Dozens of Reasons to Oppose Question 1 (And We Could Have Added More)

Hospital staffing should be decided at the bedside by nurses based on a patient’s condition, the experience and education of the nurses in the unit, the technology available at the hospital, and the availability of other care team members. Care is fluid and ever-changing and should not be determined by a rigid number arrived at through popular vote.

1. These nurses groups are voting NO on 1: Academy of Medical-Surgical Nurses – Greater Boston Chapter; American Nurses Association-Massachusetts; Emergency Nurses Association – Massachusetts State Council; Infusion Nurses Society; Massachusetts Association of Colleges of Nursing; Massachusetts Coalition of Nurse Practitioners; Organization of Nurse Leaders; Western Massachusetts Nursing Collaborative; and the national American Organization of Nurse Executives.

2. The MNA nursing union behind Question 1 represents less than 25% of the RNs in the state; the MNA does not speak for all nurses.

3. According to the most recent, scientifically sound poll from WBUR, nurses are split on Question 1 (48-45 with 4.4% margin of error). And in that poll, 85% of nurses said the best way to make rules on staffing ratios for nurses working in hospitals is NOT to put it on a ballot question decided by voters. 

4. The leading physician’s group – the Mass. Medical Society – is voting NO. So are all other leading professional physician associations, ranging from the American College of Cardiology (MA Chapter) to the Massachusetts Psychiatric Association to the Massachusetts Society of Neurosurgeons.

5. In fact, more than 100 healthcare groups in the state oppose Question 1, and that includes surgeons, pediatricians, behavioral health experts, ED doctors, community health centers, psychiatrists, senior care groups, VNA care, ambulance drivers, nursing homes, assisted living facilities, and every single hospital in the state. See the list of organizations voting NO on 1 here.

6. The commonwealth's business community opposes Question 1. Scores of Chambers of Commerce from around the state have signed on to oppose Question 1, as has Associated Industries of Massachusetts, Massachusetts Business Roundtable, and Massachusetts Taxpayers Foundation, among others. 

7. The editorial board of the Boston Globe and the Wall Street Journal are usually diametrically opposed politically, but both papers wrote strong No on 1 editorials, as did nearly every other newspaper in Massachusetts, including:   Springfield Republican; Southcoast Today; MetroWest Daily News; Milford Daily News; Bay State Banner; Boston Herald; Lowell Sun; Cape Cod Times; Falmouth Enterprise; Berkshire Eagle; Salem News; Lawrence Eagle Tribune; and Newburyport News. (Even the Harvard Crimson urged a No vote.)

8. Governor Baker is voting no, but so is the Democratic Mayor of New Bedford Jon Mitchell (along with many other pols on either side of the aisle).

9. If Question 1 passes, the state could lose 1,000 behavioral health beds, according to the Massachusetts Association of Behavioral Health Systems. Why? Because facilities currently can’t find enough nurses to staff available beds; they won’t be able to meet the mandate and will be forced to close beds. 

10. Question 1 would also worsen already serious behavioral health patient "boarding" in hospital emergency departments and force cuts to other services, including substance use disorder treatment and recovery programs, exacerbating the state's opioid crisis.

11. Facilities out of compliance with Question 1’s ratios could face fines of up to $25,000 per day, per incident. The only state with mandated ratios, California, does not impose fines on hospitals that are out of compliance. 
12. When will Question 1 go into effect? According to the proposed law, January 1, 2019. The Yes side says, don’t worry, it’ll be delayed if passed. When asked about the implementation date, the Health Policy Commission (which will implement the law) said: “The effective date is January 1, 2019.” This means thousands of registered nurses would have to be found in 37 business days or beds and services would have to be eliminated. 

13. How much will ratios cost the healthcare system? According to the state’s Health Policy Commission – which undertook its own independent analysis of the issue – up to $949 million a year, and that figure does not include the cost of implementing acuity systems, the costs to outpatient departments, the costs to non-acute hospitals, and the cost to emergency departments (EDs). Pressed to come up with an ED cost of Question 1, HPC staff said that could add an additional $110 million to the $949 million. That’s over $1 billion each and every year.

14. That cost was similar to MHA’s own initial analysis ($880 million) and to the $900-plus million estimate from a study conducted by Mass Insight Global Partnerships and BW Research Partnership. That is, three cost estimates – including one from the independent HPC – were pretty much in line with one another. 

15. If you add an annual billion dollar burden on the health system, will non-RNs lose their jobs as hospitals are forced to cut back? Yes, of course. The Yes on 1 side states, correctly, that it inserted language in Question 1 prohibiting other worker layoffs to help fund the needed additional RN hires -- but this protection wouldn’t kick in until January 1 and it’s not absolute. Hospitals faced with added costs from the mandate, and no way to fill RN positions because there are not enough nurses, will be forced to shutter units and programs, and jobs associated with those beds would be lost. 

16. The Massachusetts Association of Health Plans said of Question 1’s whopping price tag: “This increase in spending will likely result in increased premiums for employers and consumers, and based on these findings, will threaten our state’s ability to meet the health care cost growth benchmark.”

17. Non-hospital care settings, such as long-term care, behavioral health centers, home healthcare organizations, and community health centers will NOT be able to compete for nurses if Question 1 passes. These settings will likely face significant shortages and/or reduce access to services.

18. If there’s a terrible mass transit accident or some other tragedy that results in emergency departments being flooded with casualties, would ED ratios be lifted in such instances? No. Hospitals would be out of compliance if a surge of patients exceeds the four different ED ratios proposed in Question 1. The Massachusetts College of Emergency Physicians and the Emergency Nurse Association of Massachusetts both urge a NO vote on 1.

19. According to Question 1, ratios would be lifted only during a “state or nationally declared public health emergency.” There have only been four “public health” emergencies since the 1970s – the last declared by Gov. Patrick regarding the opioid crisis. “Public health” emergencies are hard to put in place, requiring a long regulatory process. The more common “states of emergency” invoked during blizzards, hurricanes, gas line explosions, etc. are not enough to waive the mandates in Question 1. Remember: “public health emergency” is different from “state of emergency.” Read the law.

20. Is imposing four different ratios for an ED even practical given the ever-changing acuity of a patient in the ED? Of course not.   

21. What is your personal opinion about how many patients a nurse should treat in a pediatric unit of a hospital? Are you comfortable setting that number for all pediatric patients and nurses in all hospitals at all times? If you answered, “I don’t know” and “No, of course I’m not going to tell a nurse how to care for children,” then vote NO on 1, which etches the pediatric ratio in stone. The American Academy of Pediatrics – Massachusetts Chapter opposes Question 1.

22. Why is this question even on the ballot and not the subject of legislative deliberations? Recently, at a Southcoast Health event, State Rep. Chris Markey (D-New Bedford) addressed that issue, saying, “There has been a bill up there [on Beacon Hill] for years each session regarding this. It hasn’t passed and there’s a reason why it hasn’t passed. Because after deliberation, which we do in the legislature, after thinking about the unintended consequences, we’ve come to a decision that this is not a good idea.”

23. Massachusetts hospitals undertook the first-in-the-nation voluntarily posting of staffing data on the PatientCareLink website. The public can see how each hospital staffs nearly every unit in the state by visiting the site.

24. According to the state’s Center for Health information and Analysis (CHIA), 19 of 62 hospitals that reported had negative operating margins in 2017, which means that roughly a third of the acute care hospitals in the state are operating in the red. For nearly 70% of acute care hospitals, the implementation costs of Question 1 exceed their operating margin. How do you destabilize hospital financials even more and drive some of them to closure? Impose an annual $1 billion mandate on them as Question 1 would do, without any benefit to patient care.

25. There are no published peer-reviewed studies that support the imposition of specific nurse-to-patient ratios. While some of the extensive studies link improved patient outcomes to improved RN staffing, none of the studies attribute the improvements to staffing alone or state that setting limits to the number of patients that nurses care for will automatically result in improved outcomes.  To the contrary, many of the studies point to the adverse, unintended consequences of imposing inflexible nurse-to-patient ratios.

26. There is NO EVIDENCE that the ratios in California led to improvements in patient care.  The Massachusetts Health Policy Commission, after its analysis of the evidence, concluded about California: “There was no systematic improvement in patient outcomes post-implementation of ratios.”

27. If we saddle our healthcare system with $1 billion in additional costs each and every year, not only will hospitals reduce employment as they sever services, but the hundreds of millions of dollars in “community benefit” programs that hospitals provide to cities and towns are at risk of being pared back dramatically. These free outreach programs that are publicly reported to the Attorney General’s Office each year are often tailored to the underserved, to programs fighting opioid use disorder, to public schools, and more.

28. The state’s Health Policy Commission has determined that the mandate’s $1 billion annual price tag will most hurt community “public payer” hospitals. That is, those hospitals that care for low-income, Medicaid populations and elderly Medicare enrollees will take the hardest hit. Those hospitals will be forced to close services, according to the HPC, harming the populations most in need.

29. There are 1,200 RN vacancies now in hospitals across the state, as well as an aging population of current nurses; 25% of Massachusetts RNs are 61 years or older, and another 27% are between the ages of 51-60. There are also difficulties in our nursing schools producing new nurses due to a shortage and aging of nurse faculty. That’s a systemic problem that requires our collective focus -- not an impractical government mandate.

30. California hospitals had five years between the legislation passing and the ratios going into effect; Massachusetts hospitals would need to come into compliance by January 1, 2019, or just 37 business days after the ballot.

31. The mandated nurse-to-patient ratios are more lenient in California than in the MNA’s proposal, meaning that Massachusetts hospitals will face higher staffing needs than California.

32. California’s law allows both registered nurses (RNs) and up to 50% licensed practical/vocational nurses (LPNs/LVNs) to count towards the ratio requirement; however, the MNA’s Question 1 proposal requires ratios to only be met by RNs.

33. Violations of the ratio mandate do not result in monetary civil penalties in California, in contrast to the MNA’s proposal which includes fines of up to $25,000 per incident, per day.

34. The California law’s legislative structure permits waivers for small/rural hospitals, while Question 1 explicitly forbids such waivers. Question 1 explicitly states that the “Massachusetts Health Policy Commission shall not promulgate any regulation that directly or indirectly permits any delay, temporary or permanent waiver, or modification of the requirements.” In other words, there is nothing in the proposal allowing for waivers and exceptions to ratios for any reason.  

35. Most importantly, Massachusetts patients receive better care than they would in California. The Bay State is ranked #2 in state health system performance by the Commonwealth Fund while California ranks 14. We're number 1 in preventing mortality and #6 in preventing infections. (California is 8 and 27 in those ranking, respectively.) Leapfrog rates Mass. #4 and Calif. #25. The Agency for Healthcare Research and Quality rates Mass. #4 and Calif. #42. Our excellent healthcare system is a crown jewel of the commonwealth!
36. No one is arguing against the right of the nurses union to collectively bargain with individual hospitals, negotiating wages and staffing based on each hospital’s patient mix, finances, and experience of nurses on hand. But a bargaining unit in a downtown Boston hospital should not impose the same standards on a small community hospital in Central or Western Massachusetts. The skill of the nursing workforce and the available resources at one hospital may bear no relation to another hospital.

37. The list of reasons to oppose Question 1 goes on and on, but in simplest terms set ratios alone are not proven to improve care and, in some instances, can adversely affect care and access to it. The cost of Question 1 is too high with no accompanying benefit, and with the possibility of harming our state’s renowned healthcare system. Please Vote NO on Question 1.

Next week, Monday Report will return to its regular mission of reporting on developments in Massachusetts healthcare and on hospitals are continually attempting to enhance their efforts to provide safe, high-quality care to individuals, families, and communities.