scorecardresearch Skip to main content

Watchdog says nurse ballot question could cost $900m a year

Question 1 would limit the number of patients assigned to hospital nurses at one time. The Massachusetts Nurses Association, a labor union, backs the ballot measure.Jonathan Wiggs/Globe Staff/File

A health care watchdog agency, weighing in on a contentious political issue, said Wednesday that a union-backed state ballot question to regulate nurse staffing in hospitals could cost the Massachusetts health care system more than $900 million a year.

The state Health Policy Commission’s new report provided ammunition to opponents of the measure about one month before Election Day and dealt a blow to the Massachusetts Nurses Association, which wrote the ballot question and has argued the costs would be modest.

In the first independent analysis of the question, the commission noted that if the proposal passes, hospitals may close services or demand higher reimbursements to cover the costs. The costs could be passed on to consumers through higher insurance premiums, the agency said.


The findings hew closely to estimates from the hospital industry, which opposes the ballot measure known as Question 1.

The measure would set strict limits on the number of patients assigned to hospital nurses, a ratio of four patients to one nurse in a typical medical unit. The Health Policy Commission said hospitals would need to hire 2,286 to 3,101 additional full-time nurses to comply with the ballot measure. The impact would be felt especially at community hospitals that serve high shares of low-income and elderly patients, the analysis said.

The report concluded that the ballot measure would come at significant cost: $676 million to $949 million per year. It called those figures “conservative.”

But the nurses union, which assailed the commission last week after the agency announced it was studying the ballot measure, hit back again on Wednesday. The union estimates the ballot question would cost about $47 million a year.

Commission staff and a consultant, Joanne Spetz of the University of California San Francisco, who wrote the report, arrived at their numbers by examining current staffing levels at Massachusetts hospitals and calculating the number of additional nurses needed to comply with the ballot question. The cost projections also assume that because of increased demand for nurses, nurse wages would increase by 4 percent to 6 percent across the state.


The ballot question requires hospitals to maintain patient limits at all times, including during overnight hours, and would go into effect Jan. 1.

“It boggles my mind how they would be able to meet the requirements of the law,” said Richard Lord, president of Associated Industries of Massachusetts, who sits on the board of the Health Policy Commission.

Julie Pinkham, executive director of the union, said the commission’s report was “irresponsible and inconsistent and resembles nothing that the HPC has ever done before.” Pinkham said the conclusion that nurses’ wages would rise 4 to 6 percent as a result of the law is “lovely dream world, but not reality.”

The commission, created in 2012, conducts studies on many issues contributing to health care costs, including large hospital mergers, but this is its first detailed analysis of a ballot question.

The commission’s estimates on Question 1 are similar to those from the Massachusetts Health & Hospital Association, a hospital industry group that opposes the ballot question and has spent millions of dollars trying to defeat it.

Officials at the commission insisted that their analysis was done independently and said they were not aiming to sway voters one way or another.

“We’re not pro-hospital. We’re not anti-hospital,” chairman Stuart Altman told reporters. “We’re surely not anti-nurses.


“We had to look at this,” he said. “If we didn’t look at it, we weren’t doing our job.”

Steve Walsh, president of the hospital association, said in a statement that the commission’s findings “conclusively confirm the outrageous costs that would be imposed by Question 1 without any benefit to patient safety.”

“I think the cost question is off the table now,” Dan Cence, a spokesman for the hospitals, told reporters.

Union officials have argued that nurses are overburdened with too many patients and that caseload limits are necessary to improve medical care. The limits set by the ballot initiative would vary by hospital unit, ranging from one patient per nurse to five patients per nurse.

“If I have four patients and you put on your call button, I can get to you,” Pinkham told reporters Wednesday. “If I have eight, you wait. What happens when you wait? Sometimes something bad happens.”

The commission report found that Question 1 could result in potential savings because additional nurses could help reduce the length of stay for hospital patients and reduce adverse events. But those potential savings — about $34 million to $47 million annually — would be far outweighed by the costs of hiring new nurses, the report said.

The question will appear on the Nov. 6 statewide ballot. Voters are split on the issue, according to recent polls. A WBUR poll found that 44 percent planned to vote yes on Question 1, and an equal share planned to vote no.


An earlier Boston Globe poll showed 51.8 percent of voters favored the question, while 33 percent planned to vote no.

Governor Charlie Baker, a Republican running for reelection, has not taken a position on the ballot question, saying through a campaign spokesman Wednesday that he “will carefully review the findings.”

His Democratic opponent, Jay Gonzalez, said in a statement that he supports Question 1 because “our top priority should be patient safety.”

Officials at the Massachusetts Association of Health Plans, which represents insurers, said they would closely review the findings.

A spokeswoman for the state’s largest health insurer, Blue Cross Blue Shield of Massachusetts, said the Health Policy Commission’s findings are “a significant concern at a time when the whole community is working hard to meet the state’s cost growth benchmark.”

Massachusetts law requires health care providers and insurers to contain the annual increase in total health spending; that target is becoming more strict, going from 3.6 percent a year to 3.1 percent a year.

Priyanka Dayal McCluskey can be reached at Follow her on Twitter @priyanka_dayal.