On Question 1, What Can Massachusetts Learn From California?

Oct 31, 2018

In Massachusetts, ballot Question 1 would limit the number of patients that a nurse can oversee in a hospital. California is the only state so far to mandate nurse staffing levels.

To learn from California's experience, NEPR reporter Karen Brown talked with Joanne Spetz, a nursing researcher in San Francisco who also evaluated the Massachusetts proposal for the state's Health Policy Commission. 

She starts with the question: what changed after the California law went into effect 14 years ago?

(And for a broader discussion on why this ballot question is so confounding to voters, listen here to a conversation between NEPR's Karen Brown and Carrie Healy.)

Joanne Spetz, researcher: Things that we've seen in the data are that nurse satisfaction appears to have risen. We did see reduction in occupational injury rates, that was quite significant. We saw wages rise for registered nurses.

Karen Brown, NEPR: What about the cons that have come since the law went into effect, if any?

There were two studies published, one of which found that hospital operating margins dropped for the hospitals that were most impacted by the ratios. Anecdotally, we heard that hospitals passed on a lot of the cost to insurance companies. But we don't have really good data to measure how much insurance premiums went up because of the ratios.

So was the debate as contentious in California as it seems to be here in Massachusetts? Out here, you've got people who generally agree on the same basic principles -- supporting unions, strong labor laws, regulation of public safety -- who are completely at odds on this question. And you've got a lot of voters who are utterly confused by which answer on the question -- yes or no on 1 -- will lead to better patient care. Were you seeing the same kinds of debates in California?

Not really. For us, this was a bill that went through the legislature, and the bill required that an agency, the Department of Health Care Services, then establish what the ratios would be. So that's a very different dynamic than having the actual ratios in a proposition for the voters to decide.

That said, it was contentious when they were in that process of determining ratios. The nurses’ union, California Nurses Association, recommended a minimum ratio of no more than three patients per nurse and Hospital Association recommended 10 patients per nurse.

Let's look a little bit at what we can learn from the California experience. You know, a lot of the critics have voiced warnings about not being able to find enough qualified nurses, or the danger of emergency rooms maybe having to occasionally close to new patients, or astronomical costs to implementing this, causing hospitals -- especially community hospitals -- to scale back on services. Have those kinds of things come to pass in California, and should we be looking at California to determine whether those things are likely to happen?

So in California, the evidence does not show any systematic or even significant closures of hospitals, closures of units, reductions of services, or even emergency department diversions.

The reason that all of those things that didn't happen in California might not apply to Massachusetts, is the timeline. The hospitals had, depending on how you count it, two to five years to get ready for this. That may mean that the concerns that hospitals have in Massachusetts may have more of a basis because it is a much tighter timeline for implementation.

I'd like to look a little bit at what the Health Policy Commission report did find. One thing that struck me was that Massachusetts already has fairly high nurse staffing levels without the mandate. Even more than California. Why do you think so many nurses in this state still feel like they can't take care of patients at the level they need to, given that the staffing levels are relatively high to other states?

The data that we examined, we were able to look at average staffing levels. But digging deeper into the data, there is a lot of variation. Some hospitals are staffing quite high and already essentially above what the ratios would require and some are staffing relatively low.

When we did our surveys in California, we found some hospitals that voluntarily told us that their staffing on the night shift was one nurse to 12 patients. Our research team had two registered nurses on it and they were like, "Oh my gosh, what are they doing with a one to 12, even on a night shift?" And that was probably some of the motivation for nurses in those hospitals to ask their legislators to vote for the bill.

Probably the part of the Health Policy Commission that you worked on that was most quoted was the cost. You came up with between $600 million and $950 million. So what should voters take from those numbers? Should cost be the primary driver of this question?

These kinds of regulations -- and most regulations -- are not free, but the benefits to voters might be worth it relative to the costs. And if the voters feel comfortable having their insurance premiums go up that additional amount, great. That is the decision that they should be making.

Listen to a debrief on why people are so confused about this ballot question.

And here's information on all three Massachusetts ballot questions in one listen.

Take a look at the NEPR Massachusetts General Election Voter Guide 2018.