Most patients arriving at a hospital share the same hopes: Get treatment, get better, and get home. Oh, and maybe get a bill in the mail a few weeks later that doesn’t ruin the family finances.
Those are the starting points to evaluate Question 1 on the Nov. 6 ballot, a controversial proposal that would require Massachusetts hospitals to hire thousands more of just one component of a hospital’s workforce: registered nurses. The increasingly bitter campaign, featuring millions of dollars in advertising, pits the Massachusetts Nurses Association, which backs the proposal, against the state’s hospitals, which oppose it along with dozens of medical organizations. The ballot battle is the culmination of a long-running fight between the hospitals and nurses union, which has been pushing the idea on Beacon Hill for more than a decade without success.
The Globe endorses the no side on Question 1 — and not because of the dire warnings from hospital executives who predict it will cause patients to die, force pregnant women to trek to Connecticut to deliver babies, or provoke an immediate staffing crisis.
Rather, the burden rests on nurses to show that their proposal would be worth it from the perspective of that patient arriving at a Massachusetts hospital. Making medical staffing decisions at the ballot box is an inherently suspect idea. And hyperbolic ads aside, Question 1 would probably have costs and consequences for access to care: adding up to $1 billion a year in expenses, hurting community hospitals, reducing the number of psychiatric beds, and sidelining other caregivers. The question’s proponents need to demonstrate to voters why they should accept those risks.
They haven’t. In fact, there is no conclusive evidence that a nurse staffing law will lead to better care. And without clear evidence, a yes vote on Question 1 represents too much of a gamble for a health care system that is already considered one of the best in the world.
WALK INTO a hospital, you’ll find an alphabet soup of health professionals: RNs (registered nurses), MDs (doctors), PAs (physicians assistants), LPNs (licensed practical nurses), LCSWs (licensed clinical social workers), MAs (medical assistants), physical therapists, mental health counselors, and the list goes on. Under current law, hospitals have ample latitude to hire the staff mix they believe can deliver the best care to patients at the lowest cost.
Question 1 would, over time, alter the makeup of those teams, leading to relatively more registered nurses — and relatively fewer of everyone else. RNs in Massachusetts hospitals make about $90,000 on average, and the hospitals would need to hire about 2,286 to 3,101 more of them, according to the only independent analysis of Question 1, which was released earlier this month by the state’s Health Policy Commission. The ballot question states that hospitals would be prohibited from meeting the staffing requirements it would impose by “reducing its level of nursing, service, maintenance, clerical, professional, and other staff.” But laws can’t prevent turnover and attrition, or alter budgetary realities. If providers are required to hire more nurses, it’s reasonable to fear they’ll let staffing in other job categories slide, including professionals like physical therapists and social workers.
Shedding other professionals to free budget space for more nurses would have consequences for patients.
“To lose social workers in the hospital would be a tragedy,” said Joan Smith, the director of social work services at Tufts Medical Center. The 18 social workers at the hospital handle tasks like discharge planning and connecting patients to services “They would try to replace our work with the nurses,” she said. “This is something nurses are not trained to do.”
The nurses’ union says hospitals have the money to employ more nurses and keep their other staff; they just choose to spend on CEO salaries and needless layers of management instead. But many of the state’s hospitals are clearly ailing: 13 of the state’s 62 acute hospitals lost money last year; margins at others are shrinking .
California, currently the only state with a nursing-staffing ratio law, shows how changing the staff mix doesn’t necessarily lead to overall quality improvements. Academic researchers haven’t found evidence that California’s health outcomes improved after the law went into effect. In fact, California lags Massachusetts in almost all nurse-associated quality measures and in overall quality of care. Joanne Spetz, a professor at the University of California, San Francisco, who studies nursing and consulted for the Health Policy Commission, said that reducing the number of aides while hiring more nurses is “hypothesized to be one of the potential reasons we did not see systematic improvements in patient outcomes.”
The Commonwealth also has its own inconclusive experience with a nurse staffing law. The Legislature instituted a mini version of Question 1 in 2014, which applied only to intensive care units. It went into effect in 2016. A 2018 peer-reviewed paper in Critical Care Medicine found no improvement in patient mortality or complications.
IN TOTAL, the commission estimated that Question 1 would cost Massachusetts hospitals up to $1 billion a year, including salaries, benefits, and other compliance costs. Unlike in California, the law would be backed up by stiff penalties of up to $25,000 per violation. Facilities that can round up enough RNs and have the market clout to pass along the cost to consumers will do so, resulting in higher premiums.
Academic medical centers, by and large, come close to meeting the proposed ratios. It is the community hospitals that rely on Medicare and Medicaid payments that would likely struggle with the new requirements. The commission estimates these hospitals would need to bump up nurse staffing by 21 to 30 percent, and Medicare is not going to boost payments to hospitals just because voters force them to hire more nurses.
Ed Moore, the CEO of Harrington Hospital in Southbridge, estimated that it would cost about $6 million to $7 million to comply with Question 1, and it would prompt some tough decisions. “I’d look at behavioral health. If it’s going to drag us down financially, even though it’s the biggest need right now, I’d have to look at the greater good, which is keeping the place afloat.”
Harrington wouldn’t be alone: Massachusetts hospitals typically lose money on behavioral health and already have trouble hiring psychiatric nurses. If the ratios go into effect, the lack of available nurses, plus the cost, would force many of those providers simply to close units. The state could be losing an estimated 1,000 psychiatric beds, in the midst of an opioid epidemic.
The health care industry worries the ripple effects from Question 1 won’t end there. Hospitals will have to find those nurses somewhere. That makes community health centers and nursing homes nervous. Cheryl Bartlett, the CEO of the Greater New Bedford Community Health Center, which serves about 25,000 predominantly low-income patients, said she fears hospitals “will recruit nurses away from nonhospital facilities like community hospital centers.”
BURNOUT IS a real problem for doctors, nurses, social workers, and other parts of the health care system. Hospitals do need to invest more in the workforce — their whole workforce.
But Question 1 isn’t the answer. It’s too blunt of an instrument, substituting a rigid numeric ratio in place of the judgment of medical professionals.
The union’s efforts on Beacon Hill have failed for a reason. There’s not enough evidence that making hospitals hire more registered nurses would further the overarching goals of access, affordability, and quality, and too many reasons to fear it might backfire on all three. The Globe urges a no vote on Question 1 on Nov. 6.