big difference to your ability to practice.”[27]
  • Tom Scott, executive director of California Citizens Against Lawsuit Abuse, said, “Trial lawyers have one goal in mind with this initiative: they want to file more lawsuits against more doctors and make more money doing it. If this initiative passes, trial lawyers will profit wildly, and California consumers will be the ones left holding the bag. A recent study found that this initiative will increase health care costs by $9.9 billion annually – or more than $1,000/year in higher health costs for a family of four.”[31]
  • Dr. Richard Thorp, president of the California Medical Association, argued, "A ballot measure that is certain to generate more medical lawsuits and drive up costs for every health consumer in California is the worst possible idea at the worst possible time. This initiative is bad for patients, bad for taxpayers and bad for California’s entire system of healthcare delivery."[32]

Donors

Three ballot measure campaign committees are registered in opposition to the initiative as of August 26, 2014:[19]

Committee Amount raised Amount spent
California Association of Health Facilities, Defend MICRA on the November Ballot Committee $102,715 $50,050
No on 46 - Patients, Providers and Healthcare Insurers to Protect Access and Contain Health Costs $56,170,655 $3,044,767
Californians Allied for Patient Protection Ballot Measure Committee $121,482 $121,482
Total $56,394,852 $3,216,299
Note: Of the $56,170,655 raised by No on 46 - Patients, Providers and Healthcare Insurers to Protect Access and Contain Health Costs, $1,692,808 or 3 percent is held as unpaid or unforgiven loans.

The following were the donors who contributed $250,000 or more to the campaign opposing the initiative as of June 10, 2014:[19]

Donor Amount
California Medical Association Physicians' Issues Committee $5,064,542
Cooperative of American Physicians Independent Expenditure Committee $5,000,000
NorCal Mutual Insurance Company $5,000,000
The Doctors Company $5,000,000
Kaiser Foundation Health Plan, Inc. $3,000,000
California Hospitals Committee on Issues $2,500,000
Medical Insurance Exchange of California $2,500,000
California Dental Association $2,000,000
The Dentists Insurance Company $1,560,000

Campaign advertisements

See also: California Proposition 46 (2014) campaign advertisements

All campaign advertisements for campaigns in opposition of the measure can be found here.

No on 46 issued an advertisement video titled, "Risk."[33]


No on 46's "Risk."

No on 46's "Risk" in Spanish.

Media editorial positions

See also: Endorsements of California ballot measures, 2014

Other opinions

Should California amend its 1975 state law capping pain-and-suffering damages in medical malpractice lawsuits at $250,000? Perhaps. Nearly 40 years ago, a quarter-million dollars amounted to a huge sum. Nowadays, it isn’t particularly much to someone who has suffered from egregious incompetence or neglect in their health care... [The measure] should be seen as part of a larger Golden State legal culture in which trial lawyers use lawsuits and the threat of lawsuits for what amounts to legal extortion... It shouldn’t be rewarded with a yes vote in November. Instead, Californians should press for sweeping reform that addresses the malpractice cap — and many other problems with the state’s legal system as well.[5]

Polls

See also: Polls, 2014 ballot measures
  • The Field Poll conducted a survey related to ballot initiatives between June 26, 2014, and July 19, 2014. They found that about 58 percent of total registered voters supported Proposition 46. Democrats supported the proposal by 62 percent, while Republicans approved of it by 58 percent. Voters not affiliated with either party supported it by 52 percent.[35]
  • The Field Poll's August 14 through August 28, 2014, poll showed a sharp drop in support for Proposition 46. The only subgroup in which the proposition was supported by 50 percent or more was people between the ages of 18 and 39. The subgroup least likely to support the initiative was people with incomes over $100,000, with 24 percent support. People living in the San Francisco Bay Area were the second least likely subgroup to support Proposition 46, with 28 percent support.[36]
California Proposition 46 (2014)
Poll Support OpposeUndecidedMargin of ErrorSample Size
The Field Poll
6/26/2014 - 7/19/2014
58.0%30.0%12.0%+/-2.61,535
The Field Poll
8/14/2014 - 8/28/2014
34.0%37.0%29.0%+/-4.8467
AVERAGES 46% 33.5% 20.5% +/-3.7 1,001
Note: The polls above may not reflect all polls that have been conducted in this race. Those displayed are a random sampling chosen by Ballotpedia staff. If you would like to nominate another poll for inclusion in the table, send an email to editor@ballotpedia.org.


Path to the ballot

See also: Signature requirements for ballot measures in California

Cost of signature collection:

The cost of collecting the signatures to qualify the initiative for the ballot came to $1,692,673. That is equivalent to $3.35 per signature.

The signature vendor was Kimball Petition Management.

See also: California ballot initiative petition signature costs

See also

External links

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Basic information

Support

Opposition

Additional reading

References

  1. 1.0 1.1 1.2 Los Angeles Times, "Special interest groups look to shape 2014 California ballot," December 7, 2013
  2. 2.0 2.1 Washington Post, "The most expensive race of 2014 could be this California ballot measure," March 25, 2014
  3. PR Newswire, "California Ballot Initiative Will Enact Nation's First Law Requiring Random Drug Testing Of Physicians, says Consumer Watchdog Campaign," April 16, 2014
  4. 4.0 4.1 4.2 California Official Voter Information Guide for the November 4, 2014, General Election, "Proposition 46 Official Title and Summary," accessed September 16, 2014
  5. 5.0 5.1 5.2 5.3 5.4 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributed to the original source.
  6. San Diego Union-Tribune, "Malpractice ballot measure: Shame on AG Kamala Harris," March 29, 2014
  7. Los Angeles Times, "Voters may decide medical malpractice cap," February 18, 2014
  8. Yes on 46, "Homepage," accessed August 25, 2014
  9. Politico, "Arena Profile: Chris Lehane," accessed August 25, 2014
  10. Reuters, "California measure to raise malpractice cap gets high-profile backer," March 31, 2014
  11. Yes on 46, "Consumer Federation of California Endorses Proposition 46," July 14, 2014
  12. Yes on 46, "Congress of California Seniors Endorses Proposition 46 To Protect Patient Safety And Save Lives," July 10, 2014
  13. Twitter, "38 Is Too Late," July 1, 2014
  14. Yes on 46, "Teamsters, Transit Workers Back Prop 46 Campaign To Protect Patient Safety," July 29, 2014
  15. Yes on 46, "Candace Lightner, Founder of Mothers Against Drunk Driving, and President of WeSaveLives.org Endorses Proposition 46 To Protect Patient Safety, Require Random Drug and Alcohol Testing of Doctors," July 11, 2014
  16. Yes on 46, "Consumer Advocate Erin Brockovich Endorses Proposition 46 Campaign To Protect Patient Safety," July 21, 2014
  17. Yes on 46, "Frequently Asked Questions," accessed August 25, 2014
  18. Consumer Watchdog, "The Problem: Medical Negligence Kills 440,000 Americans Every Year," March 24, 2014
  19. 19.0 19.1 19.2 19.3 California Secretary of State, "Campaign Finance," accessed June 9, 2014
  20. The Troy and Alana Pack Patient Safety Act, "Homepage," accessed July 7, 2014
  21. No on 46, "Homepage," accessed July 3, 2014
  22. Kaufman Campaigns, "Gale R. Kaufman," accessed August 25, 2014
  23. 23.0 23.1 23.2 Stop Higher Health Care Costs, "Who We Are, accessed July 3, 2014
  24. California Republican Party, "Party Endorsements," accessed September 10, 2014
  25. 25.0 25.1 The Sacramento Bee, "Medical malpractice initiative qualifies for California ballot," May 15, 2014
  26. Washington Post, "California’s counties weigh in on a $64 million ballot fight," September 11, 2014
  27. 27.0 27.1 27.2 Legal Newsline Legal Journal, "Damage cap battle could be most expensive ballot initiative ever in Calif., observer says," January 31, 2014
  28. 28.0 28.1 Stop Higher Health Care Costs, "CA Building Trades & CA NAACP Latest Groups to Oppose MICRA Measure and Join Newly-Numbered “No On 46” Campaign," July 7, 2014
  29. California Medical Association, "Los Angeles County Democratic Party comes out in opposition to Prop. 46," August 22, 2014
  30. Vote No on 46, "Oppose the “MICRA” Ballot Measure," accessed July 7, 2014
  31. Legal Newsline, "Calif. advocacy groups decry ballot measure to increase med-mal cap," May 20, 2014
  32. Los Angeles Times, "Backers of malpractice cap ballot measure submit signatures," March 24, 2014
  33. The Troy and Alana Pack Patient Safety Act, "Homepage," accessed July 7, 2014
  34. San Diego Union-Tribune, "Malpractice ballot measure: State needs broader legal reform," March 26, 2014
  35. The Field Poll, "2014 TCWF-Field Health Policy Poll - Part 2," August 20, 2014
  36. The Field Poll, "Voter Support Diminishing for Two Health-Related Ballot Measures, Propositions 45 and 46," September 11, 2014
  37. Larkspur-CorteMadera Patch, "Would You Support California Measure Raising Damages in Medical Malpractice Lawsuits?," March 24, 2014
  38. California Secretary of State, "Qualified Statewide Ballot Measures," accessed May 16, 2014