Question Profile: Question One

Aidan Chappuis, Journalist

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Question 1 concerns nurse-to-patient staffing ratios in hospitals. It would usually require one nurse for every 4 patients at all times, with higher ratios for sicker patients, and would fine hospitals up to $25,000 for violations.


The measure’s main backer is the Committee to Ensure Safe Patient Care, backed by the Massachusetts Nurses Association, the largest nursing union in the state. They argue that higher staffing is necessary to improve patient safety. It is opposed by the Coalition to Protect Patient Safety, which argues that the law is too rigid and too costly. The coalition is backed by multiple hospital associations and smaller nurse and nurse leader unions.


The MNA points to multiple studies showing that higher nurse staffing ratios are associated with better outcomes for patients, including fewer complications, deaths, and readmissions. Opponents claim that the studies did not look at government mandates for staffing ratios; it only compared hospitals already choosing higher ones with those choosing lower ones.


Opponents also claim that the law lacks flexibility, which could force smaller hospitals to turn away patients if there was a sudden surge in patients needing care. They give the example of a large fire or multi-car pile-up overloading a smaller hospital. Theoretically, a hospital could be penalized if too many patients were ever assigned to a nurse, even if having that many patients could not be predicted. They also assert that the law would increase wait time in the emergency room. Backers counter that the law does not automatically penalize hospitals. Furthermore, the Health Policy Commission, charged with writing regulations and enforcing the law, will first try to remedy violations and has discretion if there is a good reason for the violation. They point out that even if the attorney general goes to court to seek penalties, a judge can set them anywhere from $0 to $25,000. They also claim that higher staffing decreases wait times, and federal law prohibits turning patients away from the emergency room for any reason short of an internal emergency.


Proponents point to California, which enacted a similar law, claiming that it improved outcomes. Opponents note that the proposed law here is much stricter, has no exceptions for small rural hospitals, and doubt whether things improved in California after it was passed.


Hospitals argue that the cost of hiring new nurses and paying any possible penalties will be a major burden, especially for smaller community hospitals. They claim that they may be forced to close many money-losing services, especially psychiatric beds. Backers claim that they can afford it, pointing to the profits made by many large hospitals and networks, but do not fully address the issue for small hospitals. They also allege that any claims of a nursing shortage are untrue, since Massachusetts has many qualified nurses looking for work. According to them, hospitals do not want to hire and train younger nurses.


While backers claim that the law would be inexpensive, costing only about $47 million a year, hospitals claim it would cost more than a billion. The neutral Health Policy Commission, a state agency, recently released an estimate of $900 million, close to the hospitals’ estimate. The Committee to Ensure Safe Patient Care has claimed that the commission is biased, pointing to secretive meetings with the Massachusetts Health & Hospital Association, which opposes the measure, and noting that it is highly unusual for the commission to review proposed legislation or ballot questions.


Both sides claim to be backed by nurses, with the MNA claiming 86% support the measure, according to a poll they ran in April. Opponents claim the poll is biased, since it only asked about patient limits generally, and overrepresents union members. They also point out that only 25% of nurses are MNA members, and many smaller unions oppose the measure. Proponents point out that many of those unions represent nurse executives, and most nurses still seem to support the measure.