Whether to set nursing staff levels in Massachusetts has become the most contentious question on the ballot this election. Question 1 has pitted nurses against nurses, leaving many voters utterly confused.
The ballot question would require hospitals to limit the number of patients assigned to each nurse depending on the type of hospital unit and how sick the patients are.
The "yes" and "no" campaigns have spent more than $28 million to sway public opinion.
Here's some explanation about just why it's so confusing to voters.
Carrie Healey, NEPR Host: Why are people so mad at each other about this issue?
Karen Brown, NEPR Health Reporter: You do have a lot of people who are on the same side ideologically when it comes to labor rights, or public health, or union support, but they still can't figure out how to vote on this question. And most people seem to agree that patients should have better access to nurses and that giving nurses fewer patients generally leads to better outcomes.
But there's strong disagreement over whether this proposed law will lead to that goal. Question 1 supporters say forcing hospitals to hire more nurses can't help but be better for patients.
Here's Patty Healey from the union, the Massachusetts Nurses Association:
We think this is the best way, after all these years. To actually go to the public and have the public understand how unsafe the hospitals can be without safe staffing.
But others -- certainly hospitals and administrators, but also some nurses and doctors -- say this measure will create new problems.
Here's Angela Belmont, chief nursing officer at Cooley Dickinson Hospital in Northampton:
Currently we have a deficit of 1200 RNs in Massachusetts, and if this ballot passes, it would mean that we would need about 5000 nurses.
So the argument is: If there aren't enough nurses to take these jobs, then some hospital units might have to close, or emergency room waits might get longer, because there aren't enough nurses in a given shift to take new patients. And that's before you even get to the matter of cost.
So what about cost? The estimates out there vary widely. The nurses’ union has estimated the law will create about $47 million worth of new costs. The hospitals say more than a billion, and a report commissioned by the state's Health Policy Commission is in between, though closer to the hospital estimate. What accounts for that variation?
There are many different ways to look at costs. And researchers have some leeway in what to count. So for instance, the hospitals' data included high costs for high nursing turnover in the state, which may or may not happen. The Health Policy Commission predicted that nurse salaries will increase across the board if there's greater demand for nurses, but the union thinks that's an overestimate.
The commission also included some related costs like paying for substitute nurses or extra fringe benefits. So even good faith research includes a lot of subjective numbers.
Given that, why should voters even care about the cost? Won't that be the hospitals' problem?
Well, the union has suggested that most hospitals make plenty of money, especially the big Boston-based ones, and they should dedicate more money to nursing salaries. But it's also likely that some of the extra costs could get passed on to consumers through higher insurance premiums.
I spoke to researcher Joanne Spetz -- she co-wrote that state report. She puts it this way:
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. You know that is the decision that they should be making.
Spetz is an expert on nurse staffing in California, which is the only other state in the country with a law setting nurse to patient ratios. What can we learn from that example?
That's also not entirely clear. Joanne Spetz told me that the debate leading up to the California law was less contentious than the one here in Massachusetts, but it came about in a much different way:
For us this was a bill that went through the legislature, and the bill required that a agency the Department of Healthcare 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.
But it still seemed to me worth looking at what has occurred in California in the 15 years or so since the law went into effect. According to studies in California, nurses report greater job satisfaction and higher salaries, though there's less evidence on patient outcomes.
But I also wondered whether the worst case scenarios played out there. Did any hospitals close, or did they have to cut back on services?
Joanne Spetz says no, but she included an important caveat:
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.
And that timeline is about two months.
All of this information is very nuanced and complicated. I know a lot of voters who aren't sure they should be even voting on this question at all.
That's a very common concern, that if Ph.D.s in health policy don't agree how either scenario is going to play, out how would a layperson figure it out? And how does a voter know the best nurse to patient ratio- the exact patient-nurse ratio- when even the experts debate those numbers?
But supporters of this bill say they've tried other means to pressure hospitals into hiring more nurses, and they feel the political process is their last shot. It's also worth pointing out that if history is a judge, many laws passed by voters do go through changes after the legislature gets its hands on them. So it's possible, if it passes, that the details will change before such a law goes into effect.
Here's a longer conversation between Karen Brown and nursing researcher Joanne Spetz on lessons learned from California.
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.