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Should you vote “yes” or “no” on Question 1?

  • Lawn signs — like these on High Street — both for and against ballot Question 1 have tasked Massachusetts residents with figuring out whether to vote “yes” or “no” on the highly debated initiative. STAFF PHOTO/JOSHUA SOLOMON 



Staff Writer
Monday, October 29, 2018

GREENFIELD — Potentially the biggest driver of voters to the polls on Nov. 6, Question 1, continues to puzzle many people interested in nurse staffing at hospitals.

To date, the referendum on nurse-patient staffing ratios, proposed by the statewide nurses union, has led to nearly $30 million in campaign spending, much of it by the two chief antagonists, the Massachusetts Nurses Association and the Massachusetts Health & Hospital Association.

This has led to a saturation of TV and radio commercials along with lawn signs scattered across the region, both touting that nurses are for and against 

In short: 

What is it? Question 1 seeks to mandate specific nurse-patient staffing ratios in hospitals.

Why? Some union nurses say this will prevent a nurse from having to care for too many patients at once, which they say will make it safer for patients and result in better outcomes.

Why not? Other nurses and hospitals say these new rules are “too rigid” and describe the “government mandates” as handcuffing the flexibility of nurse managers from deciding what nurses and departments need help and when. They argue it will cost the state health care system hundreds of millions extra a year, without any certainty of better outcomes and contend trying to put this into effect by Jan. 1 is unworkable. California took four years to enact the nation’s only other similar plan.

Who wants it?  The Massachusetts Nurses Association, a nurses union, helped to bring the question onto the statewide ballot and has been the major voice pushing for it. The lobby supporting it, the Committee to Ensure Safe Patient Care, has spent about $10 million during the campaign. The MNA union includes the registered nurses of Baystate Franklin Medical Center, but represents only about 18 percent of the state’s registered nurses.

Who doesn’t want it?Hospital executives have been the most vocal in knocking the ballot question, through the Massachusetts Health & Hospital Association.  But the American Nurses Association of Massachusetts, a professional organization for nurses, not a union, also is one of the louder voices against the ballot. Locally, one of the region’s major nonprofit social service providers, ServiceNet, opposes Question 1. The Coalition to Protect Patient Safety, has spent around $18 million on its campaign to defeat Question 1. 

What’s the cost?It’s debated, although the state’s Health Policy Commission did attempt to come up with an answer, estimating the cost at $676 million to $949 million, annually, of which 37 to 40 percent would come from additional nurses needed in acute care hospitals. Some of this cost would be born by taxpayers through state-funded health programs and some through people’s private insurance policies and premiums. The nurses union dismisses the analysis as wildly inaccurate. 

Will this affect Baystate Franklin Medical Center? Probably. The hospital has said patients may be turned away and the hospital may have to serve fewer patients overall, for a variety of reasons. The nurses union disputes this as well, and points out that its recently settled contract states if Question 1 were to pass, nothing would go into effect until July 2020 — but necessary changes at Springfield’s Baystate Health, which does not have unionized nurses, could have a ripple effect here in Greenfield. And other area hospitals like Athol Hospital and Cooley Dickinson Hospital might be impacted right away as well and that could affect Baystate Franklin.

What is Question 1 asking?

The question looks to set how many nurses are needed per unit to safely care for the number of patients. The law, as written, would go into effect Jan. 1, although the Legislature has the power amend the law if passed by voters.

A “no” vote keeps things as they are, leaving staffing decisions in the hands of nurse managers at hospitals, and in some cases, nurses contracts, to decide what is best staffing at any given time. 

According to the Secretary of State’s Office, in the emergency services department, for example, there would be a limit of one critical or intensive care patient per nurse, or two patients if the nurse has determined each patient is in stable condition. One nurse in this department can have two urgent, non-stable patients, three urgent, stable patients or five non-urgent, stable patients. 

For general medical surgical patients the limit would be four, which is the maximum for the various types of patients specified in the referendum – except for psychiatric patients and rehabilitation patients, where five would be allowed. At present, depending on many factors, that number can range upwards to five, six or, theoretically, more. ICU staffing is already set by the state.

Question 1 staffing rules would be enforced by the state’s Health Policy Commission. For every violation, the commission can impose a fine up to a $25,000 a day, a factor Question 1 opponents say will prevent nurse managers or nurses from making common sense decisions in busy times. 

The law would not override a hospital’s contract with nurses that has more stringent patient limits. After the contract expired, the law would take effect. 

For any state or nationally declared public health emergency, the law would be suspended. 

Precedent in California, sort of

Nearly two decades ago, California passed a similar law. 

In 1999 that state’s legislature agreed to implement limits on nurse staffing, but it didn’t go into full effect until 2004. California remains the only state to have this type of law. Academic reports are mixed on measuring its success.

How does this relate to Baystate Franklin contract negotiations?

Because local nurses won many staffing concessions from the hospital in the five-year contract signed in May, Question 1 will have limited immediate impact on staffing levels here. That contract established nurse staffing rules much like those in Question 1. If Question 1 passes, it would not replace the local contract rules until July 2020.

Nonetheless, Baystate has often stated there will be an effect on the High Street hospital beginning Jan. 1. The nurses at Baystate Health in Springfield are not unionized and do not have a contract that would override this ballot initiative, which may lead to necessary staffing adjustments throughout the Baystate system, potentially affecting Greenfield, hospital officials contend. Exactly what this effect might be remains unclear. Others note that competition for registered nurses will drive up costs overall.

Enough nurses?

One of the prevailing arguments from those opposing the ballot initiative is that there simply are not enough nurses to meet the legal requirements today.

Currently in Massachusetts there are about 130,000 registered nurses, and a total of 151,000 nurses if you include licensed practical nurses.  The MNA estimates there about 100,000 active RNs in the state, based on its mailings. 

The number of registered nurses has steadily grown in recent years. Since 2010, the total RNs in the state has increased by 14.5 percent and grown by about 2,700 nurses per year, according to the state Department of Public Health. Upper end estimates say there will need to be close to 3,000 nurses hired to fill the need by the ballot initiative, which advocates then say is doable over time. These numbers don’t take into account potential retirements by baby boom nurses.

The federal Bureau of Labor and Statistics estimated in December of 2015, with its most recent data, that the nursing profession is projected to be among the top growing professions in the country.  In 2017, the U.S. Department of Health and Human Services estimated that by 2030, Massachusetts will have a surplus in nurses. 

The American Nurses Association of Massachusetts pushes back on this suggestion that the surplus estimated will be enough. 

First, the ANA of Massachusetts says the number of retiring nurses is greater than the number of new nurses entering the workforce, rounding out to a roughly 4:3 ratio of outgoing-to-incoming nurses. 

Second, the professional association says the incoming nurses who are fresh out of school are not necessarily ready to be thrown into the thick of things without six to 12 months of training or shadowing.

Lastly, the association says despite the labor department’s projections of a surplus, it’s without factoring in what may happen if the question were to pass into law.

Are current staffing numbers safe?

Naturally, it depends who you ask about whether there are enough nurses now.

Those against the initiative point to Massachusetts hospitals ranking among the best in the country and ranked better than California hospitals, which are the lone hospitals with some form of across-the-board staffing ratios. 

The MNA points to dozens of academic studies that state that Massachusetts isn’t quite as good as some say. The union points to research indicating that in fact Massachusetts hospitals have among the worst hospital re-admission rates in the country and in 2017 they ranked 49th  in the country in emergency department wait times, according to a ProPublica analysis. Studies the advocates point to state the worse the re-admission rates are, the higher the cost on the health care system. 

Nurse vs. nurse

The MNA represents about 23,000 nurses in the state at about 70 percent of the acute care hospitals in the state, it says. The 23,000 accounts for about 23 percent of working nurses in the state, the union says, and comes to about 18 percent of the total registered nurses in the state, which includes retirees. 

The American Nurses Association of Massachusetts is independent from the national ANA organization, but still affiliated. Across the country, there are 200,000 members of the association, it says, but 2,300 in Massachusetts.

While the MNA’s membership is typically thought of as “bedside nurses,” the ANA’s membership is considered more varied, including RNs on the floor, nurse managers, nurse executives and academics. About 50 percent of the state and national membership of the ANA are staff nurses.

The ANA of Massachusetts said it opposes the referendum because it’s a “one size fits all” approach. 

Interim Executive Director of the ANA of Massachusetts Carmela A. Townsend said to reform staffing law, there needs to be a better way to take into account the intensity, complexity and stability of patients — typically known as the acuity of the patient. The education and experience of a nurse needs to also be accounted for, so that someone like a nurse manager can assess how many RNs they need for a particular situation. 

“We support safe staffing, unit specific and acuity-based that has direct involvement to staff nurses, but we do not support a one-size fits all mandated ratio bill of Question 1,” Townsend said.  

Financial impact? 

In the Secretary of State’s official ballot question information packet, the fiscal consequences of the initiative are estimated to cost state-owned hospitals between $67.8 million and $74.8 million to comply with the proposed law, according to numbers calculated by the Executive Office of Administration and Finance. It would cost an estimated $1.3 million for the Health Policy Commission to enforce the law. 

“The overall fiscal consequences to state and municipal finances, however, are difficult to project due to the lack of reliable data,” the literature from the packet says. 

By October, the Health Policy Commission released a report estimating the overall impact  of Question 1 at $676 to $949 million, annually, of which 37 to 40 percent would come from additional nurses mandated in acute care hospitals.

The analysis was ripped by the nurses union. Its president has slammed the report’s projection of increases in wages for nurses over time because of competition among hospitals to hire the nurses. 

Nonetheless, the commission’s report, which is touted by the “no” camp, is the closest the public has gotten to an impact statement from a relatively neutral party.

The report was conducted primarily by two researchers: the commission’s director for research and cost trends, David Auerbach, a health economist, and Joanne Spetz, an honorary fellow of the American Academy of Nursing, and a professor at the Institute for Health Policy Studies at the University of California, San Francisco. 

A key component of the analysis is viewing the effectiveness of the California staffing ratios, which are similar but not the same. The four takeaways were: significant increase in nurse staffing, moderate effect on nurse wages, no systematic improvement in patient outcomes, but, there has not been a “comprehensive, retrospective analysis of implementation costs.” 

The department that will require the most hiring, the analysis says, will be the general medical-surgical department, followed by a distant second and third of psychiatric and labor-delivery. 

Questions regarding possible increases in insurance premiums weren’t directly answered by the commission’s study, but it does state the costs from the law could “lead to higher commercial prices for hospital care, potentially leading to higher premiums.”

Both sides have released studies they back, which vary greatly from each other in potential cost.

What do local politicians have to say? 

Many elected officials across the state have vocalized support for Question 1. The lone major name to come out publicly against the ballot initiative is Republican Gov. Charlie Baker, who stated his opposition after the Health Policy Commission’s report came out.

Of locally elected officials, the biggest name to back the question is U.S. Congressman Jim McGovern, D-Worcester. McGovern though, as a federal lawmaker, would have no involvement with the law if it passes.  

Among the five elected officials representing Franklin County in the state Legislature, who would be able to affect the law if passed, two have stated they favor Question 1. 

Rep. Paul Mark, D-Peru, a card-carrying union member himself, was often seen on the picket line with the Baystate Franklin nurses during their contract negotiations. 

The expected new state senator for many Franklin County communities, Joe Comerford of Northampton, was seen last week at a rally in Greenfield to back the nurses union and the “yes” vote. 

Rep. Susannah Whipps, I-Athol, also spent time on the picket line with the Baystate Franklin nurses, but not often. In her community, Athol Hospital has stated it is against the ballot initiative. Whipps was not available for comment on her views on Question 1. 

Primary winner for state representative Natalie Blais of Sunderland, who faces no opposition Nov. 6, added her name to those voting “yes” on Question 1. 

State Sen. Adam Hinds, D-Pittsfield, has not taken a public position on the issue, a spokesperson from his office said. 

Greenfield city councilors who have spoken on the record about the ballot initiative have supported it.

City Council President Karen “Rudy” Renaud works for the Massachusetts Nurses Association and often tries to separate her work from her role in municipal government. The progressives who won election last November, Sheila Gilmour, Doug Mayo, Otis Wheeler and Tim Dolan, have also been vocal backers of the nurses union. 

Greenfield Mayor William Martin, a former registered nurse in the Army in Vietnam and back in the States, said he will be voting “no.” He based his stance on his views of an individual nurse’s license to practice that states they need to help those in an emergency; the ballot initiative only specifically allows for it to be superseded by a state or national declaration of emergency. 

He also sees it as an economics issue for the city of Greenfield and, at large, Franklin County. 

Martin doesn’t like that a question of this complexity and magnitude was left up to the voters to decide instead of the Legislature, saying Beacon Hill “kicked this can to the referendum.” 

While Greenfield Community College was not taking a political stance on this issue, its Assistant Dean of Nursing Nancy Craig-Williams said she has been discussing the topic with her students. Educating themselves on both sides of the issue, Craig-Williams said the nursing program students have been passionate about it and have views on both sides. One of the most useful pieces for students have been reading the bill itself.