Hillary Clinton Hillary Diane Rodham ClintonWhat Senate Republicans have said about election-year Supreme Court vacancies Bipartisan praise pours in after Ginsburg's death Trump carries on with rally, unaware of Ginsburg's death MORE is under mounting pressure from supporters of Sen. Bernie Sanders Bernie SandersKenosha will be a good bellwether in 2020 Biden's fiscal program: What is the likely market impact? McConnell accuses Democrats of sowing division by 'downplaying progress' on election security MORE (I-Vt.) to back California’s ballot measure aimed at reducing steep drug prices ahead of the state’s primary on Tuesday.

The first-in-the-nation ballot measure would allow California’s health agencies to negotiate directly with drug companies to lower drug costs.

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Sanders and his supporters are now pressing Clinton to put teeth behind her oft-repeated campaign promise to crack down on price-gouging by “big pharma.”

“There’s no reason – other than the greed of the prescription drug companies – to not support this ballot initiative,” Warren Gunnels, senior policy advisor for Sanders’ campaign, said in an interview with The Hill on Friday.

“It’s very important, it could lower drug prices in California and it could lead to lower prices everywhere,” he said.

Only about 5 million people would be affected if the provision became law: those with Medicaid plans and those enrolled in the state’s HIV/AIDS drug assistance program.

But the initiative has become the focus of a powerful opposition campaign by groups like the Pharmaceutical Research and Manufacturers of America (PhRMA) and the Biotechnology Industry Organization (BIO). Those in opposition are expected to spend as much as $100 million to stamp down the initiative.

Sanders and other supporters say it could become ground zero for a national fight to empower Medicare to negotiate drug prices – an idea touted by both Clinton and Sanders to save billions annually.

Garry South, who leads the group pushing the ballot measure, said it’s crucial for Clinton to throw her weight behind the ballot measure as it is the only one focused on drug pricing on any state ballot this fall.

“It will look pretty odd if the Democratic nominee for president, who’s been making a major push for drug pricing, is basically standing down [on this],” South said in an interview.

He pointed to Clinton’s numerous town halls, speeches and panel discussions on drug pricing and said California’s ballot measure is a chance to show what can actually have an effect.

“She is going to be the Democratic nominee and she has plenty of time to come out on this,” South added.

Clinton has so far avoided weighing in on the initiative, and her campaign did not return requests for comment. South said he has regularly updated Clinton’s campaign about the initiative, including two new endorsements inked in the last week from state branches of the AARP and the Urban League.

It's also received support from bold-faced Democratic names like Rev. Al Sharpton and vocal Clinton supporters like Rep. Mike Honda (D-Calif.).

Even before Sanders’ endorsement of the provision last month, the idea was buzzing nationally. Opposition groups, led by drug giants, spent $58 million in the first few months alone, making it one of the costliest ballot fights in any state in 2016. Costs are expected to rise to almost $100 million by the date of the election.

Those groups have been up against the AIDS Healthcare Foundation, which says it has spent a few million dollars to get the initiative on the ballot this year.

Other states are also almost certain to test the idea if it’s approved in California, given the growing costs of drugs and the scrutiny on companies that make them.

Under the ballot initiative, California would be required to pay the same drug prices as those paid by the U.S. Department of Veterans Affairs. That agency is believed to pay some of the lowest prices nationally for drugs because it’s allowed to directly negotiate with manufacturers – making it an appealing model for drug cost-control advocates.

A 2005 report from the nonpartisan Congressional Budget Office found that the VA pays an average of 42 percent of a brand name drug’s sticker price – compares to 51 percent paid by state Medicaid programs.

From the beginning, drug companies have been working to defeat the provision. A spokeswoman for PhRMA recently warned that it would “reduce the number of drug choices available” while costing millions in “state bureaucracy and lawsuits.”

A handful of health advocacy groups, including HIV groups, have also been on the fence because of what they describe as confusing bill language and difficult-to-enforce provisions.

The California Medical Association, which is a branch of the powerful National Medication Association, is also opposing what they call a “deeply flawed and unworkable” proposal, according to a statement from the group’s president, Dr. Steven Larson, last month.

Larson warned that it could create a new “prior approval process” for patients with state insurance and that it would wipe out existing agreements between the state and drug companies that he said are already helping to lower costs.

Similar opposition campaigns have taken root in states like Ohio, where supporters say they’ve been kept off the ballot, in part, because of the drug and business lobbies’ strong stance.

In Ohio, a group that includes PhRMA and the Ohio Chamber of Commerce filed a lawsuit in February with Ohio’s Supreme Court to block the provision.

Pharmaceutical groups have also played a role in opposing bills in Congress from lawmakers like Sanders to allow federal health agencies, like Medicare, to negotiate drug prices.

Gunnels, the policy advisor for Sanders’ campaign, said California’s bill could help shake up a years-old “David and Goliath” fight in Congress.

“While Congress has not been able to stand up to the greed of the prescription drug industry, Californians can by supporting this ballot initiative,” Gunnels said.