To hear the stark scenarios posited on both sides, there is no more consequential decision on Tuesday’s ballot than your vote on Question 1.

In the superheated rhetoric of ads around this issue, which can be confusing in portraying registered nurses advocating both “Yes” and “No” votes on a ballot question promoted by the Massachusetts Nurses Association on one side and fought by a coalition of hospitals and others, including the American Nurses Association in Massachusetts, patient safety, access to health care and the viability of some hospitals or hospital services are all said to be at stake.

Elsewhere on today’s page you’ll find two presentations, one from each side of the question, speaking directly to you from their perspectives on the impact and need for Question 1.

But in our view, let’s just start with the fact that a question this technical and involving complex assessments such as patient care and outcomes in every aspect of hospital care, and with far-reaching effects on hospitals, on both public and private health insurers, on businesses, on government budgets and spending at all levels, and on your personal access and cost to health care should not be decided by a ballot question.

Ballot questions, just by their nature in being formulated and introduced by their strongest advocates, often overreach and often lead to unanticipated consequences, including problems.

The fact that the MNA and the Massachusetts Health Policy Commission disagree over the potential costs of Question 1 by a factor up to 27 times is a shocker. The MNA puts the estimated annual cost at $35 million to $47 million. The Health Policy Commission puts those costs at $676 million to $949 million, and adds that these may be on the low side.

How can those estimates be off by so much? And the MNA’s Question 1 has this same state Health Policy Commission overseeing the implementation, regulation and operation of this act. One explanation from the MNA is that is that the state report, with data from the hospitals, all of which oppose this, is ladled with “pork.” Save that for the bargaining table. Better to put it in terms of factors, perhaps, such as not accounting for existing union contracts that won’t be superseded – although someday they will expire, leaving the new ratios as the starting point that can only get lower under the law. Also, perhaps that instead of hiring new full-time staff, hours could be added to part-time staff. But consider that even an impact in between those numbers would be very significant.

Equally troubling, in our view, is that Question 1′s wording includes a section saying that hospitals can assign fewer patients than required per registered nurse, but only if there’s no staffing reductions of “the health care workforce assigned to the facility’s patients.” That workforce, defined in Question 1, includes “unlicensed assistive personnel, service, maintenance, clerical, professional and technical workers.” It’s the sort of job guarantee and management prerogative which, if it can’t be won at the bargaining table, shouldn’t be tucked into a long, complex law for the state’s voters to review and decide in the ballot box.

Also, Question 1′s staffing ratios for RNs can’t be violated at any time unless a state or national health emergency is declared, and establishes penalties of up to $25,000 per violation. Enforcement is through litigation by the attorney general’s office. Plus, it sets up a hotline for reporting complaints. Imagine what might happen if a nurse is out sick or has to leave, or in a sudden surge of flu cases. It’s a prescription for polarization, rancor and management chaos.

We should mention that the hospitals do operate under a required staffing ratio for intensive care units. But only one other state, California, has implemented anything like Question 1′s broad requirements. Passage there, in 1999, took five years for implementation in a staggered fashion, including enabling time to hire and train the “significant increase” in staffing to meet their requirements, which was also accompanied by a “moderate” increase in RN wages in order to find and keep nurses at the newly required levels. In Massachusetts, Question 1 requires implementation of the new standards that are more strict than California’s in some ways in just two months, another prescription for chaos.

Tellingly, the state’s Health Policy Commission found, “There was no systematic improvement in patient outcomes post-implementation of ratios” in California. While so-called “failure to rescue” incidents following a medical complication decreased significantly in some California hospitals, compared to other states, other California outcomes “were mixed – some worsened, some improved, and some did not change.”

Finally, Massachusetts staffing of registered nurses in hospitals as of 2016 was higher than California’s, according to the report, and certainly higher than the national average. Plus, the report found, Massachusetts hospitals outperform California hospitals on five out of six “nursing-sensitive quality measures.” So what problem is Question 1 fixing? It also said community hospitals, which are more economically vulnerable, would need to increase RNs by up to 30 percent. The varying needs by hospital service could result in some hospitals curtailing those services. In order to not fall under patient ratios, incoming patients could be kept waiting for admission, even backed up in ambulances or diverted. Imagine the cascading impact, including on fire departments in small communities that provide ambulance services. Or the impact on nursing homes, for instance, that find their RNs being recruited by hospitals in a local market here for RNs that’s tighter than all but nine other states. Even more prescriptions for chaos.

In our opinion, these issues should be sorted out at the professional or administrative level, at the bargaining table, or deliberated at the legislative level, and not thrown to voters because of lack of movement at the above. If the nurses union backing this and the state agency it wants to oversee it are so far apart on its impacts, how is the average voter supposed to make a rational decision?

Consequently, we urge a “No” vote.

Read the Editorial at the Telegram & Gazette »